Treatment of disseminated
tuberculosis in children≤6years has not been optimized. The
pyrazinamide-containing combination regimen used to treat disseminated
tuberculosis in babies and toddlers was extrapolated from adult
pulmonary tuberculosis. Due to hepatotoxicity worries, there are no dose-response studies in children. We designed a hollow fiber system model of disseminated intracellular
tuberculosis with co-perfused three-dimensional organotypic liver modules to simultaneously test for efficacy and toxicity. We utilized pediatric pharmacokinetics of
pyrazinamide and
acetaminophen to determine dose-dependent
pyrazinamide efficacy and hepatotoxicity.
Acetaminophen concentrations that cause hepatotoxicity in children led to elevated liver function tests, while 100mg/kg
pyrazinamide did not. Surprisingly,
pyrazinamide did not kill intracellular Mycobacterium tuberculosis up to fourfold the standard dose as monotherapy or as combination
therapy, despite achieving high intracellular concentrations. Host-pathogen
RNA-sequencing revealed lack of a
pyrazinamide exposure transcript signature in intracellular bacteria or of phagolysosome acidification on pH imaging. Artificial intelligence algorithms confirmed that
pyrazinamide was not predictive of good clinical outcomes in children≤6years who had
extrapulmonary tuberculosis. Thus, adding a drug that works inside macrophages could benefit children with disseminated
tuberculosis. Our in vitro model can be used to identify such new regimens that could accelerate cure while minimizing toxicity.