The influence of pyrazinamide resistant associated gene mutations on multidrug-resistant mycobacterium tuberculosis in China

The influence of pyrazinamide resistant associated gene mutations on multidrug-resistant mycobacterium tuberculosis in China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The influence of pyrazinamide resistant associated gene mutations on multidrug-resistant mycobacterium tuberculosis in China Yuzhen Zhang, Yifan Li, Yao Liu, Xianglong Kong, Huaichen Li, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4061680/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Pyrazinamide (PZA) is essential for the treatment of drug-susceptible and drug-resistant tuberculosis (TB), especially multidrug-resistant (MDR) TB, but the condition of PZA resistance (PZA-R) across China is unknown. Our aim is to clarify the genetic mutations of PZA-R and the relationship between PZA-R and MDR-TB in China, from 2007 to 2019. Methods A total of 3202 TB strains with gene sequences results in China were included, among which 1447 strains were sequenced and 1775 were download from the European Nucleic Acid Sequence Database. Drug resistance was investigated by detecting resistance-conferring mutations. A phylogenetic tree was constructed to illustrate the genetic structure of the TB strains. Fisher's exact or Pearson's chi-square tests, as well as logistic regression analysis were used for correlation analysis. Those were calculated by SPSS software. Results All the 3202 strains were divided into four lineages (L1, L2, L3, L4), most belonged to L2 (2745, 85.7%), followed by L4 (443, 13.8%), the rest L1 plus L3 (14, 0.4%). About 45.6% (n = 1459) strains referred to isoniazid resistance (INH-R), 43.4% (n = 1389) rifampicin resistance (RIF-R), and 40.5% (n = 1296) MDR. There were 591 isolates resistant to PZA, among which 96.1% (n = 568) were also MDR. The rate of PZA-R was 43.8% (568/1296) among MDR isolates. The trends of PZA-R fluctuated in accordance with the trends of MDR, INH-R, RIF-R during 2007–2019. Up to 254 kinds of mutations associated with PZA-R were found, with 16.5% (n = 42) isolates harboring ≥ 2 PZA-R associated mutations. Codons 11 (encoding pncA_c.011A > G , n = 30, 11.8%), 76 (encoding pncA_p.Thr76Pro , n = 13, 5.1%), and 139 (encoding pncA_p.Val139Leu , n = 13, 5.1%) were the top three PZA-R associated mutation sites. All PZA-R mutation sites accounting at least 1% were included to analyse the influence of PZA-R on other drug resistance (MDR, INH-R, RIF-R). Finally, three PZA-R related mutations ( pncA_p.Val139Ala, pncA_p.Thr47Ala, pncA_p.Leu85Pro ) were associated with MDR, four were associate with ( pncA_p.Thr76Pro , pncA_p.Val139Ala, pncA_p.Thr47Ala, pncA_p.Leu85Pro) INH-R and none was associated with RIF-R. Conclusion PZA-R especially gene mutation referred to pncA region may promote MDR, this phenomenon mainly associated with the function of PZA-R on INH-R. It is important to consider PZA-R particularly the three associated mutations (pncA region associated mutations) into consideration in treating MDR-TB and explore its mechanism. MDR-TB PZA-R WGS Gene Mutations pncA region Figures Figure 1 Figure 2 Figure 3 Background Tuberculosis (TB) is a complex disease that poses a significant burden, particularly in regions with limited resources, weak healthcare systems, and limited capacity for diagnosis and treatment. In recent years, the emergence of multiple drug resistant (MDR) TB and extensively drug-resistant (XDR) TB significantly restricted the effectiveness of clinical management in treating this disease. MDR-TB, defined as TB that is resistant to rifampicin (RIF) and isoniazid (INH), poses a significant challenge to TB control globally. China has the second-highest burden of MDR-TB worldwide[ 1 ]. Although MDR-TB and XDR-TB can be treated by existing diagnostic techniques and drugs, the prognoses of these patients were more poor with higher cost and mortality compared to drug-susceptible TB[ 2 ]. Pyrazinamide (PZA) was discovered in 1952 and introduced into TB chemotherapy in the early 1950s[ 3 ]. As an important first-line anti-TB drug, the unique bactericidal effect of PZA is crucial for improving the efficacy of TB treatment. By adding PZA in the treatment regimen for MDR-TB patients who were also susceptible to PZA, the treatment duration of these patients shortened from 18–24 months to 12 months[ 4 ]. PZA primarily exerts its antimycobacterial activity through pyrazinoic acid (POA)[ 5 ], effectively targeting semi-dormant mycobacteria that are not easily killed by other anti-TB drugs[ 6 ]. However, the use of PZA in MDR-TB treatment has been hindered by the emergence of PZA resistance (PZA-R)[ 7 ]. PZA-R mutations have been observed in the pncA , rpsA , panD , clpC1 , mas and ppsA-E regions,etc[ 8 – 10 ]. With wide distribution and high diversity, pncA region seems the primary PZA-R associated mutation site[ 11 ]. Moreover, the pncA gene region which encodes pyrazinamidase (PZase) can convert PZA into its active form POA[ 12 ]. Previous study reported 57% PZA-R among MDR-TB cases worldwide[ 7 ] and a PZA-R rate of 43.5% among MDR-TB cases across five regions in China. The emerge of PZA-R indeed impeded the prognosis of MDR-TB, but the influence of PZA-R on the prevention of MDR is still to be explored. There are many methods to identify the drug susceptibility of mycobacterium tuberculosis (MTB). Drug susceptibility testing (DST) is considered the gold standard for identifying drug resistance in MTB. PZA activity is dependent on an acidic pH. When the pH of the culture medium drops below 5.5, the growth of MTB is hindered, making it challenging to assess PZA-R using conventional techniques[ 13 ]. Drug resistance identified by whole-genome sequencing (WGS) was reported an average of 9 days sooner than that detected through traditional culture-based first-line DST, and on average 32 days earlier than the less commonly performed culture-based second-line DST[ 14 ]. Molecular drug susceptibility testing (mDST) a quick DR diagnostic method can get results within 2 hours, but its sensitivity depends on the number of detected drug resistance mutations[ 10 ]. Rapid phenotypic drug susceptibility tests, such as the radiation method BACTEC 460 and the fluorescence method MGIT 960[ 15 ], can provide quicker results for drug susceptibility testing of MTB isolates. However, these methods may not be as accurate as the in vitro synthesized PZase assay. Among these techniques, the PCR-mediated Sanger DNA sequencing molecular method is more commonly utilized[ 16 ]. In recent years, WGS has emerged as a powerful tool that can sequence a large number of DNA fragments simultaneously, allowing for deep sequencing of multiple samples with comprehensive nucleotide coverage and analysis of drug resistance and susceptibility mutations[ 17 , 18 ]. Since PZA-R relative mutations do not have hotspot regions[ 10 , 19 ], the main mechanism of PZA-R was found to be the pncA mutation, accounting for 70–97% of cases[ 20 ]. DNA sequencing of the pncA gene can serve as a rapid method for detecting PZA-R in tuberculosis. WGS is required to identify mutations in the pncA region associated with PZA-R[ 18 , 21 ]. The spectrum of drug resistance mutations, including mutation types and frequencies, may vary across regions[ 22 ]. Previous studies on PZA in China have been limited to specific local areas[ 23 , 24 ]. This research investigated drug resistance of PZA on the level of gene. We further explore the influence of PZA-R associated gene mutations on MDR-TB in China. This research has great potential significance in achieving precision medicine goals for the prevention and treatment of MDR-TB in China. Methods Isolates We collected 1550 culture-confirmed TB cases from Shandong Public Health Clinical Research Center (SPHCC) and Weifang Respiratory Clinical Hospital (WRCH) during 2009–2018. This research passed the examination of the Ethics Committee of Shandong Provincial Hospital, which is affiliated with Shandong First Medical University. Whole-genome sequencing and SNP Identification The genomic DNA of 1468 strains were successfully extracted from 1550 culture-confirmed TB cases in Shandong province, of which 1447 samples passed the quality test (Supplementary Table 1). The Illumina HiSeq 4000 system was used for genome sequencing, and the low quality sequences at the 3' end of the sequencing data were filtered out (the sequencing base quality threshold was set at 20, and the sequencing fragment length threshold was set at 20). The complete genome sequence of MTB H37Rv standard strain (NC_000962.2) was used as the reference sequence, and the sequencing data were aligned to the reference sequence by Bowtie2 software. The SAMtools software was used to identify SNPS in each sample, cut alignments and repeated reads were removed, and samples with coverage less than 98% and depth less than 20 were excluded. In this project, variant calls were done using Freebayes(version 1.3.2) and bcftools(version 1.15.1)[ 25 , 26 ] with a filter index FMT/GT="1/1" &&QUAL > = 100&&FMT /DP > = 10&& (FMT/AO)/(FMT/DP) > = 0. SNPS in existing segments of repetition were excluded, including (the high GC content PPE/PE-PCRS gene family and DR SNPS), repeated sites generated by TRF(version 4.09) and Repeatmask(version 4.1.2). The filtered vcf documents were annotated by snpEff (version 4.3t), and the final SNPs were obtained. A total of 1755 strains from China with publicly available complete genome sequence data were downloaded from the European Nucleic Acid Sequence Database (Supplementary Table 2)[ 27 – 34 ]. The genomes were sampled from 2007–2019. The average sequencing depth > 10 times, genome coverage > 95% and geographic information of strains were used as the criteria for screening data. In total, we obtained the gene sequences of 3202 strains. Drug susceptibility testing We used the TBProfiler (version 2.8.12) and the tuberculosis database (TBDB) to compare resistance-conferring indels and SNPs based on the World Health Organization (WHO)[ 16 ]. We searched drug resistance mutations in both first-line drugs and second-line drugs. The identification of MDR strains was achieved through the assessment of resistance to INH and RIF. The drug resistance information of 3202 strains is shown in Supplementary Table 3. Phylogenetic analysis To understand the genetic results of TB strains in this study, we applied IQ-TREE (version 1.6.12) to build phylogenetic trees by maximum likelihood and generated visualizations through the iTOL( https://itol.embl.de/ ). Statistical Analysis Fisher's exact or Pearson's chi-square tests, as well as logistic regression analysis, were used for correlation analysis. A P value of < 0.05 was defined statistically significant. Those were calculated by SPSS software (version 25.0). Results Characteristics of the isolates By building phylogenetic tree (Fig. 1 ), we found that 3202 strains could be divided into four lineages (L1, L2, L3, L4), most isolates belonged to L2 2745(85.7%), followed by L4 443 (13.8%), L1 and L3 were 14 (0.4%) in total. About 45.6% (n = 1459) strains referred to isoniazid resistance (INH-R), 43.4% (n = 1389) rifampicin resistance (RIF-R), and 40.5% (n = 1296) MDR. There were 591 isolates resistant to PZA, among which 96.1% (n = 568) were also MDR. The rate of PZA-R was 43.8% (568/1296) among MDR isolates. Strains epidemiology and characteristics of genetic mutations The trends of PZA-R seems similar with that of MDR-TB, INH-R, and RIF-R during 2007–2019 (Fig. 2 ). We further analyzed PZA-R related gene sites. The analysis of pncA region showed that there were 254 kinds of mutations, with 42 isolates harboring multiple mutations. The most frequent mutations sites were observed at codons 11 (encoding pncA_c.011A > G , n = 30), 76 (encoding pncA_p.Thr76Pro , n = 13), and 139 (encoding pncA_p.Val139Leu , n = 13) (Table 1 ). For L2, we found that 29 strains bore two mutations, six strains bore three mutations, one strain bore four mutations in pncA region. In L4, we found that five strains bore two mutations, one strains bore three mutations. Table 1 Sites accounting at least 1%. Base Number n = 254(%) pncA_c.011A > G 30(11.8) pncA_p.Thr76Pro 13(5.1) pncA_p.Val139Leu 13(5.1) pncA_p.Thr47Ala 12(4.7) pncA_c.390_391dupGG 11(4.3) pncA_p.Ala146Thr 9(3.5) pncA_p.Asp12Ala 9(3.5) pncA_p.Pro62Leu 9(3.5) pncA_p.Leu85Pro 9(3.5) pncA_p.Gln141* 8(3.1) pncA_p.His51Arg 8(3.1) pncA_p.Val139Ala 8(3.1) pncA_p.Val155Gly 7(2.8) pncA_p.Gln141Pro 7(2.8) pncA_p.Gly132Asp 7(2.8) pncA_p.Lys96Thr 7(2.8) pncA_p.Val139Gly 6(2.4) pncA_p.Thr142Ala 6(2.4) pncA_p.Asp136Gly 6(2.4) pncA_p.Leu85Arg 6(2.4) pncA_p.Gly132Ala 6(2.4) pncA_p.Met175Val 6(2.4) pncA_p.Val9Ala 6(2.4) Relationship between PZA-R with others. In order to clarify the relationship between PZA-R and MDR-TB, INH-R and RIF-R, We further analysed the influence of PZA-R associated gene mutations on MDR-TB, INH-R and RIF-R, the sites with burden of < 0.01 were excluded. 