Resistance to second-line drugs in multidrug-resistant tuberculosis.

www.thelancet.com Vol 381 February 23, 2013 625 The lack of participation of India and China, who between them share 50% of the world’s burden of multidrugresistant (MDR) tuberculosis, is a major limitation of the Preserving Eff ective TB Treatment (PETTS) study. Despite this limitation, the fi ndings of the PETTS investigators fi nd great and ominous resonance in India. Second-line drugs are prescribed with brazen impunity by a range of private practitioners in India, many of them not even allopaths. A study from Dharavi, Asia’s largest slum, located in the heart of Mumbai, showed that, of the 106 practitioners prescribing second-line drugs to a hypothetical patient with MDR tuberculosis, 60% were trained in one of the alternative systems of medicine (homoeopathy, ayurveda, or unani) that fl ourish in India. Only fi ve of these 106 physicians could write an appropriate prescription with a minimum of three new secondline drugs in the right doses for a minimum recommended duration of 18 months. Most respondents added a single second-line drug, which 70% of the time was a fl uoroquinolone. More tragically, these inappropriate prescriptions would be dispensed without any checks or safeguards in place, since tuberculosis prescriptions are not controlled in India and even the most inexperienced doctor can prescribe second-line drugs with impunity. India has 1 million chemists policed by just 4000 drug inspectors, and even if laws Resistance to secondline drugs in multidrugresistant tuberculosis