Editorial: the treatment of multi-drug resistant tuberculosis--a return to the pre-antibiotic era?

When Magdalena was 15 years old she was diagnosed with smear-positive pulmonary tuberculosis (TB). She lived with her mother, a stepfather and 13 siblings in a very humble dwelling in an Andean country. Her stepfather would often beat her because she was unable to perform her assigned domestic chores. As a result, she would flee and abandon her treatment. She was prescribed several regimens which she took erratically. Three years later she was still smear-positive; the chest X-ray showed multiple cavities in both apices and drug susceptibility testing confirmed resistance to isoniacid (H), rifampicin (R), ethambutol (E) and streptomycin (S). The following year she became pregnant and died of respiratory insufficiency 6 months later. Peter is a 45-year-old primary school teacher in an Eastern African country; he lives with his wife and several children. In September 2000, he was diagnosed with smear-positive TB and was given the category I regimen (2HRZE/6HE; Z 1⁄4 pyrazinamide); at the completion of treatment he was still smear-positive. Despite taking the category II regimen (2HRZES/1HRZE/5HRE) twice, he remained smear-positive. He saw a consultant in the capital who prescribed the entire gamut of secondline TB medications. The only drug which Peter was able to find was ciprofloxacin, which he took for several months. His latest drug susceptibility tests have demonstrated resistance to H, R, E, S and ciprofloxacin; the chest X-ray shows multiple cavities, especially in the left lung. He remains weak, emaciated, dyspnoeic and smear-positive. These two patients from different continents had two characteristics in common: first, they suffered from a very serious form of TB; and secondly, they could not be treated adequately for lack of medication. Let us briefly examine the reasons underlying their clinical condition and lack of effective treatment.