Increasing antituberculosis drug resistance in the United Kingdom: analysis of national surveillance data

doi:10.1136/bmj.39546.573067.25

BMJ 2008;336:1231-1234 (31 May), doi:10.1136/bmj.39546.573067.25 (published 1 May 2008)

Research

Increasing antituberculosis drug resistance in the United Kingdom: analysis of national surveillance data

Michelle E Kruijshaar, senior scientist¹, John M Watson, director¹, Francis Drobniewski, director and consultant medical microbiologist², Charlotte Anderson, scientist¹, Timothy J Brown, clinical scientist², John G Magee, director³, E Grace Smith, director⁴, Alistair Story, tuberculosis nurse specialist¹, Ibrahim Abubakar, consultant epidemiologist and head of tuberculosis section¹^,5

¹ Respiratory Diseases Department, Centre for Infections, Health Protection Agency, London NW9 5EQ, ² Mycobacterium Reference Unit, Barts and the London, Queen Mary’s School of Medicine and Dentistry, London E1 2AT, ³ Regional Centre for Mycobacteriology, Health Protection Agency North East, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE, ⁴ Regional Centre for Mycobacteriology, Health Protection Agency, Heart of England NHS Foundation Trust, Birmingham B9 5SS, ⁵ School of Medicine, Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ

Correspondence to: M E Kruijshaar michelle.kruijshaar{at}hpa.org.uk

Objective To identify recent trends in, and factors associatedwith, resistance to antituberculosis drugs in England, Wales,and Northern Ireland.

Design Cohort of tuberculosis cases reported to the enhancedtuberculosis surveillance system matched to data on drug susceptibilityand national strain typing data.

Setting England, Wales, and Northern Ireland 1998-2005.

Main outcome measures Unadjusted and adjusted odds ratios fordrug resistance and associated factors. Proportion of multidrugresistant tuberculosis cases clustered.

Results 28 620 culture confirmed cases were available for analysis.The proportion of cases resistant to isoniazid increased from5% to 7%. Rifampicin resistance increased from 1.0% to 1.2%and multidrug resistance from 0.8% to 0.9%. Ethambutol and pyrazinamideresistance remained stable at around 0.4% and 0.6%, respectively.Regression analyses showed a significant increase in isoniazidresistance outside London (odds ratio 1.04, 95% confidence interval1.01 to 1.07, a year, associated with changes in age (0.98,0.98 to 0.99, a year), place of birth (1.49, 1.16 to 1.92),and ethnicity (P<0.05). In London, the rise (1.05, 1.02 to1.08, a year) was related mainly to an ongoing outbreak. Increasesin rifampicin resistance (1.06, 1.01 to 1.11, a year) and multidrugresistance (1.06, 1.00 to 1.12, a year) were small. A fifthof patients with multidrug resistant tuberculosis in 2004-5had indistinguishable strain types, and one case was identifiedas extensively drug resistant.

Conclusions The rise in isoniazid resistance reflects increasingnumbers of patients from sub-Saharan Africa and the Indian subcontinent,who might have acquired resistance abroad, and inadequate controlof transmission in London. The observed increases highlightthe need for early case detection, rapid testing of susceptibilityto drugs, and improved treatment completion.

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