Re-think first-line tuberculosis treatment.

In the June issue of the European Respiratory Journal (ERJ), A. Skrahina and co-workers reported alarming rates of multidrug-resistant tuberculosis (MDR-TB) in Minsk, Belarus. In their survey, they diagnosed MDR-TB in 35.3% of new patients and 76.5% of previously treated patients [1]. The reflex response to such figures is to strengthen classical infection control activities, to intensify case detection, and to strengthen adherence to and rational use of the first-line antituberculosis regimen. Unfortunately, with the MDR-TB rates now emerging from Eastern Europe and Central Asia, it is questionable how appropriate the current first-line regimen and its rigid use in newly diagnosed cases are in that setting. Is it not time to consider an entirely new first-line treatment for countries or regions where, for example, .25% of tuberculosis in previously untreated patients is MDR-TB? In a different setting, that of community-acquired pneumonia, the use of macrolides as first-line therapy despite 25% macrolide resistance among its causative agents results in therapy-attributable mortality in around one in 100 persons treated [2]. Generally speaking, should we not consider revising the current first-line regimen once a yet-to-be-determined level of MDR-TB is measured, in order to prevent therapy-attributable mortality?