1.The relationship between PZA-R with MDR. MDR strains prone to had higher risk of PZA-R than those non-MDR (COR 63.876, 95% 41.737–97.759). Strains with MDR were more likely to have pncA_p.Val139Ala (aOR7.039, 95%CI 1.532–32.344), pncA_p.Thr47Ala (aOR6.263, 95%CI 1.342–29.236), pncA_p.Leu85Pro (aOR12.014, 95%CI 1.501–96.17) mutation than those with non-MDR (Table 2 ). Table 2 Effect of PZA mutations and resistance on MDR. MDR n = 1296(%) non-MDR n = 1906(%) P COR(95% CI) P aOR(95% CI) Base pncA_c.011A > G 30(2.3) 0 0.998 * - - pncA_p.Thr76Pro 12(0.9) 1(0.1) 0.006 17.804(2.312-137.089) 0.999 * pncA_p.Val139Leu 11(0.8) 2(0.1) 0.006 8.149(1.803–36.827) 0.012 7.039(1.532–32.344) pncA_p.Thr47Ala 10(0.8) 2(0.1) 0.01 7.403(1.619–33.841) 0.02 6.263(1.342–29.236) pncA_c.390_391dupGG 11(0.8) 0 0.999 * - - pncA_p.Ala146Thr 9(0.7) 0 0.999 * - - pncA_p.Asp12Ala 6(0.5) 3(0.2) 0.126 2.95(0.737–11.818) - - pncA_p.Pro62Leu 9(0.7) 0 0.999 * - - pncA_p.Leu85Pro 8(0.6) 1(0.1) 0.02 11.832(1.478–94.717) 0.019 12.014(1.501–96.17) pncA_p.Gln141* 8(0.6) 0 0.999 * - - pncA_p.His51Arg 8(0.6) 0 0.999 * - - pncA_p.Val139Ala 8(0.6) 0 0.999 * - - pncA_p.Val155Gly 7(0.5) 0 0.999 * - - pncA_p.Gln141Pro 7(0.5) 0 0.999 * - - pncA_p.Gly132Asp 7(0.5) 0 0.999 * - - pncA_p.Lys96Thr 7(0.5) 0 0.999 * - - pncA_p.Val139Gly 6(0.5) 0 0.999 * - - pncA_p.Thr142Ala 6(0.5) 0 0.999 * - - pncA_p.Asp136Gly 6(0.5) 0 0.999 * - - pncA_p.Leu85Arg 5(0.4) 1(0.1) 0.068 7.378(0.861–63.225) - - pncA_p.Gly132Ala 6(0.5) 0 0.999 * - - pncA_p.Met175Val 6(0.5) 0 0.999 * - - pncA_p.Val9Ala 6(0.5) 0 0.999 * - - PZA PZA-R 568(43.8) 23(1.2) < 0.001 63.876(41.737–97.759) PZA-S 728(56.2) 1883(98.8) Referent Referent - - *Beyond Number. -no meaning. 2.The relationship between PZA-R with RIF-R. RIF-R strains tended had higher risk of PZA-R (COR331.011, 95%CI 123.387-888.004) than those RIF-susceptible (RIF-S) strains (Table 3 ). We found no significant effect of RIF-R on gene mutations (Table 3 ). Table 3 Effect of PZA mutations and resistance on RIF-R. RIF n = 1389(%) NON-RIF n = 1813(%) P COR (95% CI) Base pncA_c.011A > G 30(2.2) 0 0.998 * pncA_p.Thr76Pro 13(0.9) 0 0.998 * pncA_p.Val139Leu 13(0.9) 0 0.998 * pncA_p.Thr47Ala 12(0.9) 0 0.999 * pncA_c.390_391dupGG 11(0.8) 0 0.999 * pncA_p.Ala146Thr 9(0.6) 0 0.999 * pncA_p.Asp12Ala 9(0.6) 0 0.999 * pncA_p.Pro62Leu 9(0.6) 0 0.999 * pncA_p.Leu85Pro 9(0.6) 0 0.999 * pncA_p.Gln141* 8(0.6) 0 0.999 * pncA_p.His51Arg 8(0.6) 0 0.999 * pncA_p.Val139Ala 8(0.6) 0 0.999 * pncA_p.Val155Gly 7(0.5) 0 0.999 * pncA_p.Gln141Pro 7(0.5) 0 0.999 * pncA_p.Gly132Asp 7(0.5) 0 0.999 * pncA_p.Lys96Thr 7(0.5) 0 0.999 * pncA_p.Val139Gly 6(0.4) 0 0.999 * pncA_p.Thr142Ala 6(0.4) 0 0.999 * pncA_p.Asp136Gly 6(0.4) 0 0.999 * pncA_p.Leu85Arg 5(0.4) 1(0.1) 0.086 6.546(0.764–56.096) pncA_p.Gly132Ala 6(0.4) 0 0.999 * pncA_p.Met175Val 6(0.4) 0 0.999 * pncA_p.Val9Ala 6(0.4) 0 0.999 * PZA PZA-R 587(42.3) 4(0.2) < 0.001 331.011(123.387-888.004) PZA-S 802(57.7) 1809(99.8) Referent Referent *Beyond Number. 3.The relationship between PZA-R with INH-R. INH-R strains were more likely to have PZA-R than those INH-susceptible (INH-S) strains (COR50.013, 95%CI 32.42-77.151) (Table 4 ). Strains with INH-R had significantly higher odds of pncA_p.Thr76Pro compared with those without this (aOR13.494, 95%CI 1.741-104.581). Strains with INH-R were more likely to have pncA_p.Val139Ala than did strains without the resistance (aOR5.654, 95%CI 1.227–26.047). The INH-R increased the pncA_p.Thr47Ala by 5.029 times (aOR5.029, 95%CI 1.074–23.548). Strains which have INH-R tended to carry pncA_p.Leu85Pro (aOR9.78, 95%CI 1.222–78.284) (Table 4 ) . Table 4 Effect of PZA mutations and resistance on INH-R. INH-R n = 1459(%) INH-S n = 1743(%) P COR(95% CI) P aOR(95% CI) Base pncA_c.011A > G 30(2.1) 0 0.998 * - - pncA_p.Thr76Pro 12(0.8) 1(0.1) 0.01 14.446(1.876-111.234) 0.013 13.494(1.741-104.581) pncA_p.Val139Leu 11(0.8) 2(0.1) 0.014 6.613(1.463–29.882) 0.026 5.654(1.227–26.047) pncA_p.Thr47Ala 10(0.7) 2(0.1) 0.021 6.008(1.314–27.462) 0.04 5.029(1.074–23.548) pncA_c.390_391dupGG 11(0.8) 0 0.999 * - - pncA_p.Ala146Thr 9(0.6) 0 0.999 * - - pncA_p.Asp12Ala 6(0.4) 3(0.2) 0.217 2.395(0.598–9.593) - - pncA_p.Pro62Leu 9(0.6) 0 0.999 * - - pncA_p.Leu85Pro 8(0.5) 1(0.1) 0.033 9.604(1.2-76.88) 0.032 9.78(1.222–78.284) pncA_p.Gln141* 8(0.5) 0 0.999 * - - pncA_p.His51Arg 8(0.5) 0 0.999 * - - pncA_p.Val139Ala 8(0.5) 0 0.999 * - - pncA_p.Val155Gly 7(0.5) 0 0.999 * - - pncA_p.Gln141Pro 7(0.5) 0 0.999 * - - pncA_p.Gly132Asp 7(0.5) 0 0.999 * - - pncA_p.Lys96Thr 7(0.5) 0 0.999 * - - pncA_p.Val139Gly 6(0.4) 0 0.999 * - - pncA_p.Thr142Ala 6(0.4) 0 0.999 * - - pncA_p.Asp136Gly 6(0.4) 0 0.999 * - - pncA_p.Leu85Arg 6(0.4) 0 0.999 * - - pncA_p.Gly132Ala 6(0.4) 0 0.999 * - - pncA_p.Met175Val 6(0.4) 0 0.999 * - - pncA_p.Val9Ala 6(0.4) 0 0.999 * - - PZA PZA-R 569(39.0) 22(1.3) < 0.001 50.013(32.42-77.151) - - PZA-S 890(61.0) 1721(98.7) Referent Referent - - *Beyond Number. -no meaning. Three kinds of mutations were found to be higher in MDR than non-MDR. Strains which with INH-R tended to have four kinds of mutations (Fig. 3 ). Discussion This study discussed the drug resustant TB on gene level based on WGS. The results showed that 96.1% of PZA-R isolates were MDR-TB isolates, and the rate of PZA-R was 43.8% among MDR isolates. The trends of PZA-R fluctuated in accordance with the trends of MDR, INH-R, RIF-R during 2007–2019. Further analyse suggested that PZA-R gene mutation may promote MDR, this phenomenon mainly associated with the function of PZA-R on INH-R, particularly with three associated mutations. Among the strains collected, we found 85.7% were classified under L2, and 13.8% under L4. The Mycobacterium tuberculosis complex (MTBC) ancestor, initially identified as a pathogen, evolved into multiple lineages specialized for humans and different mammals. MTB and Mycobacterium africanum are the primary causative agents of human TB. Human-adapted MTBCs display a notable geographic structure, with certain lineages found worldwide while others show distinct geographic limitations. Globally, L2 and L4 are the most prevalent, with L2 being predominant in East Asia. L1 and L3 are primarily found in the region surrounding the Indian Ocean. Conversely, L5 and L6 are highly localized to West Africa. Additionally, L7 is predominantly present in Ethiopia[ 35 , 36 ]. Africa is the continent hosting seven human-adapted MTBC lineages. PZA, a commonly used basic drug in the treatment of MDR-TB, has been shown to reduce the treatment period of MDR-TB[ 37 ]. PZA-R hinders the prevention and treatment of MDR-TB. We found 43.8% of MDR-TB strains were resistant to PZA. The prevalence of PZA-R has been documented in various regions identified by the World Health Organization (WHO) in a 2015 study. Among cases of MDR-TB, the prevalence of PZA-R was 60.5%. Studies from Uzbekistan, Myanmar, Georgia, Sweden, Hunan Province, and Chongqing have reported that the rate of PZA-R among MDR-TB cases ranges from 57.9–73.6%[ 7 , 38 – 42 ]. The situation with PZA-R is not promising, so we should pay more attention to PZA-R. This study found that the number of PZA-R cases varied with the MDR, INH-R and RIF-R strains. MDR, INH-R and RIF-R strains prone to had higher risk of PZA-R. Antibiotics eliminate the susceptible population and allow resistant bacteria to dominate[ 43 ]. Dormant bacteria can remain latent in the body without being easily eliminated, increasing the likelihood of developing drug-resistant strains[ 44 , 45 ]. PZA plays a crucial role in destroying dormant MTB and shortening the treatment period for MDR-TB that is sensitive to PZA [ 44 ]. When PZA-R is present, the treatment cycles for MDR-TB become longer, and patient compliance decreases, thereby accelerating the development of MDR-TB. Therefore, it is recommended to use PZA in the treatment of MDR-TB infection after confirming its sensitivity. Mutations in the pncA gene are various, encompassing amino acid substitutions, nucleotide insertions or deletions from missense and nonsense mutations in both structural and regulatory regions [ 46 , 47 ]. A study conducted in vitro saturation mutagenesis of pncA, screening for drug resistance in a comprehensive library of pncA polymorphisms, identified over 300 resistant substances that could potentially replace PZA. Additionally, PZA-R involves 171 PZase amino acids[ 12 ]. Single nucleotide polymorphisms (SNPs) are found throughout the pncA gene and its flanking regions, without specific hotspot regions. Mutations tend to concentrate in three specific regions 3–17, 61–85, and 132–142, which contain the catalytic site of the PZase[ 48 ]. Our research revealed 254 PZA-R mutations in the pncA region, indicating a wide distribution of mutations. Major mutation types were pncAc.011A > G , pncA_p.Thr76Pro , and pncA_p.Val139Leu. Therefore, understanding PZA-R in tuberculosis strains and the gene mutation spectrum in the pncA region is crucial for the prevention and management of MDR-TB. We discovered that strains with MDR had significantly higher chances of developing three specific mutations compared to those without it. However, we did not observe any significant impact of RIF-R on gene mutations. Strains with INH-R showed a tendency towards having four types of mutations. We can conclude that the promotion of MDR by PZA primarily relies on its effect on INH-R. So, it is important to consider PZA-R and pncA gene mutation spectrum of TB for the prevention and control of MDR-TB, particularly with the three mutations and explore the mechanism. To improve prevention and management of MDR-TB, it is necessary to address barriers to implementing early diagnosis and prompt initiation of effective treatment for drug-resistant tuberculosis. Additionally, controlling risk factors and promptly treating mutated strains are crucial[ 49 , 50 ]. We acknowledge several limitations of this study. The samples used in this study were only from China, which may reduce the generalizability of the findings. Expanding the sampling scope to include more diverse locations would enhance the credibility of the study. While the main findings of the research indicate that PZA-R mutations, particularly