A NOVEL MEDIUM FOR GROWTH AND ANTIBIOTIC SUSCEPTIBILITY TEST

OF MYCOBACTERIA

Technical Field

This invention relates in particular to a novel medium developed with the aim of growing Mycobacterium tuberculosis leading to tuberculosis cases from clinical samples and ensuring the determination of their drug resistance and also for use in biochemical tests for identification of mycobacteria .

State of the art

Tuberculosis (phthisis) is one of the oldest health problems that still cannot be solved completely all over the world and is a chronic, granulomatous bacterial and contagious infection disease caused by infection of M. tuberculosis bacillus.

The main characteristics of bacteria of Mycobacterium genus are that they grow slowly, they have resistance to acid, and they have high content of mycolic acid (lipid) in their cell walls. Considering from clinical aspect, M. tuberculosis is the most essential member of the genus because of its disease infection potential and close association with the public health and is the main cause of tuberculosis encountered in humans today.

Diagnosis of tuberculosis can be determined by clinical signs and symptoms, and by assessment of skin test result and also by identifying M. tuberculosis via biochemical tests in the mycobacteria cultured in culture medium.

Because of the difficulties in diagnosis and treatment of tuberculosis, it becomes harder to keep the disease under control. Therefore, studies are still being conducted to develop novel media especially for effective treatment, early identification of the agent and drug resistance.

Direct microscopic examination and acid-fast bacteria (AFB) staining method are used as a fast and simple method having most common usage in clinical studies. However, by means of microscopic examination, bacillus of M. tuberculosis is encountered in 40-80% of pulmonary tuberculosis cases.

Therefore, the presence of AFB in direct examination neither makes the diagnosis of tuberculosis certain and nor gives an accurate result. This agent is required to be grown in a medium.

Mycobacterium culture methods used are the most frequently applied methods for the diagnosis of tuberculosis with regard to the fact that they allow for obtaining the isolates needed for the identification processes to be conducted after growing the bacteria, and for the bacteria to show their viabilities, and for the diseases to be accurately treated by performing the drug susceptibility tests, and for obtaining the epidemiological data. However, disadvantage of these methods is that the diagnosis of bacteria requires some time since the growth period of bacteria takes a long time.

It is possible to divide mycobacterium culture methods into two as solid and liquid media. The World Health Organization also suggests the simultaneous use of a solid and a liquid medium for the culturing of mycobacteria.

The culture processes in solid media are time-consuming and laborious. Several weeks are needed for colonies to become visible .

Solid media is divided into two as egg and agar-based media: Egg based media: These are Lowenstein-Jensen (LJ) ,

Petragnani and American Trudeau Society (ATS) . The most commonly used one is the LJ medium. It takes 18-24 days for the colonies to become visible. Furthermore, due to its high egg-based protein content and possibility that the antibiotics can be inactivated during its solidification by heating it up to 80°C brings along disadvantage in susceptibility tests. Agar-based media: Middlebrook 7H10 and 7H11 agars are the most preferred ones. Oleic acid-albumin-dextrose-catalase (OADC) enricher should be added in it before use. Mycobacteria become visible 10-12 days after cultivation while their media is transparent, thence the time to detect positivity is shorter compared to the LJ medium. In the case of a small number of bacteria in the sample or presence of strong decontamination, the monitoring of specific colonies may take a long time of about 6 to 8 weeks. Furthermore, it is expensive due to the enrichment used and in the case of contamination, medium losses occur since the whole surface of the medium is often influenced .

Liquid Media :

The detection of mycobacteria by the liquid cultures is performed in shorter time and in higher sensitivity. They contain Middlebrook 7H9 and Dubos Tween albumin fluids therein. Fast culture systems are grouped as manual, semi- automated or fully automated systems according to the fact that whether they are evaluated by device and computer or not. However, the requirement of additional device and equipment for the automated systems in which this medium is used also bring along a disadvantage in terms of costs.

Sensitivity of LJ medium in the isolation of mycobacteria from clinical samples is lower compared to the Middlebrook 7H10, 7H11 and its liquid form 7H9 medium (broth) because of the reasons such as longer growth time and late detection of colony formation.

Mycobacteria are handled after being primarily grouped according to their growth times, growth temperatures, colony morphology that they created on the medium and pigment characteristics and by the determination of appropriate biochemical tests.

