Clinical Review

Managing drug resistant tuberculosis

BMJ 2008; 337 doi: 10.1136/bmj.a1110 (Published 28 August 2008)
Cite this as: BMJ 2008;337:a1110

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  1. Alison Grant, consultant physician1, consultant physician 2,
  2. Philip Gothard, consultant physician1,
  3. Guy Thwaites, Wellcome Trust clinician scientist1, Wellcome Trust clinician scientist3
  1. 1Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London WC1E 6JB
  2. 2Clinical Research Unit, London School of Hygiene & Tropical Medicine, London WC1E 7HT
  3. 3Centre for Molecular Microbiology and Infection, Imperial College, London SW7 2AZ
  1. Correspondence to: A Grant alison.grant{at}lshtm.ac.uk

    402;295;199;200;254;210;217;355;223

    Summary points

    • Drug resistant tuberculosis is becoming more common

    • Traditional laboratory methods for detecting drug resistance are slow and not generally available outside specialist laboratories. Rapid molecular methods are increasingly used in well resourced settings, and simple, cheap alternatives are being developed for resource limited settings

    • The evidence base to guide drug treatment of resistant tuberculosis is weak, and randomised controlled trials are needed

    • A service advising on the management of multidrug resistant tuberculosis is available in the United Kingdom

    • Priorities for prevention of drug resistant tuberculosis include prompt detection of cases, effective treatment of drug sensitive and drug resistant cases, and prevention of tuberculosis transmission

    Antituberculosis drug resistance is increasing both in the United Kingdom and internationally.1 2 It has come to greater public attention with the emergence of extensively drug resistant tuberculosis (box 1) in South Africa, where an outbreak proved rapidly fatal among people with advanced HIV infection.3 In this article we review recent global and UK trends in drug resistant tuberculosis and summarise its diagnosis, treatment, and control. Few data are available from randomised controlled trials to guide treatment of drug resistant tuberculosis, and none for multidrug resistant tuberculosis; this review is based primarily on data from observational epidemiological studies and on national and international guidelines.

    Box 1 Definitions relating to tuberculosis and drug resistance

    • Drug resistant tuberculosis—Tuberculosis that is resistant to any first line antituberculosis drug (see table 1⇓)

    • Multidrug resistant tuberculosis (MDR-TB)—Tuberculosis that is resistant to at least isoniazid and rifampicin

    • Extensively drug resistant tuberculosis (XDR-TB)—Tuberculosis that is resistant to at least isoniazid and rifampicin and also to a fluoroquinolone and a second line injectable agent (amikacin, capreomycin, or kanamycin)

    • Drug resistance in new tuberculosis cases (primary drug resistance)—Drug resistant tuberculosis in a person with no history of tuberculosis treatment, implying they were infected with a resistant …

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