in the pncA gene region, may contribute to MDR, this effect is primarily linked to the role of PZA-R in INH-R. we could give no biochemical or transgenic substantiation of the mechanism. Thus, it is crucial to validate our discoveries with additional experimental proof in the foreseeable future. However, our study initially outlined the molecular properties of PZA-R and the correlation between PZA-R and MDR in China, offering valuable insights for the treatment of MDR-TB patients in this area plagued by high rates of MDR-TB. By considering the microbiological characteristics of the infecting bacteria and the clinical characteristics of the patient, personalized treatment can be optimized to reduce the incidence of MDR-TB. Shortening the duration of exposure to untreated MDR-TB can help in lowering the risk of MDR cases. Additionally, efforts to minimize the emergence of MDR and enhance the prevention and management of MDR-TB can lead to improved outcomes. Conclusion We conducted an analysis of the epidemiology and mutational profile of PZA-R, focusing on the relationship between PZA-R and MDR strains in China over the past 13 years. Our study identified that PZA-R and gene mutations in the pncA region contribute to the development of MDR, primarily by promoting INH-R. Considering PZA-R is crucial in the treatment of MDR-TB, especially when three mutations are present. Further research is needed to explore the underlying mechanism. Abbreviations DOTS Directly-Observed Treatment Strategy MDR-TB multiple drug resistant tuberculosis mDST Molecular drug susceptibility testing MTB mycobacterium tuberculosis PZase pyrazinamidase POA pyrazinoic acid SNPs single nucleotide polymorphisms TB tuberculosis WGS whole genome sequencing XDR-TB extensively drug-resistant tuberculosis 2019- nCoV 2020- 2019 novel coronavirus Declarations Acknowledgments We thank all healthcare workers and investigators for their contributions to data collection for this study. Author Contributions YZZ analyzed the data and drafted the manuscript. YFL, YL, XLK, TTW, YML, XHZ, QQA, QLH, WWF and YYL commented and revised the manuscript. NNT and FL conceptualized, designed the study, and acquired funding for the present study. Funding This work was supported by the Natural Science Foundation of Shandong Province (grant number ZR2022QH259). Data availability The newly sequenced whole genome dataset of 1,447 M. tuberculosis strains was deposited in the NCBI Bio Project (access number is PRJNA1002108), and 1755 other isolates were downloaded from the European Nucleotide Archive repository. Any additional data are available from the corresponding authors upon reasonable request. Consent for publication All authors approved publication of the manuscript. Disclosure statement The authors declare that they have no competing financial interests. References Falzon D, Jaramillo E, Schunemann HJ, Arentz M, Bauer M, Bayona J, Blanc L, Caminero JA, Daley CL, Duncombe C, et al. WHO guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update. EUR RESPIR J. 2011;38(3):516–28. Gandhi NR, Nunn P, Dheda K, Schaaf HS, Zignol M, van Soolingen D, Jensen P, Bayona J. Multidrug-resistant and extensively drug-resistant tuberculosis: a threat to global control of tuberculosis. Lancet. 2010;375(9728):1830–43. Njire M, Tan Y, Mugweru J, Wang C, Guo J, Yew W, Tan S, Zhang T. Pyrazinamide resistance in Mycobacterium tuberculosis: Review and update. ADV MED SCI-POLAND. 2016;61(1):63–71. ©. 1996 Nature Publishing Group http://www.nature.com/naturemedicine . PYRAZINAMIDE SUSCEPTIBILITY. AND AMIDASE ACTIVITY OF TUBERCLE BACILLJl. 2. Heifets L, Lindholm-Levy P. Pyrazinamide sterilizing activity in vitro against semidormant Mycobacterium tuberculosis bacterial populations. Am Rev Respir Dis. 1992;145(5):1223. Whitfield MG, Soeters HM, Warren RM, York T, Sampson SL, Streicher EM, van Helden PD, van Rie A. A Global Perspective on Pyrazinamide Resistance: Systematic Review and Meta-Analysis. PLoS ONE. 2015;10(7):e133869. Shi W, Zhang X, Jiang X, Yuan H, Lee JS, Barry CE, Wang H, Zhang W, Zhang Y. Pyrazinamide Inhibits Trans-Translation inMycobacterium tuberculosis. Science. 2011;333(6049):1630–2. Gopal P, Yee M, Sarathy J, Low JL, Sarathy JP, Kaya F, Dartois V, Gengenbacher M, Dick T. Pyrazinamide Resistance Is Caused by Two Distinct Mechanisms: Prevention of Coenzyme A Depletion and Loss of Virulence Factor Synthesis. ACS INFECT DIS. 2016;2(9):616–26. Miotto P, Cabibbe AM, Feuerriegel S, Casali N, Drobniewski F, Rodionova Y, Bakonyte D, Stakenas P, Pimkina E, Augustynowicz-Kopeć E, et al. Mycobacterium tuberculosis pyrazinamide resistance determinants: a multicenter study. MBIO. 2014;5(5):e1814–9. Rajendran A, Palaniyandi K. Mutations Associated with Pyrazinamide Resistance in Mycobacterium tuberculosis: A Review and Update. CURR MICROBIOL. 2022;79(11):348. Ramirez-Busby SM, Valafar F. Systematic Review of Mutations in Pyrazinamidase Associated with Pyrazinamide Resistance in Mycobacterium tuberculosis Clinical Isolates. ANTIMICROB AGENTS CH. 2015;59(9):5267–77. Zhang Y, Zhang H, Sun Z. Susceptibility of Mycobacterium tuberculosis to weak acids. J ANTIMICROB CHEMOTH. 2003;52(1):56–60. Shea J, Halse TA, Lapierre P, Shudt M, Kohlerschmidt D, Van Roey P, Limberger R, Taylor J, Escuyer V, Musser KA, et al. Comprehensive Whole-Genome Sequencing and Reporting of Drug Resistance Profiles on Clinical Cases of Mycobacterium tuberculosis in New York State. J CLIN MICROBIOL. 2017;55(6):1871–82. Zhang Y, Mitchison D. The curious characteristics of pyrazinamide: a review. INT J TUBERC LUNG D. 2003;7(1):6–21. Walker TM, Kohl TA, Omar SV, Hedge J, Del Ojo Elias C, Bradley P, Iqbal Z, Feuerriegel S, Niehaus KE, Wilson DJ, et al. Whole-genome sequencing for prediction of Mycobacterium tuberculosis drug susceptibility and resistance: a retrospective cohort study. Lancet Infect Dis. 2015;15(10):1193–202. Maningi NE, Daum LT, Rodriguez JD, Mphahlele M, Peters RPH, Fischer GW, Chambers JP, Fourie PB, Land GA. Improved Detection by Next-Generation Sequencing of Pyrazinamide Resistance in Mycobacterium tuberculosis Isolates. J CLIN MICROBIOL. 2015;53(12):3779–83. Meehan CJ, Goig GA, Kohl TA, Verboven L, Dippenaar A, Ezewudo M, Farhat MR, Guthrie JL, Laukens K, Miotto P, et al. Whole genome sequencing of Mycobacterium tuberculosis: current standards and open issues. NAT REV MICROBIOL. 2019;17(9):533–45. Ramirez-Busby SM, Valafar F. Systematic review of mutations in pyrazinamidase associated with pyrazinamide resistance in Mycobacterium tuberculosis clinical isolates. ANTIMICROB AGENTS CH. 2015;59(9):5267–77. Hirano K, Takahashi M, Kazumi Y, Fukasawa Y, Abe C. Mutation in pncA is a major mechanism of pyrazinamide resistance in Mycobacterium tuberculosis. Tuber Lung Dis. 1998;78(2):117–22. Maningi NE, Daum LT, Rodriguez JD, Mphahlele M, Peters RPH, Fischer GW, Chambers JP, Fourie PB. Improved Detection by Next-Generation Sequencing of Pyrazinamide Resistance in Mycobacterium tuberculosis Isolates. J CLIN MICROBIOL. 2015;53(12):3779–83. Tan Y, Hu Z, Zhang T, Cai X, Kuang H, Liu Y, Chen J, Yang F, Zhang K, Tan S, et al. Role ofpncA andrpsA Gene Sequencing in Detection of Pyrazinamide Resistance in Mycobacterium tuberculosis Isolates from Southern China. J CLIN MICROBIOL. 2014;52(1):291–7. ACCEPTED MANUSCRIPT. Pang Y, Zhu D, Zheng H, Shen J, Hu Y, Liu J, Zhao Y. Prevalence and molecular characterization of pyrazinamide resistance among multidrug-resistant Mycobacterium tuberculosis isolates from Southern China. BMC INFECT DIS. 2017;17(1):711. Li H, Durbin R. Fast and accurate short read alignment with Burrows–Wheeler transform. Bioinformatics. 2009;25(14):1754–60. Li H, Handsaker B, Wysoker A, Fennell T, Ruan J, Homer N, Marth G, Abecasis G, Durbin R. The Sequence Alignment/Map format and SAMtools. Bioinformatics. 2009;25(16):2078–9. Qingyun Liu AMLW, Beibei WTL, Yang Z, Hong-Xiang Zheng QJMG, Mei L, Chongguang YLJ, Comas I, Sebastien GYZ, Caitlin SPAQ. China’s tuberculosis epidemic stems from historical expansion of four strains of Mycobacterium tuberculosis. NAT ECOL EVOL; 2018. Qi Jiang QLLJ, Jinli L, Yaling Z, Liangguang M, Geyang L, Yang C, Howard ETZY, Weiguo T, Weiye YQG. Citywide transmission of MDR-TB under China’s rapid urbanization a retrospective population-based genomic spatial epidemiological study. CLIN INFECT DIS; 2019. Hicks ND, Yang J, Zhang X, Zhao B, Grad YH, Liu L, Ou X, Chang Z, Xia H, Zhou Y, et al. Clinically prevalent mutations in Mycobacterium tuberculosis alter propionate metabolism and mediate multidrug tolerance. NAT MICROBIOL. 2018;3(9):1032–42. Huang H, Ding N, Yang T, Li C, Jia X, Wang G, Zhong J, Zhang J, Jiang G, Wang S, et al. Cross-sectional Whole-genome Sequencing and Epidemiological Study of Multidrug-resistant Mycobacterium tuberculosis in China. CLIN INFECT DIS. 2019;69(3):405–13. Xinchang Chen GHSW, Siran L, Jiazhen C, And, Zhang W. Evaluation of Whole-Genome Sequence Method to Diagnose Resistance of 13 Anti-tuberculosis Drugs and Characterize Resistance Genes in Clinical Multi-Drug Resistance Mycobacterium tuberculosis Isolates From China. FRONT MICROBIOL 2019. Zhang H, Li D, Zhao L, Fleming J, Lin N, Wang T, Liu Z, Li C, Galwey N, Deng J, et al. Genome sequencing of 161 Mycobacterium tuberculosis isolates from China identifies genes and intergenic regions associated with drug resistance. NAT GENET. 2013;45(10):1255–60. Luo T, Comas I, Luo D, Lu B, Wu J, Wei L, Yang C, Liu Q, Gan M, Sun G, et al. Southern East Asian origin and coexpansion of Mycobacterium tuberculosis Beijing family with Han Chinese. P NATL ACAD SCI USA. 2015;112(26):8136–41. Yang C, Luo T, Shen X, Wu J, Gan M, Xu P, Wu Z, Lin S, Tian J, Liu Q, et al. Transmission of multidrug-resistant Mycobacterium tuberculosis in Shanghai, China: a retrospective observational study using whole-genome sequencing and epidemiological investigation. Lancet Infect Dis. 2017;17(3):275–84. Gagneux S. Ecology and evolution of Mycobacterium tuberculosis. Nat Rev Microbiol. 2018;16(4):202–13. Chen H, He L, Huang H, Shi C, Ni X, Dai G, Ma L, Li W. Mycobacterium tuberculosis Lineage Distribution in Xinjiang and Gansu Provinces, China. SCI REP-UK. 2017;7(1):1068. Sun F, Li Y, Chen Y, Guan W, Jiang X, Wang X, Ren P, Li J, Shi J, He G, et al. Introducing molecular testing of pyrazinamide susceptibility improves multidrug-resistant tuberculosis treatment outcomes: a prospective cohort study. Eur Respir J. 2019;53(3):1801770. Kuhlin J, Smith C, Khaemraev A, Tigay Z, Parpieva N, Tillyashaykhov M, Achar J, Hajek J, Greig J, du Cros P, et al. Impact of pyrazinamide resistance on multidrug-resistant tuberculosis in Karakalpakstan, Uzbekistan. INT J TUBERC LUNG D. 2018;22(5):544–50. Aung WW, Ei PW, Nyunt WW, Htwe MM, Win SM, Aye KT, Mon AS, Aung ST, Chang CL, Lee JS. Pyrazinamide Resistance among Multidrug-Resistant Mycobacterium tuberculosis Clinical Isolates in Myanmar. ANTIMICROB AGENTS CH 2018, 62(3). Sengstake S, Bergval IL, Schuitema AR, de Beer JL, Phelan J, de Zwaan R, Clark TG, van Soolingen D, Anthony RM. Pyrazinamide resistance-conferring mutations in pncA and the transmission of multidrug resistant TB in Georgia. BMC INFECT DIS. 2017;17(1):491. Mansjo M, Werngren J, Hoffner S. Characterization of pyrazinamide resistance in consecutive multidrug-resistant mycobacterium tuberculosis isolates in sweden between 2003 and 2015. INT J MYCOBACT. 