Biochemical tests used to identify mycobacteria:

Catalase test, arylsulfatase test, growth in Mac Conkey agar without crystal violet, iron uptake, niacin accumulation, nitrate reduction, pyrazineamidase test, sodium chloride tolerance test, inhibition by thiophene-2-carboxylic acid hydrazide, tellurite reduction, hydrolyze of Tween 80, and urease activity is among the biochemical tests used in the identification of mycobacteria.

Determination of the growth characteristics of mycobacteria and their identification by conventional biochemical methods can take approximately 3-6 weeks or sometimes even longer.

Susceptibility methods are direct method by which cultivation of clinical samples, comprising acid fast bacteria in which calculating the average number of bacteria in one milliliter of the sample, into the media in a drug and drug-free manner after homogenization-decontamination procedures, and indirect method wherein the cultivation into drug and drug-free media after preparing appropriate inoculum by isolating the acid- fast bacteria in pure culture state from the clinical samples.

Middlebrook 7H10 and 7H11 media enriched with oleic acid- albumin-dextrose-catalase (OADC) and egg-based LJ medium are used in the susceptibility tests of mycobacteria.

The drugs developed against M. tuberculosis in the mid-1950s have been widely used for many years. Although effective drugs against tuberculosis have been on the market for many years and it has been considered as a treatable disease, the main reason of the difficulty in treatments is the development of resistance to anti-TB drugs. Application of biochemical tests used for the diagnosis of tuberculosis make the process difficult in terms of both cost and preparation times due to their above-mentioned disadvantages.

In the state of the art, the patent application US6951733B2 relates to a novel agar-based medium for the isolation, sub culturing, and indirect or direct drug susceptibility test of M. tuberculosis . This agar medium suitable for the growth of M. tuberculosis comprises 200 units/ml of polymyxin B, 50 microgram/ml carbenicillin, 10 microgram/ml amphotericin B and 20 microgram/ml trimethoprim lactate of antimicrobial agents. It is mentioned that the final volume of the resulting agar medium contains bovine serum at a concentration of about 8% to 12%. The agar used to prepare the said medium is selected from the group consisting of Middlebrook and Cohn 7H10 and Middlebrook and Cohn 7H11. In that invention, bovine serum of 8% to 12% of the final volume of agar medium was used instead of OACD as an enricher.

In the state of the art, the medium mentioned in the application "CA2807357A1" contains the substances Glycerol 5.0 mL, sodium caseinate 2.0 g, L-asparagine 0.1 g, sodium propionate 4.0 g, dipotassium phosphate 0.5 g, magnesium sulfate 0.1 g, iron sulfate 0.001 g, 1.0 L water (750 ml of Artificial Sea Water + 250 mL of demineralized water) , agar powder 15.0 g, final pH (at 25°C) 7.4 to 7.8.

The media existing in the state of the art mentioned above, has disadvantages due to the fact that growth of the bacteria takes a long time and that the costs are high. Problems aimed to be solved by the invention

The aim of the invention is to ensure that M. tuberculosis leading to tuberculosis and other mycobacteria are grown in a short period of time and that colony formation is detected earlier .

Further aim of the invention is to ensure that the antibiotic susceptibility of M. tuberculosis isolates is determined by using the solid and liquid medium as defined by the present invention .

Description of Invention

This invention relates particularly to a novel medium developed with the aim to use in biochemical tests for culturing M. tuberculosis leading to tuberculosis cases and other mycobacteria from clinical samples, for determining the drug resistance in M. tuberculosis isolates and for identifying the mycobacteria.

For the simultaneously use of a solid and a liquid medium, analogous medium substances are used and the medium which brings along cost efficient advantages by using serum/plasma of animal origin instead of OADC as enrichment agent, and which at the same time shortens visibility time of mycobacteria for about a week is achieved.

The unexpected technical effect in the subject matter product is that; the medium formed by use of enrichment of animal origin together with the substances on the medium has both provided advantage in terms of costs and reduced the growing time of the mycobacteria. By this measure, it has reduced the determination time thereby the detection time of tuberculosis bacteria which is one of the biggest problems encountered in the state of the art. Thus, intervening to tuberculosis disease caused by M. tuberculosis in a shorter period of time come into being. Another problem is that the enrichment agent such as OADC used in existing media is expensive. This problem is also eliminated by using enricher of animal origin in the subject matter of the invention. Furthermore, it is advantageous that it is cost efficient during the diagnosis considering that the disease is observed particularly in developing countries.

Both solid and liquid medium is achieved during forming of the medium that allow for subject matter mycobacteria to be cultured and their antibiotic susceptibilities to be tested.

