Abstract
BACKGROUND: Strain diversity in Mycobacterium tuberculosis (Mtb) underlies distinct clinical presentations and outcomes, but the range of drug susceptibility phenotypes among clinical isolates is poorly understood. We aimed to identify drug response patterns in phylogenetically diverse clinical isolates to combination treatment. METHODS: Out of 641 drug-sensitive clinical isolates, we selected 13 strains that capture local and global phylogenetic diversity and included Erdman ATCC-35801 as a reference. We selected ten antibiotics with diverse mechanisms of action to study phenotypic responses to combination therapy. We treated each strain with 10 single drugs, 45 drug pairs, and 20 three-way combinations in standard and cholesterol-rich media. To compare combination treatment responses across strains and conditions that have varying doubling times, we computed normalized growth rate inhibition metrics (GR(max)). FINDINGS: Mtb clinical strains displayed a broad range of drug response phenotypes across the 65 drug combinations and two metabolic conditions tested. The most effective drug pairs (based on potency and synergy) varied both by strain and metabolic condition. Within our 14-strain panel, strains that were less sensitive to single drugs were also less sensitive to combination treatment, with very few exceptions. For all drug combinations tested, the magnitude of GR(max) variation across all strains was driven primarily by variation among genetically related strains, rather than between genetically distant strain groups. INTERPRETATION: Preclinical studies should reflect the diversity of Mtb clinical strains; our data suggest that selecting strains based on the range of drug response phenotypes displayed, rather than by genetic diversity alone, may better account for the effects of strain variation. Our findings also support the understanding that constituent drug pairs of high-order combinations target metabolically heterogeneous Mtb. Selection of these pairs should likely involve multiple factors including the infecting strain, metabolic niche, and drug response metrics. FUNDING: Gates Foundation INV-027276; NIH P01AI143575&1F32AI174653; Wellcome 206724/Z/17/Z.