2017;6(2):156–61. Pang Y, Zhu D, Zheng H, Shen J, Hu Y, Liu J, Zhao Y. Prevalence and molecular characterization of pyrazinamide resistance among multidrug-resistant Mycobacterium tuberculosis isolates from Southern China. BMC INFECT DIS. 2017;17(1):711. Jose M, Munita CAA. Mechanisms of Antibiotic Resistance. MICROBIOL SPECTR 2016. Zhang Y, Shi W, Zhang W, Mitchison D. Mechanisms of Pyrazinamide Action and Resistance. MICROBIOL SPECTR 2014, 2(4). Mechanisms of resistance to delamani Source Tuberculosis Edinb. 2018 Jan 108 186194. Köser CU, Comas I, Feuerriegel S, Niemann S, Gagneux S, Peacock SJ. Genetic diversity within Mycobacterium tuberculosis complex impacts on the accuracy of genotypic pyrazinamide drug-susceptibility assay. TUBERCULOSIS. 2014;94(4):451–3. Akhmetova A, Kozhamkulov U, Bismilda V, Chingissova L, Abildaev T, Dymova M, Filipenko M, Ramanculov E. Mutations in the pncA and rpsA genes among 77 Mycobacterium tuberculosis isolates in Kazakhstan. INT J TUBERC LUNG D. 2015;19(2):179–84. Lemaitre N, Callebaut I, Frenois F, Jarlier V, Sougakoff W. Study of the structure-activity relationships for the pyrazinamidase (PncA) from Mycobacterium tuberculosis. BIOCHEM J. 2001;353(Pt 3):453–8. Gelmanova IY, Keshavjee S, Golubchikova VT, Berezina VI, Strelis AK, Yanova GV, Atwood S, Murray M. Barriers to successful tuberculosis treatment in Tomsk, Russian Federation: non-adherence, default and the acquisition of multidrug resistance. B WORLD HEALTH ORGAN. 2007;85(9):703–11. Nathavitharana RR, Lederer P, Tierney DB, Nardell E. Treatment as prevention and other interventions to reduce transmission of multidrug-resistant tuberculosis. Int J Tuberc Lung Dis. 2019;23(4):396. Additional Declarations No competing interests reported. Supplementary Files SupplementTable1.xls SupplementTable2.xls SupplementTable3.xls Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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strains.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4061680/v1/f90f368dde06e0189d587d53.jpg"},{"id":53476604,"identity":"2e9cf4b9-be32-48a5-94da-6ee6fe32e171","added_by":"auto","created_at":"2024-03-26 12:45:38","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":148867,"visible":true,"origin":"","legend":"\u003cp\u003eFluctuations of the number of MDR-TB cases and PZA-R, INH-R and RIF-R cases, in 2007-2019.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4061680/v1/3820812c7ae2d30b89273c71.jpg"},{"id":53476601,"identity":"9c6ab0a2-b9ce-44a4-a04f-5e5b1b3dbbec","added_by":"auto","created_at":"2024-03-26 12:45:38","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":102431,"visible":true,"origin":"","legend":"\u003cp\u003eMutations related to INH-R and MDR.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4061680/v1/5880ef4c716c9a02cf8d99e6.jpg"},{"id":88736055,"identity":"84126c5a-e8e8-44aa-b2f5-5e316890e8c7","added_by":"auto","created_at":"2025-08-10 23:01:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1944767,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4061680/v1/26b52af1-e296-4daa-8976-d58fee4c2dc3.pdf"},{"id":53476597,"identity":"08050c3c-269e-4db2-8681-ef3410e02f73","added_by":"auto","created_at":"2024-03-26 12:45:37","extension":"xls","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":288768,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementTable1.xls","url":"https://assets-eu.researchsquare.com/files/rs-4061680/v1/6456a8819f069399b792aafc.xls"},{"id":53476599,"identity":"3ecdb7c5-5573-4fbb-85e4-fd49e55094b7","added_by":"auto","created_at":"2024-03-26 12:45:38","extension":"xls","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":367104,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementTable2.xls","url":"https://assets-eu.researchsquare.com/files/rs-4061680/v1/39ec46a3c5d322543cc91e5c.xls"},{"id":53476600,"identity":"7b352517-2ccd-407e-90ef-927ca7e5d950","added_by":"auto","created_at":"2024-03-26 12:45:38","extension":"xls","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":1191424,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementTable3.xls","url":"https://assets-eu.researchsquare.com/files/rs-4061680/v1/f6ab28239ef80ea27314a926.xls"}],"financialInterests":"No competing interests reported.","formattedTitle":"The influence of pyrazinamide resistant associated gene mutations on multidrug-resistant mycobacterium tuberculosis in China","fulltext":[{"header":"Background","content":"\u003cp\u003eTuberculosis (TB) is a complex disease that poses a significant burden, particularly in regions with limited resources, weak healthcare systems, and limited capacity for diagnosis and treatment. In recent years, the emergence of multiple drug resistant (MDR) TB and extensively drug-resistant (XDR) TB significantly restricted the effectiveness of clinical management in treating this disease. MDR-TB, defined as TB that is resistant to rifampicin (RIF) and isoniazid (INH), poses a significant challenge to TB control globally. China has the second-highest burden of MDR-TB worldwide[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although MDR-TB and XDR-TB can be treated by existing diagnostic techniques and drugs, the prognoses of these patients were more poor with higher cost and mortality compared to drug-susceptible TB[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePyrazinamide (PZA) was discovered in 1952 and introduced into TB chemotherapy in the early 1950s[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. As an important first-line anti-TB drug, the unique bactericidal effect of PZA is crucial for improving the efficacy of TB treatment. By adding PZA in the treatment regimen for MDR-TB patients who were also susceptible to PZA, the treatment duration of these patients shortened from 18\u0026ndash;24 months to 12 months[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. PZA primarily exerts its antimycobacterial activity through pyrazinoic acid (POA)[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], effectively targeting semi-dormant mycobacteria that are not easily killed by other anti-TB drugs[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, the use of PZA in MDR-TB treatment has been hindered by the emergence of PZA resistance (PZA-R)[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. PZA-R mutations have been observed in the \u003cem\u003epncA\u003c/em\u003e, \u003cem\u003erpsA\u003c/em\u003e, \u003cem\u003epanD\u003c/em\u003e, \u003cem\u003eclpC1\u003c/em\u003e, \u003cem\u003emas\u003c/em\u003e and \u003cem\u003eppsA-E\u003c/em\u003e regions,etc[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. With wide distribution and high diversity, pncA region seems the primary PZA-R associated mutation site[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Moreover, the pncA gene region which encodes pyrazinamidase (PZase) can convert PZA into its active form POA[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Previous study reported 57% PZA-R among MDR-TB cases worldwide[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and a PZA-R rate of 43.5% among MDR-TB cases across five regions in China. The emerge of PZA-R indeed impeded the prognosis of MDR-TB, but the influence of PZA-R on the prevention of MDR is still to be explored.\u003c/p\u003e \u003cp\u003eThere are many methods to identify the drug susceptibility of mycobacterium tuberculosis (MTB). Drug susceptibility testing (DST) is considered the gold standard for identifying drug resistance in MTB. PZA activity is dependent on an acidic pH. When the pH of the culture medium drops below 5.5, the growth of MTB is hindered, making it challenging to assess PZA-R using conventional techniques[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Drug resistance identified by whole-genome sequencing (WGS) was reported an average of 9 days sooner than that detected through traditional culture-based first-line DST, and on average 32 days earlier than the less commonly performed culture-based second-line DST[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Molecular drug susceptibility testing (mDST) a quick DR diagnostic method can get results within 2 hours, but its sensitivity depends on the number of detected drug resistance mutations[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Rapid phenotypic drug susceptibility tests, such as the radiation method BACTEC 460 and the fluorescence method MGIT 960[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], can provide quicker results for drug susceptibility testing of MTB isolates. However, these methods may not be as accurate as the in vitro synthesized PZase assay. Among these techniques, the PCR-mediated Sanger DNA sequencing molecular method is more commonly utilized[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In recent years, WGS has emerged as a powerful tool that can sequence a large number of DNA fragments simultaneously, allowing for deep sequencing of multiple samples with comprehensive nucleotide coverage and analysis of drug resistance and susceptibility mutations[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Since PZA-R relative mutations do not have hotspot regions[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], the main mechanism of PZA-R was found to be the pncA mutation, accounting for 70\u0026ndash;97% of cases[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. DNA sequencing of the pncA gene can serve as a rapid method for detecting PZA-R in tuberculosis. WGS is required to identify mutations in the pncA region associated with PZA-R[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe spectrum of drug resistance mutations, including mutation types and frequencies, may vary across regions[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Previous studies on PZA in China have been limited to specific local areas[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This research investigated drug resistance of PZA on the level of gene. We further explore the influence of PZA-R associated gene mutations on MDR-TB in China. This research has great potential significance in achieving precision medicine goals for the prevention and treatment of MDR-TB in China.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eIsolates\u003c/h2\u003e \u003cp\u003eWe collected 1550 culture-confirmed TB cases from Shandong Public Health Clinical Research Center (SPHCC) and Weifang Respiratory Clinical Hospital (WRCH) during 2009\u0026ndash;2018. This research passed the examination of the Ethics Committee of Shandong Provincial Hospital, which is affiliated with Shandong\u003c/p\u003e \u003cp\u003eFirst Medical University.