PONE-D-22-08463Minimum inhibitory concentrations of rifampin and isoniazid among multidrug and isoniazid resistant Mycobacterium tuberculosis isolatesPLOS ONE

Dear Dr.  Getahun,

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

Reviewer #3: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear Author,

This article on "Minimum inhibitory concentrations of rifampin and isoniazid among multidrug and isoniazid resistant Mycobacterium tuberculosis isolates" was very well written, concise and easy to follow. In the context of Ethiopia, this type of study is highly significant. Since there was significant number of patients were identified with HIV positive, it was not discussed about the possible outcome/impact of HIV on MDR TB. However, please review the attached file for detailed comments.

Thanks

Reviewer #2: In the manuscript entitled “Minimum inhibitory concentrations of rifampin and isoniazid among multidrug and isoniazid resistant Mycobacterium tuberculosis isolates”, Getahun et al describe the drug sensitivity profiling of 74 clinical isolates against two first-line anti-TB drugs and rifabutin from different locations of Ethiopia. Using both growth inhibition and line probe assay, they estimated the minimum inhibitory concentration of the isolates and categorized them as drug sensitive or resistant. Importantly, the authors find that a fraction of the MDR/RR-TB remain susceptible to rifabutin indicating the importance of rifabutin in MDR-TB regimen. In addition, more than 50% of the MDR isolates are only moderately resistant to INH leading them to suggest a high dose INH treatment for MDR-TB.

The manuscript is brief and well written with sufficient details. However, I would still make a few points on the conclusion made by the authors.

Major comments:

1) Study sample size: The manuscript provides drug susceptibility data for 74 samples isolated from 32 health facilities from different locations of Ethiopia. However, the given sample size is far too small for making a representation of the TB drug susceptibility profile of Ethiopia. The authors could consider increasing the sample size.

2) Based on their observation, the authors recommend considering the use of rifabutin and high dose INH for the treatment of MDR-TB. It seems plausible. However, despite the available references on the use of rifabutin and high dose INH for treatment of MDR-TB, I feel that the sample size of the current study and the fraction (9 out of 48 MDR isolates, 19%) is yet very small to conclude this point.

3) The title of the manuscript looks very general. I would suggest revising the manuscript title to include the specific geographical location that is the country name.

Minor comments:

1) Add the full form of RFB in the first place

2) L94 : Underwent

3) L100: Subcultured

Reviewer #3: The manuscript entitled “Minimum inhibitory concentrations of rifampicin and isoniazid among multidrug and isoniazid resistant Mycobacterium tuberculosis isolates” has been reviewed and I would like to comment on the overall hypothesis and its execution. Authors here had tried to demonstrate that how important is the dose spectrum of the current anti-TB drugs. And how this can affect the treatment choices and outcome. This is a very serious concern where it is difficult to deicide on clinical breakpoints of these drugs for effective treatment outcome. My comments are below which would help in better understanding of the current study and if fulfilled, I would recommend acceptance.

1) My major concern is the use of LPA which; by now have several modifications after 2011 for determining the resistance of drugs. However, authors use a latest version of LPA which was modified in 2017/2018 but I am not sure if there are additional guidelines by Hains in 2019 to calculate the resistance of these drugs? Author should clarify this and give a detail about it.

2) What is the concentration used for sub- culturing these strains on 7H11 plates?

3) What is the difference between no growth on subculture and not retrieved group?

4) I am curious to know if there are inoculum differences when the strains were scrapped off from the 7H11 plate to resuspend for McFarland standard? For example, how much cfu/ml would it be in the borderline strains?

5) The detection rate of different type of mutations, for example mutations at different SNP’s have authors considered for detection rate, when determining the type of mutation?

6) I understand the authors mentioned about the data regarding treatment is not accessible but important to know that the mutation outside Rifampicin determining region in those two borderline mutant strains is a result of treatment failure/lost follow up.

7) Is there any possibility of predicting that mutations will occur in which region and whether they are correlated with the MIC? Are there any models? Authors may give description about it.

8) Are the suspects in the newly diagnosed category have a known TST and IGRA status?

9) I am always skeptical about using high concentrations of drugs, authors mention the use high concentrations of INH for treatment. Unfortunately, mechanistically it remains poorly understood. Also, it is important to note that INH is poorly penetrant and its possible to have side effects and emergence of persisters later. However, I do not deny that there are studies done but those TB treated subjects I am not sure if they followed up which remains a cause of concern.

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Reviewer #1: No

Reviewer #2: Yes: Jees Sebastian

Reviewer #3: Yes: Vartika Sharma

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Attachments

Attachment

Submitted filename: Minimum inhibitory concentrations of rifampin and isoniazid among multidrug and isoniazid resistant Mycobacterium tuberculosis isolates.docx

Attachment

Submitted filename: Review_ethiopia.docx

Minimum inhibitory concentrations of rifampin and isoniazid among multidrug and isoniazid resistant Mycobacterium tuberculosis in Ethiopia.

PONE-D-22-08463R1

Dear Dr. Getahun,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Dwij Raj Bhatta, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Authors have included all the points in revised manuscript as suggested by reviewers! Such revision has been verified by original reviewers and suggested for acceptance of the current version, threfore this highly important research Article on MDR MTB isolates and rifamicin and isoniazid MIC determination , alternative treatment options for MDR TB be accepted for publication!

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: No

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

Reviewer #3: (No Response)

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: Yes: Jees Sebastian

Reviewer #3: No

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