What is multidrug-resistant tuberculosis (MDR-TB) and how do

we control it?
Online Q&A
Reviewed March 2017

Q: What is multidrug-resistant tuberculosis and how do we control it?

A: The bacteria that cause tuberculosis (TB) can develop resistance to the antimicrobial drugs used to cure the
disease. Multidrug-resistant TB (MDR-TB) is TB that does not respond to at least isoniazid and rifampicin, the 2
most powerful anti-TB drugs.
The 2 reasons why multidrug resistance continues to emerge and spread are mismanagement of TB treatment
and person-to-person transmission. Most people with TB are cured by a strictly followed, 6-month drug regimen
that is provided to patients with support and supervision. Inappropriate or incorrect use of antimicrobial drugs, or
use of ineffective formulations of drugs (such as use of single drugs, poor quality medicines or bad storage
conditions), and premature treatment interruption can cause drug resistance, which can then be transmitted,
especially in crowded settings such as prisons and hospitals.
In some countries, it is becoming increasingly difficult to treat MDR-TB. Treatment options are limited and
expensive, recommended medicines are not always available, and patients experience many adverse effects from
the drugs. In some cases even more severe drug-resistant TB may develop. Extensively drug-resistant TB, XDR-
TB, is a form of multidrug-resistant TB with additional resistance to more anti-TB drugs that therefore responds
to even fewer available medicines. It has been reported in 117 countries worldwide.
Drug resistance can be detected using special laboratory tests which test the bacteria for sensitivity to the drugs
or detect resistance patterns. These tests can be molecular in type (such as Xpert MTB/RIF) or else culture-
based. Molecular techniques can provide results within hours and have been successfully implemented even in
low resource settings.
New WHO recommendations aim to speed up detection and improve treatment outcomes for MDR-TB through
use of a novel rapid diagnostic test and a shorter, cheaper treatment regimen. At less than US$ 1000 per patient,
the new treatment regimen can be completed in 912 months. Not only is it less expensive than current
regimens, but it is also expected to improve outcomes and potentially decrease deaths due to better adherence to
treatment and reduced loss to follow-up.
Solutions to control drug-resistant TB are to:
cure the TB patient the first time around
provide access to diagnosis
ensure adequate infection control in facilities where patients are treated
ensure the appropriate use of recommended second-line drugs.
In 2015, an estimated 480 000 people worldwide developed MDR-TB, and an additional 100 000 people with
rifampicin-resistant TB were also newly eligible for MDR-TB treatment. India, China, and the Russian
Federation accounted for 45% of the 580 000 cases. It is estimated that about 9.5% of these cases were XDR-
TB.

Drug- and multidrug-resistant tuberculosis (MDR-TB) -

Frequently asked questions
How does drug-susceptible TB become drug-resistant TB?
Drug resistance arises due to the improper use of antibiotics in chemotherapy of drug-susceptible TB patients.
This improper use is a result of a number of actions, including administration of improper treatment regimens by
health care workers and failure to ensure that patients complete the whole course of treatment. Essentially, drug-
resistance arises in areas with poor TB control programmes.
What is multidrug-resistant tuberculosis (MDR-TB)?
MDR-TB is a specific form of drug-resistant TB due to a bacillus resistant to at least isoniazid and rifampicin,
the two most powerful anti-TB drugs.
What is the difference between the management of drug-resistant TB and drug-susceptible
TB?
In areas of minimal or no MDR-TB, DOTS achieves cure rates of up to 95%; rates high enough to dramatically
reduce the TB burden while preventing the emergence of drug-resistant TB. However, an effective strategy, the
management of drug-resistant TB is still in pilot stage. While drug-susceptible TB can be cured within six
months, forms of drug-resistant TB (such as MDR-TB) require extensive chemotherapy (with drugs which have
more side effects) for up to two years.
How do we measure drug-resistant TB globally?
In 1994, WHO, the International Union Against TB and Lung Disease, and other partners began the Global
Project on Drug Resistance Surveillance in order to standardize the sampling and laboratory methodologies used
to measure drug resistant tuberculosis. Today, areas representing almost half of global TB cases have been
surveyed.
Are TB and drug-resistant TB real threats to everyone?
Presently, TB is the second greatest contributor among infectious diseases to adult mortality causing
approximately 1.7 million deaths a year worldwide. WHO estimates that one-third of the world's population is
infected with Mycobacterium tuberculosis. The WHO/IUATLD Global Project on Drug Resistance Surveillance
has found MDR-TB (prevalence > 4% among new TB cases) in Eastern Europe, Latin America, Africa, and
Asia.
Given the increasing trend toward globalisation, trans-national migration, and tourism, all countries are potential
targets for outbreaks of MDR-TB.
How is WHO addressing the problem of drug resistance?
In 1998 WHO and several partners around the world conceived a strategy for the management of MDR-TB. The
approach to the management of MDR-TB is under continuous development and testing. The latest
recommendations on the management of drug-resistant TB are published in the Emergency Update of the
WHO Guidelines for the programmatic management of drug-resistant TB. A working group on MDR-TB of the
STOP TB Partnership was established in 1999 to assist in producing policy recommendations for Member States
on the management of MDR-TB, based on the assessment of the feasibility, effectiveness and cost-effectiveness
data generated by pilot projects implemented by the agencies/institutions participating in the Working Group, or
by the World Health Organization (WHO); to coordinate and monitor the implementation of internationally
comparable pilot projects for the management of MDR-TB; to establish a system that allows WHO Member
States to have access to high-quality second-line drugs at reduced prices and, at the same time, prevents misuse
of such drugs; to review progress achieved in countries managing MDR-TB through the Green Light Committee
(GLC); and to identify resources to fund and implement MDR-TB control and to assist with global coordination
of the initiative.