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eWhole-genome sequencing and SNP Identification\u003c/h2\u003e \u003cp\u003eThe genomic DNA of 1468 strains were successfully extracted from 1550 culture-confirmed TB cases in Shandong province, of which 1447 samples passed the quality test (Supplementary Table\u0026nbsp;1). The Illumina HiSeq 4000 system was used for genome sequencing, and the low quality sequences at the 3' end of the sequencing data were filtered out (the sequencing base quality threshold was set at 20, and the sequencing fragment length threshold was set at 20). The complete genome sequence of MTB H37Rv standard strain (NC_000962.2) was used as the reference sequence, and the sequencing data were aligned to the reference sequence by Bowtie2 software. The SAMtools software was used to identify SNPS in each sample, cut alignments and repeated reads were removed, and samples with coverage less than 98% and depth less than 20 were excluded. In this project, variant calls were done using Freebayes(version 1.3.2) and bcftools(version 1.15.1)[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] with a filter index FMT/GT=\"1/1\" \u0026amp;\u0026amp;QUAL\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;100\u0026amp;\u0026amp;FMT /DP\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;10\u0026amp;\u0026amp; (FMT/AO)/(FMT/DP)\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;0. SNPS in existing segments of repetition were excluded, including (the high GC content PPE/PE-PCRS gene family and DR SNPS), repeated sites generated by TRF(version 4.09) and Repeatmask(version 4.1.2). The filtered vcf documents were annotated by snpEff (version 4.3t), and the final SNPs were obtained. A total of 1755 strains from China with publicly available complete genome sequence data were downloaded from the European Nucleic Acid Sequence Database (Supplementary Table\u0026nbsp;2)[\u003cspan additionalcitationids=\"CR28 CR29 CR30 CR31 CR32 CR33\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The genomes were sampled from 2007\u0026ndash;2019. The average sequencing depth\u0026thinsp;\u0026gt;\u0026thinsp;10 times, genome coverage\u0026thinsp;\u0026gt;\u0026thinsp;95% and geographic information of strains were used as the criteria for screening data. In total, we obtained the gene sequences of 3202 strains.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eDrug susceptibility testing\u003c/h2\u003e \u003cp\u003eWe used the TBProfiler (version 2.8.12) and the tuberculosis database (TBDB) to compare resistance-conferring indels and SNPs based on the World Health Organization (WHO)[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. We searched drug resistance mutations in both first-line drugs and second-line drugs. The identification of MDR strains was achieved through the assessment of resistance to INH and RIF. The drug resistance information of 3202 strains is shown in Supplementary Table\u0026nbsp;3.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ePhylogenetic analysis\u003c/h2\u003e \u003cp\u003eTo understand the genetic results of TB strains in this study, we applied IQ-TREE (version 1.6.12) to build phylogenetic trees by maximum likelihood and generated visualizations through the iTOL(\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://itol.embl.de/\u003c/span\u003e\u003cspan address=\"https://itol.embl.de/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eFisher's exact or Pearson's chi-square tests, as well as logistic regression analysis, were used for correlation analysis. A P value of \u0026lt;\u0026thinsp;0.05 was defined statistically significant. Those were calculated by SPSS software (version 25.0).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of the isolates\u003c/h2\u003e \u003cp\u003eBy building phylogenetic tree (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), we found that 3202 strains could be divided into four lineages (L1, L2, L3, L4), most isolates belonged to L2 2745(85.7%), followed by L4 443 (13.8%), L1 and L3 were 14 (0.4%) in total. About 45.6% (n\u0026thinsp;=\u0026thinsp;1459) strains referred to isoniazid resistance (INH-R), 43.4% (n\u0026thinsp;=\u0026thinsp;1389) rifampicin resistance (RIF-R), and 40.5% (n\u0026thinsp;=\u0026thinsp;1296) MDR. There were 591 isolates resistant to PZA, among which 96.1% (n\u0026thinsp;=\u0026thinsp;568) were also MDR. The rate of PZA-R was 43.8% (568/1296) among MDR isolates.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStrains epidemiology and characteristics of genetic mutations\u003c/h2\u003e \u003cp\u003eThe trends of PZA-R seems similar with that of MDR-TB, INH-R, and RIF-R during 2007\u0026ndash;2019 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). We further analyzed PZA-R related gene sites. The analysis of pncA region showed that there were 254 kinds of mutations, with 42 isolates harboring multiple mutations. The most frequent mutations sites were observed at codons 11 (encoding \u003cem\u003epncA_c.011A\u0026thinsp;\u0026gt;\u0026thinsp;G\u003c/em\u003e, n\u0026thinsp;=\u0026thinsp;30), 76 (encoding \u003cem\u003epncA_p.Thr76Pro\u003c/em\u003e, n\u0026thinsp;=\u0026thinsp;13), and 139 (encoding \u003cem\u003epncA_p.Val139Leu\u003c/em\u003e, n\u0026thinsp;=\u0026thinsp;13) (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). For L2, we found that 29 strains bore two mutations, six strains bore three mutations, one strain bore four mutations in pncA region. In L4, we found that five strains bore two mutations, one strains bore three mutations.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSites accounting at least 1%.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber n\u0026thinsp;=\u0026thinsp;254(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_c.011A\u0026thinsp;\u0026gt;\u0026thinsp;G\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30(11.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Thr76Pro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13(5.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Val139Leu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13(5.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Thr47Ala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12(4.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_c.390_391dupGG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11(4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Ala146Thr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9(3.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Asp12Ala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9(3.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Pro62Leu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9(3.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Leu85Pro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9(3.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Gln141*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8(3.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.His51Arg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8(3.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Val139Ala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8(3.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Val155Gly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7(2.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Gln141Pro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7(2.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Gly132Asp\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7(2.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Lys96Thr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7(2.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Val139Gly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Thr142Ala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Asp136Gly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Leu85Arg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Gly132Ala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Met175Val\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Val9Ala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eRelationship between PZA-R with others.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn order to clarify the relationship between PZA-R and MDR-TB, INH-R and RIF-R, We further analysed the influence of PZA-R associated gene mutations on MDR-TB, INH-R and RIF-R, the sites with burden of \u0026lt;\u0026thinsp;0.01 were excluded.\u003c/p\u003e \u003cp\u003e \u003cb\u003e1.The relationship between PZA-R with MDR.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eMDR strains prone to had higher risk of PZA-R than those non-MDR (COR 63.876, 95% 41.737\u0026ndash;97.759). Strains with MDR were more likely to have \u003cem\u003epncA_p.Val139Ala\u003c/em\u003e (aOR7.039, 95%CI 1.532\u0026ndash;32.344), \u003cem\u003epncA_p.Thr47Ala\u003c/em\u003e (aOR6.263, 95%CI 1.342\u0026ndash;29.236), \u003cem\u003epncA_p.Leu85Pro\u003c/em\u003e (aOR12.014, 95%CI 1.501\u0026ndash;96.17) mutation than those with non-MDR (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEffect of PZA mutations and resistance on MDR.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMDR n\u0026thinsp;=\u0026thinsp;1296(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003enon-MDR n\u0026thinsp;=\u0026thinsp;1906(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCOR(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eaOR(95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_c.011A\u0026thinsp;\u0026gt;\u0026thinsp;G\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30(2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.998\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Thr76Pro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12(0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.804(2.312-137.089)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Val139Leu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11(0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.149(1.803\u0026ndash;36.827)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.039(1.532\u0026ndash;32.344)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Thr47Ala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10(0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.403(1.619\u0026ndash;33.841)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.263(1.342\u0026ndash;29.236)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_c.390_391dupGG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11(0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Ala146Thr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9(0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Asp12Ala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.95(0.737\u0026ndash;11.818)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Pro62Leu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9(0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Leu85Pro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8(0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.832(1.478\u0026ndash;94.717)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12.014(1.501\u0026ndash;96.17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Gln141*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8(0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.His51Arg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8(0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Val139Ala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8(0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Val155Gly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7(0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Gln141Pro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7(0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Gly132Asp\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7(0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Lys96Thr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7(0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Val139Gly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Thr142Ala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Asp136Gly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Leu85Arg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5(0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.378(0.861\u0026ndash;63.225)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Gly132Ala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Met175Val\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Val9Ala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePZA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePZA-R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e568(43.