Con DogovskiStanley C. XieGaetan BurgioJess BridgfordSachel MokJames M. McCawKesinee ChotivanichShannon KennyNina GnädigJudith StraimerZbynek BozdechDavid A. FidockJulie A. SimpsonArjen M. DondorpSimon FooteNectarios KlonisLeann TilleyBio21 Molecular Science and Biotechnology InstituteAustralian National UniversityMacquarie University, Australian School of Advanced MedicineNanyang Technological UniversityUniversity of MelbourneRoyal Children's Hospital, MelbourneMahidol UniversityColumbia University Medical CenterNuffield Department of Clinical Medicine2018-11-232018-11-232015-04-22PLoS Biology. Vol.13, No.4 (2015)15457885154491732-s2.0-84929493850https://repository.li.mahidol.ac.th/handle/20.500.14594/35173© 2015 Dogovski et al. Successful control of falciparum malaria depends greatly on treatment with artemisinin combination therapies. Thus, reports that resistance to artemisinins (ARTs) has emerged, and that the prevalence of this resistance is increasing, are alarming. ART resistance has recently been linked to mutations in the K13 propeller protein. We undertook a detailed kinetic analysis of the drug responses of K13 wild-type and mutant isolates of Plasmodium falciparum sourced from a region in Cambodia (Pailin). We demonstrate that ART treatment induces growth retardation and an accumulation of ubiquitinated proteins, indicative of a cellular stress response that engages the ubiquitin/proteasome system. We show that resistant parasites exhibit lower levels of ubiquitinated proteins and delayed onset of cell death, indicating an enhanced cell stress response. We found that the stress response can be targeted by inhibiting the proteasome. Accordingly, clinically used proteasome inhibitors strongly synergize ART activity against both sensitive and resistant parasites, including isogenic lines expressing mutant or wild-type K13. Synergy is also observed against Plasmodium berghei in vivo. We developed a detailed model of parasite responses that enables us to infer, for the first time, in vivo parasite clearance profiles from in vitro assessments of ART sensitivity. We provide evidence that the clinical marker of resistance (delayed parasite clearance) is an indirect measure of drug efficacy because of the persistence of unviable parasites with unchanged morphology in the circulation, and we suggest alternative approaches for the direct measurement of viability. Our model predicts that extending current three-day ART treatment courses to four days, or splitting the doses, will efficiently clear resistant parasite infections. This work provides a rationale for improving the detection of ART resistance in the field and for treatment strategies that can be employed in areas with ART resistance.Mahidol UniversityAgricultural and Biological SciencesBiochemistry, Genetics and Molecular BiologyImmunology and MicrobiologyArticleSCOPUS10.1371/journal.pbio.1002132