Solid and liquid media are the formulations that provide maximum growth of bacteria. By means of substances forming the solid and liquid medium and of usage amounts of said substances, inactivation of the antibiotics is inhibited. The usage amounts of subject matter medium substances and the amount of enrichment added are therefore essential. The amount of the enricher used to increase the growth rate of mycobacteria is also important.

The prepared solid media is agar-based media containing asparagine, monopotassium phosphate, magnesium sulfate, peptone, agar, magnesium citrate, glycerol and distilled water. The medium in question is clear/transparent and the colonies begin to appear 5 to 7 days after cultivation.

The compositions and the amounts of the medium obtained are shown in Table 1.

Table 1: Table showing the compositions and the substance amounts of the medium

For the preparation of the solid medium, the substances of the above table are used, and the final solid medium product is obtained by the following culturing method, which is comprised by the process steps of:

• Mixing 3-4 grams of L-asparagine, 2-3 grams of monopotassium phosphate, 0.2-0.3 grams of magnesium sulfate, 15-20 grams of peptone, 15 grams of agar, 0.3-1 grams of magnesium citrate, 3-7 milliliters of glycerol in 900-950 milliliters of distilled water,

• Sterilizing of the mixture by autoclave for 15 minutes at atmospheric pressure of 1 at 121°C,

• Cooling of the mixture sterilized by autoclave for 15 minutes under atmospheric pressure of 1 at 121°C to 50°C,

• Adding 5-10% (50-100 milliliters) of filter-sterilized inactivated sheep serum and/or sheep plasma and/or fetal bovine serum to the mixture cooled to 50°C,

• Developing the media by stirring the mixture to which filter-sterilized inactivated sheep serum and/or sheep plasma and/or fetal bovine serum is added,

• Dispersion of the resulting medium into sterile tubes of 5-7 milliliters,

• Solidification of the medium dispersed in sterile tubes in a horizontal position. The prepared solid medium is stored at +4°C until it is used in order to be prevent from the contamination and to be protected from moisture and light. The prepared solid medium can be used in growing of mycobacteria from clinical samples. Analogously, it can also be used in susceptibility tests by adding anti-tuberculosis drugs in appropriate concentrations to the medium. In addition to the solid medium described above, it is also possible to obtain medium in liquid form. The liquid medium and the solid medium vary in content and agar is not used in the liquid medium.

The prepared liquid medium contains L-asparagine, monopotassium phosphate, magnesium sulfate, peptone, magnesium citrate, glycerol and distilled water.

The compositions and the amounts of the medium obtained are shown in Table 2.

Table 2: Table showing the compositions and the substance amounts of the medium

For the preparation of the liquid medium, the substances described in the above table are used and the final product that is liquid product is obtained by the following culturing method, which is comprised of the process steps of:

• Mixing 3-4 grams of L-asparagine, 2-3 grams of monopotassium phosphate, 0.2-0.3 grams of magnesium sulfate, 15-20 grams of peptone, 0.3-1 grams of magnesium citrate, 3-7 milliliters o_f gly _^ c_e_ro_l in 900-950 milliliters of distilled water,

Sterilizing of the mixture by autoclave for 15 minutes at atmospheric pressure of 1 at 121°C,

Cooling of the mixture sterilized by autoclave for 15 minutes under atmospheric pressure of 1 at 121°C to 50°C, Adding 5-10% (50-100 milliliters) of filter-sterilized inactivated sheep serum and/or sheep plasma and/or fetal bovine serum to the mixture cooled to 50°C,

Developing the media by stirring the mixture to which filter-sterilized inactivated sheep serum and/or sheep plasma and/or fetal bovine serum is added,

Dispersion of the resulting medium into sterile tubes of 5-7 milliliters,

The prepared liquid medium is stored at +4°C until it is used. The solid and liquid medium that is subject matter of the invention provides the basic ingredients necessary for the growth of mycobacteria during the culturing stage and allows for the growth of the bacteria in a shorter time by the addition of inactivated sheep serum and/or sheep plasma and/or fetal bovine serum as the enrichment.

Liquid medium can also be used in existing automated systems thereby minimizing the costs and the growth time.

Solid medium and liquid medium are both used in the growth of mycobacteria as well as in antibiotic susceptibility tests, wherein they have formulations that is readily applicable for enabling the growth of mycobacteria. By this means, cost and growth time of bacteria are decreased for the diagnosis to be conducted and for their antibiotic susceptibilities to be tested .