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23(1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63.876(41.737\u0026ndash;97.759)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePZA-S\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e728(56.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1883(98.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReferent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReferent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Beyond Number.\u003c/p\u003e \u003cp\u003e-no meaning.\u003c/p\u003e \u003cp\u003e \u003cb\u003e2.The relationship between PZA-R with RIF-R.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eRIF-R strains tended had higher risk of PZA-R (COR331.011, 95%CI 123.387-888.004) than those RIF-susceptible (RIF-S) strains (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). We found no significant effect of RIF-R on gene mutations (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEffect of PZA mutations and resistance on RIF-R.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRIF n\u0026thinsp;=\u0026thinsp;1389(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNON-RIF n\u0026thinsp;=\u0026thinsp;1813(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_c.011A\u0026thinsp;\u0026gt;\u0026thinsp;G\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30(2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.998\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Thr76Pro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13(0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.998\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Val139Leu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13(0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.998\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Thr47Ala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12(0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_c.390_391dupGG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11(0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Ala146Thr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9(0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Asp12Ala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9(0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Pro62Leu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9(0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Leu85Pro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9(0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Gln141*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8(0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.His51Arg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8(0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Val139Ala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8(0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Val155Gly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7(0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Gln141Pro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7(0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Gly132Asp\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7(0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Lys96Thr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7(0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Val139Gly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Thr142Ala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Asp136Gly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Leu85Arg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5(0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.086\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.546(0.764\u0026ndash;56.096)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Gly132Ala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Met175Val\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Val9Ala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePZA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePZA-R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e587(42.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e331.011(123.387-888.004)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePZA-S\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e802(57.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1809(99.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReferent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReferent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Beyond Number.\u003c/p\u003e \u003cp\u003e \u003cb\u003e3.The relationship between PZA-R with INH-R.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eINH-R strains were more likely to have PZA-R than those INH-susceptible (INH-S) strains (COR50.013, 95%CI 32.42-77.151) (Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Strains with INH-R had significantly higher odds of \u003cem\u003epncA_p.Thr76Pro\u003c/em\u003e compared with those without this (aOR13.494, 95%CI 1.741-104.581). Strains with INH-R were more likely to have \u003cem\u003epncA_p.Val139Ala\u003c/em\u003e than did strains without the resistance (aOR5.654, 95%CI 1.227\u0026ndash;26.047). The INH-R increased the \u003cem\u003epncA_p.Thr47Ala\u003c/em\u003e by 5.029 times (aOR5.029, 95%CI 1.074\u0026ndash;23.548). Strains which have INH-R tended to carry \u003cem\u003epncA_p.Leu85Pro\u003c/em\u003e (aOR9.78, 95%CI 1.222\u0026ndash;78.284) (Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) .\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEffect of PZA mutations and resistance on INH-R.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eINH-R n\u0026thinsp;=\u0026thinsp;1459(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eINH-S n\u0026thinsp;=\u0026thinsp;1743(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCOR(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eaOR(95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_c.011A\u0026thinsp;\u0026gt;\u0026thinsp;G\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30(2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.998\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Thr76Pro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12(0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.446(1.876-111.234)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003ctd 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colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Ala146Thr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9(0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e 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\u003cp\u003e6(0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Asp136Gly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Leu85Arg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Gly132Ala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Met175Val\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epncA_p.Val9Ala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePZA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePZA-R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e569(39.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22(1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.013(32.42-77.151)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePZA-S\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e890(61.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1721(98.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReferent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReferent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Beyond Number.\u003c/p\u003e \u003cp\u003e-no meaning.\u003c/p\u003e \u003cp\u003eThree kinds of mutations were found to be higher in MDR than non-MDR. Strains which with INH-R tended to have four kinds of mutations (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study discussed the drug resustant TB on gene level based on WGS. The results showed that 96.1% of PZA-R isolates were MDR-TB isolates, and the rate of PZA-R was 43.8% among MDR isolates. The trends of PZA-R fluctuated in accordance with the trends of MDR, INH-R, RIF-R during 2007\u0026ndash;2019. Further analyse suggested that PZA-R gene mutation may promote MDR, this phenomenon mainly associated with the function of PZA-R on INH-R, particularly with three associated mutations.\u003c/p\u003e \u003cp\u003eAmong the strains collected, we found 85.7% were classified under L2, and 13.8% under L4. The Mycobacterium tuberculosis complex (MTBC) ancestor, initially identified as a pathogen, evolved into multiple lineages specialized for humans and different mammals. MTB and Mycobacterium africanum are the primary causative agents of human TB. Human-adapted MTBCs display a notable geographic structure, with certain lineages found worldwide while others show distinct geographic limitations. Globally, L2 and L4 are the most prevalent, with L2 being predominant in East Asia. L1 and L3 are primarily found in the region surrounding the Indian Ocean. Conversely, L5 and L6 are highly localized to West Africa. Additionally, L7 is predominantly present in Ethiopia[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Africa is the continent hosting seven human-adapted MTBC lineages.\u003c/p\u003e \u003cp\u003ePZA, a commonly used basic drug in the treatment of MDR-TB, has been shown to reduce the treatment period of MDR-TB[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. PZA-R hinders the prevention and treatment of MDR-TB. We found 43.8% of MDR-TB strains were resistant to PZA. The prevalence of PZA-R has been documented in various regions identified by the World Health Organization (WHO) in a 2015 study. Among cases of MDR-TB, the prevalence of PZA-R was 60.5%. Studies from Uzbekistan, Myanmar, Georgia, Sweden, Hunan Province, and Chongqing have reported that the rate of PZA-R among MDR-TB cases ranges from 57.9\u0026ndash;73.6%[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR39 CR40 CR41\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The situation with PZA-R is not promising, so we should pay more attention to PZA-R.\u003c/p\u003e \u003cp\u003eThis study found that the number of PZA-R cases varied with the MDR, INH-R and RIF-R strains. MDR, INH-R and RIF-R strains prone to had higher risk of PZA-R. Antibiotics eliminate the susceptible population and allow resistant bacteria to dominate[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Dormant bacteria can remain latent in the body without being easily eliminated, increasing the likelihood of developing drug-resistant strains[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. PZA plays a crucial role in destroying dormant MTB and shortening the treatment period for MDR-TB that is sensitive to PZA [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. When PZA-R is present, the treatment cycles for MDR-TB become longer, and patient compliance decreases, thereby accelerating the development of MDR-TB. Therefore, it is recommended to use PZA in the treatment of MDR-TB infection after confirming its sensitivity.