Antibiotic resistance acquisition versus primary transmission in the presentation of extensively drug-resistant tuberculosis.

Mycobacterium tuberculosis is the leading cause of mortality worldwide due to a single bacterial pathogen. Of concern is the negative impact that the COVID-19 pandemic has had on the control of tuberculosis (TB) including drug-resistant forms of the disease. Antimicrobial resistance increases the likelihood of worsened outcomes in TB patients including treatment failure and death. Multidrug-resistant (MDR) strains, resistant to first-line drugs isoniazid and rifampin, and extensively drug-resistant (XDR) strains with further resistance to second-line drugs (SLD), threaten control programs designed to lower TB incidence and end the disease as a public health challenge by 2030, in accordance with UN Sustainable Development Goals. Tackling TB requires an understanding of the pathways through which drug resistance emerges. Here, the roles of acquired resistance mutation, and primary transmission, are examined with regard to XDR-TB. It is apparent that XDR-TB can emerge from MDR-TB through a small number of additional resistance mutations that occur in patients undergoing drug treatment. Rapid detection of resistance, to first-line drugs and SLD, at the initiation of and during treatment, and prompt adjustment of regimens are required to ensure treatment success in these patients. Primary transmission is predicted to make an increasing contribution to the XDR-TB caseload in the future. Much work is required to improve the implementation of the World Health Organization-recommended infection control practices and block onward transmission of XDR-TB patients to contacts including health-care workers. Finally, limiting background resistance to fluoroquinolones in pre-XDR strains of M. tuberculosis will necessitate better antimicrobial stewardship in the broader use of this drug class.

Extensively Drug-Resistant Tuberculosis in the Time of COVID-19-How has the Landscape Changed for Pakistan?

The incidence of extensively drug-resistant tuberculosis (XDR-TB) has been rising consistently in Pakistan, and the country is likely to experience another surge of cases in the midst of the COVID-19 crisis. It is imperative to consider how the rising proportion of XDR-TB is best tackled during the pandemic; this includes finding a solution to the problem of non-adherence at the level of community-based healthcare, the utility and practicality of simultaneous testing for COVID-19 and TB, and reconciliation of the World Health Organization's recommendation of home-based treatment with the need for frequent monitoring of anti-tubercular therapy in XDR-TB. Operational research is needed expeditiously to bypass these limitations.