\u003c/p\u003e \u003cp\u003eMutations in the pncA gene are various, encompassing amino acid substitutions, nucleotide insertions or deletions from missense and nonsense mutations in both structural and regulatory regions [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. A study conducted in vitro saturation mutagenesis of pncA, screening for drug resistance in a comprehensive library of pncA polymorphisms, identified over 300 resistant substances that could potentially replace PZA. Additionally, PZA-R involves 171 PZase amino acids[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Single nucleotide polymorphisms (SNPs) are found throughout the pncA gene and its flanking regions, without specific hotspot regions. Mutations tend to concentrate in three specific regions 3\u0026ndash;17, 61\u0026ndash;85, and 132\u0026ndash;142, which contain the catalytic site of the PZase[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Our research revealed 254 PZA-R mutations in the pncA region, indicating a wide distribution of mutations. Major mutation types were \u003cem\u003epncAc.011A\u0026thinsp;\u0026gt;\u0026thinsp;G\u003c/em\u003e, \u003cem\u003epncA_p.Thr76Pro\u003c/em\u003e, and \u003cem\u003epncA_p.Val139Leu.\u003c/em\u003e Therefore, understanding PZA-R in tuberculosis strains and the gene mutation spectrum in the pncA region is crucial for the prevention and management of MDR-TB.\u003c/p\u003e \u003cp\u003eWe discovered that strains with MDR had significantly higher chances of developing three specific mutations compared to those without it. However, we did not observe any significant impact of RIF-R on gene mutations. Strains with INH-R showed a tendency towards having four types of mutations. We can conclude that the promotion of MDR by PZA primarily relies on its effect on INH-R. So, it is important to consider PZA-R and pncA gene mutation spectrum of TB for the prevention and control of MDR-TB, particularly with the three mutations and explore the mechanism. To improve prevention and management of MDR-TB, it is necessary to address barriers to implementing early diagnosis and prompt initiation of effective treatment for drug-resistant tuberculosis. Additionally, controlling risk factors and promptly treating mutated strains are crucial[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe acknowledge several limitations of this study. The samples used in this study were only from China, which may reduce the generalizability of the findings. Expanding the sampling scope to include more diverse locations would enhance the credibility of the study. While the main findings of the research indicate that PZA-R mutations, particularly in the pncA gene region, may contribute to MDR, this effect is primarily linked to the role of PZA-R in INH-R. we could give no biochemical or transgenic substantiation of the mechanism. Thus, it is crucial to validate our discoveries with additional experimental proof in the foreseeable future. However, our study initially outlined the molecular properties of PZA-R and the correlation between PZA-R and MDR in China, offering valuable insights for the treatment of MDR-TB patients in this area plagued by high rates of MDR-TB. By considering the microbiological characteristics of the infecting bacteria and the clinical characteristics of the patient, personalized treatment can be optimized to reduce the incidence of MDR-TB. Shortening the duration of exposure to untreated MDR-TB can help in lowering the risk of MDR cases. Additionally, efforts to minimize the emergence of MDR and enhance the prevention and management of MDR-TB can lead to improved outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe conducted an analysis of the epidemiology and mutational profile of PZA-R, focusing on the relationship between PZA-R and MDR strains in China over the past 13 years. Our study identified that PZA-R and gene mutations in the pncA region contribute to the development of MDR, primarily by promoting INH-R. Considering PZA-R is crucial in the treatment of MDR-TB, especially when three mutations are present. Further research is needed to explore the underlying mechanism.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDOTS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDirectly-Observed Treatment Strategy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMDR-TB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emultiple drug resistant tuberculosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003emDST\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMolecular drug susceptibility testing\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMTB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emycobacterium tuberculosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePZase\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epyrazinamidase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePOA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epyrazinoic acid\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSNPs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esingle nucleotide polymorphisms\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etuberculosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWGS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ewhole genome sequencing\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eXDR-TB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eextensively drug-resistant tuberculosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e2019- nCoV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e2020- 2019 novel coronavirus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all healthcare workers and investigators for their contributions to data collection for this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYZZ analyzed the data and drafted the manuscript. YFL, YL, XLK, TTW, YML, XHZ, QQA, QLH, WWF and YYL commented and revised the manuscript. NNT and FL conceptualized, designed the study, and acquired funding for the present study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Natural Science Foundation of Shandong Province (grant number ZR2022QH259).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe newly sequenced whole genome dataset of 1,447 M. tuberculosis strains was deposited in the NCBI Bio Project (access number is PRJNA1002108), and 1755 other isolates were downloaded from the European Nucleotide Archive repository. Any additional data are available from the corresponding authors upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors approved publication of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure statement\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing financial interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFalzon D, Jaramillo E, Schunemann HJ, Arentz M, Bauer M, Bayona J, Blanc L, Caminero JA, Daley CL, Duncombe C, et al. WHO guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update. EUR RESPIR J. 2011;38(3):516\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGandhi NR, Nunn P, Dheda K, Schaaf HS, Zignol M, van Soolingen D, Jensen P, Bayona J. Multidrug-resistant and extensively drug-resistant tuberculosis: a threat to global control of tuberculosis. Lancet. 2010;375(9728):1830\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNjire M, Tan Y, Mugweru J, Wang C, Guo J, Yew W, Tan S, Zhang T. Pyrazinamide resistance in Mycobacterium tuberculosis: Review and update. ADV MED SCI-POLAND. 2016;61(1):63\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026copy;. 1996 Nature Publishing Group \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.nature.com/naturemedicine\u003c/span\u003e\u003cspan address=\"http://www.nature.com/naturemedicine\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePYRAZINAMIDE SUSCEPTIBILITY. AND AMIDASE ACTIVITY OF TUBERCLE BACILLJl. 2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeifets L, Lindholm-Levy P. Pyrazinamide sterilizing activity in vitro against semidormant Mycobacterium tuberculosis bacterial populations. Am Rev Respir Dis. 1992;145(5):1223.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhitfield MG, Soeters HM, Warren RM, York T, Sampson SL, Streicher EM, van Helden PD, van Rie A. A Global Perspective on Pyrazinamide Resistance: Systematic Review and Meta-Analysis. PLoS ONE. 2015;10(7):e133869.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShi W, Zhang X, Jiang X, Yuan H, Lee JS, Barry CE, Wang H, Zhang W, Zhang Y. Pyrazinamide Inhibits Trans-Translation inMycobacterium tuberculosis. Science. 2011;333(6049):1630\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGopal P, Yee M, Sarathy J, Low JL, Sarathy JP, Kaya F, Dartois V, Gengenbacher M, Dick T. Pyrazinamide Resistance Is Caused by Two Distinct Mechanisms: Prevention of Coenzyme A Depletion and Loss of Virulence Factor Synthesis. ACS INFECT DIS. 2016;2(9):616\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiotto P, Cabibbe AM, Feuerriegel S, Casali N, Drobniewski F, Rodionova Y, Bakonyte D, Stakenas P, Pimkina E, Augustynowicz-Kopeć E, et al. Mycobacterium tuberculosis pyrazinamide resistance determinants: a multicenter study. MBIO. 2014;5(5):e1814\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajendran A, Palaniyandi K. Mutations Associated with Pyrazinamide Resistance in Mycobacterium tuberculosis: A Review and Update. CURR MICROBIOL. 2022;79(11):348.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamirez-Busby SM, Valafar F. Systematic Review of Mutations in Pyrazinamidase Associated with Pyrazinamide Resistance in Mycobacterium tuberculosis Clinical Isolates. ANTIMICROB AGENTS CH. 2015;59(9):5267\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang Y, Zhang H, Sun Z. Susceptibility of Mycobacterium tuberculosis to weak acids. J ANTIMICROB CHEMOTH. 2003;52(1):56\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShea J, Halse TA, Lapierre P, Shudt M, Kohlerschmidt D, Van Roey P, Limberger R, Taylor J, Escuyer V, Musser KA, et al. Comprehensive Whole-Genome Sequencing and Reporting of Drug Resistance Profiles on Clinical Cases of Mycobacterium tuberculosis in New York State. J CLIN MICROBIOL. 2017;55(6):1871\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang Y, Mitchison D. The curious characteristics of pyrazinamide: a review. INT J TUBERC LUNG D. 2003;7(1):6\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalker TM, Kohl TA, Omar SV, Hedge J, Del Ojo Elias C, Bradley P, Iqbal Z, Feuerriegel S, Niehaus KE, Wilson DJ, et al. Whole-genome sequencing for prediction of Mycobacterium tuberculosis drug susceptibility and resistance: a retrospective cohort study. Lancet Infect Dis. 2015;15(10):1193\u0026ndash;202.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManingi NE, Daum LT, Rodriguez JD, Mphahlele M, Peters RPH, Fischer GW, Chambers JP, Fourie PB, Land GA. Improved Detection by Next-Generation Sequencing of Pyrazinamide Resistance in Mycobacterium tuberculosis Isolates. J CLIN MICROBIOL. 2015;53(12):3779\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeehan CJ, Goig GA, Kohl TA, Verboven L, Dippenaar A, Ezewudo M, Farhat MR, Guthrie JL, Laukens K, Miotto P, et al. Whole genome sequencing of Mycobacterium tuberculosis: current standards and open issues. NAT REV MICROBIOL. 2019;17(9):533\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamirez-Busby SM, Valafar F. Systematic review of mutations in pyrazinamidase associated with pyrazinamide resistance in Mycobacterium tuberculosis clinical isolates. ANTIMICROB AGENTS CH. 2015;59(9):5267\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHirano K, Takahashi M, Kazumi Y, Fukasawa Y, Abe C. Mutation in pncA is a major mechanism of pyrazinamide resistance in Mycobacterium tuberculosis. Tuber Lung Dis. 1998;78(2):117\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManingi NE, Daum LT, Rodriguez JD, Mphahlele M, Peters RPH, Fischer GW, Chambers JP, Fourie PB. Improved Detection by Next-Generation Sequencing of Pyrazinamide Resistance in Mycobacterium tuberculosis Isolates. J CLIN MICROBIOL. 2015;53(12):3779\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTan Y, Hu Z, Zhang T, Cai X, Kuang H, Liu Y, Chen J, Yang F, Zhang K, Tan S, et al. Role ofpncA andrpsA Gene Sequencing in Detection of Pyrazinamide Resistance in Mycobacterium tuberculosis Isolates from Southern China. J CLIN MICROBIOL. 2014;52(1):291\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eACCEPTED MANUSCRIPT.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePang Y, Zhu D, Zheng H, Shen J, Hu Y, Liu J, Zhao Y. Prevalence and molecular characterization of pyrazinamide resistance among multidrug-resistant Mycobacterium tuberculosis isolates from Southern China. BMC INFECT DIS. 2017;17(1):711.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi H, Durbin R. Fast and accurate short read alignment with Burrows\u0026ndash;Wheeler transform. Bioinformatics. 2009;25(14):1754\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi H, Handsaker B, Wysoker A, Fennell T, Ruan J, Homer N, Marth G, Abecasis G, Durbin R. The Sequence Alignment/Map format and SAMtools. Bioinformatics. 2009;25(16):2078\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQingyun Liu AMLW, Beibei WTL, Yang Z, Hong-Xiang Zheng QJMG, Mei L, Chongguang YLJ, Comas I, Sebastien GYZ, Caitlin SPAQ. China\u0026rsquo;s tuberculosis epidemic stems from historical expansion of four strains of Mycobacterium tuberculosis. NAT ECOL EVOL; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQi Jiang QLLJ, Jinli L, Yaling Z, Liangguang M, Geyang L, Yang C, Howard ETZY, Weiguo T, Weiye YQG. Citywide transmission of MDR-TB under China\u0026rsquo;s rapid urbanization a retrospective population-based genomic spatial epidemiological study. CLIN INFECT DIS; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHicks ND, Yang J, Zhang X, Zhao B, Grad YH, Liu L, Ou X, Chang Z, Xia H, Zhou Y, et al. Clinically prevalent mutations in Mycobacterium tuberculosis alter propionate metabolism and mediate multidrug tolerance. NAT MICROBIOL. 2018;3(9):1032\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang H, Ding N, Yang T, Li C, Jia X, Wang G, Zhong J, Zhang J, Jiang G, Wang S, et al. Cross-sectional Whole-genome Sequencing and Epidemiological Study of Multidrug-resistant Mycobacterium tuberculosis in China. CLIN INFECT DIS. 2019;69(3):405\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXinchang Chen GHSW, Siran L, Jiazhen C, And, Zhang W. Evaluation of Whole-Genome Sequence Method to Diagnose Resistance of 13 Anti-tuberculosis Drugs and Characterize Resistance Genes in Clinical Multi-Drug Resistance Mycobacterium tuberculosis Isolates From China. FRONT MICROBIOL 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang H, Li D, Zhao L, Fleming J, Lin N, Wang T, Liu Z, Li C, Galwey N, Deng J, et al. Genome sequencing of 161 Mycobacterium tuberculosis isolates from China identifies genes and intergenic regions associated with drug resistance. NAT GENET. 2013;45(10):1255\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuo T, Comas I, Luo D, Lu B, Wu J, Wei L, Yang C, Liu Q, Gan M, Sun G, et al. Southern East Asian origin and coexpansion of Mycobacterium tuberculosis Beijing family with Han Chinese. P NATL ACAD SCI USA. 2015;112(26):8136\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang C, Luo T, Shen X, Wu J, Gan M, Xu P, Wu Z, Lin S, Tian J, Liu Q, et al. Transmission of multidrug-resistant Mycobacterium tuberculosis in Shanghai, China: a retrospective observational study using whole-genome sequencing and epidemiological investigation. Lancet Infect Dis. 2017;17(3):275\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGagneux S. Ecology and evolution of Mycobacterium tuberculosis. Nat Rev Microbiol. 2018;16(4):202\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen H, He L, Huang H, Shi C, Ni X, Dai G, Ma L, Li W. Mycobacterium tuberculosis Lineage Distribution in Xinjiang and Gansu Provinces, China. SCI REP-UK. 2017;7(1):1068.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSun F, Li Y, Chen Y, Guan W, Jiang X, Wang X, Ren P, Li J, Shi J, He G, et al. Introducing molecular testing of pyrazinamide susceptibility improves multidrug-resistant tuberculosis treatment outcomes: a prospective cohort study. Eur Respir J. 2019;53(3):1801770.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuhlin J, Smith C, Khaemraev A, Tigay Z, Parpieva N, Tillyashaykhov M, Achar J, Hajek J, Greig J, du Cros P, et al. Impact of pyrazinamide resistance on multidrug-resistant tuberculosis in Karakalpakstan, Uzbekistan. INT J TUBERC LUNG D. 2018;22(5):544\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAung WW, Ei PW, Nyunt WW, Htwe MM, Win SM, Aye KT, Mon AS, Aung ST, Chang CL, Lee JS. Pyrazinamide Resistance among Multidrug-Resistant Mycobacterium tuberculosis Clinical Isolates in Myanmar. ANTIMICROB AGENTS CH 2018, 62(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSengstake S, Bergval IL, Schuitema AR, de Beer JL, Phelan J, de Zwaan R, Clark TG, van Soolingen D, Anthony RM. Pyrazinamide resistance-conferring mutations in pncA and the transmission of multidrug resistant TB in Georgia. BMC INFECT DIS. 2017;17(1):491.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMansjo M, Werngren J, Hoffner S. Characterization of pyrazinamide resistance in consecutive multidrug-resistant mycobacterium tuberculosis isolates in sweden between 2003 and 2015. INT J MYCOBACT. 2017;6(2):156\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePang Y, Zhu D, Zheng H, Shen J, Hu Y, Liu J, Zhao Y. Prevalence and molecular characterization of pyrazinamide resistance among multidrug-resistant Mycobacterium tuberculosis isolates from Southern China. BMC INFECT DIS. 2017;17(1):711.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJose M, Munita CAA. Mechanisms of Antibiotic Resistance. MICROBIOL SPECTR 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang Y, Shi W, Zhang W, Mitchison D. Mechanisms of Pyrazinamide Action and Resistance. MICROBIOL SPECTR 2014, 2(4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMechanisms of resistance to delamani Source Tuberculosis Edinb. 2018 Jan 108 186194.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eK\u0026ouml;ser CU, Comas I, Feuerriegel S, Niemann S, Gagneux S, Peacock SJ. Genetic diversity within Mycobacterium tuberculosis complex impacts on the accuracy of genotypic pyrazinamide drug-susceptibility assay. TUBERCULOSIS. 2014;94(4):451\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkhmetova A, Kozhamkulov U, Bismilda V, Chingissova L, Abildaev T, Dymova M, Filipenko M, Ramanculov E. Mutations in the pncA and rpsA genes among 77 Mycobacterium tuberculosis isolates in Kazakhstan. INT J TUBERC LUNG D. 2015;19(2):179\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLemaitre N, Callebaut I, Frenois F, Jarlier V, Sougakoff W. Study of the structure-activity relationships for the pyrazinamidase (PncA) from Mycobacterium tuberculosis. BIOCHEM J. 2001;353(Pt 3):453\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGelmanova IY, Keshavjee S, Golubchikova VT, Berezina VI, Strelis AK, Yanova GV, Atwood S, Murray M. Barriers to successful tuberculosis treatment in Tomsk, Russian Federation: non-adherence, default and the acquisition of multidrug resistance. B WORLD HEALTH ORGAN. 2007;85(9):703\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNathavitharana RR, Lederer P, Tierney DB, Nardell E. Treatment as prevention and other interventions to reduce transmission of multidrug-resistant tuberculosis. Int J Tuberc Lung Dis. 2019;23(4):396.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"MDR-TB, PZA-R, WGS, Gene Mutations, pncA region","lastPublishedDoi":"10.21203/rs.3.rs-4061680/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4061680/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePyrazinamide (PZA) is essential for the treatment of drug-susceptible and drug-resistant tuberculosis (TB), especially multidrug-resistant (MDR) TB, but the condition of PZA resistance (PZA-R) across China is unknown. Our aim is to clarify the genetic mutations of PZA-R and the relationship between PZA-R and MDR-TB in China, from 2007 to 2019.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 3202 TB strains with gene sequences results in China were included, among which 1447 strains were sequenced and 1775 were download from the European Nucleic Acid Sequence Database. Drug resistance was investigated by detecting resistance-conferring mutations. A phylogenetic tree was constructed to illustrate the genetic structure of the TB strains. Fisher's exact or Pearson's chi-square tests, as well as logistic regression analysis were used for correlation analysis. Those were calculated by SPSS software.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAll the 3202 strains were divided into four lineages (L1, L2, L3, L4), most belonged to L2 (2745, 85.7%), followed by L4 (443, 13.8%), the rest L1 plus L3 (14, 0.4%). About 45.6% (n\u0026thinsp;=\u0026thinsp;1459) strains referred to isoniazid resistance (INH-R), 43.4% (n\u0026thinsp;=\u0026thinsp;1389) rifampicin resistance (RIF-R), and 40.5% (n\u0026thinsp;=\u0026thinsp;1296) MDR. There were 591 isolates resistant to PZA, among which 96.1% (n\u0026thinsp;=\u0026thinsp;568) were also MDR. The rate of PZA-R was 43.8% (568/1296) among MDR isolates. The trends of PZA-R fluctuated in accordance with the trends of MDR, INH-R, RIF-R during 2007\u0026ndash;2019. Up to 254 kinds of mutations associated with PZA-R were found, with 16.5% (n\u0026thinsp;=\u0026thinsp;42) isolates harboring\u0026thinsp;\u0026ge;\u0026thinsp;2 PZA-R associated mutations. Codons 11 (encoding \u003cem\u003epncA_c.011A\u0026thinsp;\u0026gt;\u0026thinsp;G\u003c/em\u003e, n\u0026thinsp;=\u0026thinsp;30, 11.8%), 76 (encoding \u003cem\u003epncA_p.Thr76Pro\u003c/em\u003e, n\u0026thinsp;=\u0026thinsp;13, 5.1%), and 139 (encoding \u003cem\u003epncA_p.Val139Leu\u003c/em\u003e, n\u0026thinsp;=\u0026thinsp;13, 5.1%) were the top three PZA-R associated mutation sites. All PZA-R mutation sites accounting at least 1% were included to analyse the influence of PZA-R on other drug resistance (MDR, INH-R, RIF-R). Finally, three PZA-R related mutations (\u003cem\u003epncA_p.Val139Ala, pncA_p.Thr47Ala, pncA_p.Leu85Pro\u003c/em\u003e) were associated with MDR, four were associate with (\u003cem\u003epncA_p.Thr76Pro\u003c/em\u003e, \u003cem\u003epncA_p.Val139Ala, pncA_p.Thr47Ala, pncA_p.Leu85Pro)\u003c/em\u003e INH-R and none was associated with RIF-R.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePZA-R especially gene mutation referred to pncA region may promote MDR, this phenomenon mainly associated with the function of PZA-R on INH-R. It is important to consider PZA-R particularly the three associated mutations (pncA region associated mutations) into consideration in treating MDR-TB and explore its mechanism.\u003c/p\u003e","manuscriptTitle":"The influence of pyrazinamide resistant associated gene mutations on multidrug-resistant mycobacterium tuberculosis in China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-26 12:45:33","doi":"10.21203/rs.3.rs-4061680/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d328a8f5-4dcd-4e78-8ebd-26a632bb4e48","owner":[],"postedDate":"March 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-10T22:53:25+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-26 12:45:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4061680","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4061680","identity":"rs-4061680","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}