To the Editor:
The prevalence of drug resistance among tuberculosis (TB) cases is increasing in the UK [1] and worldwide [2], with increasing proportions of cases with multidrug- and extensively drug-resistant TB (MDR-/XDR-TB) being reported [1, 2]. Toxicity and poor efficacy of treatment are major problems and long durations with culture-positive disease increase the risk of transmission. This report describes difficulties in managing XDR-TB and the pre-license use of bedaquiline outside of clinical trials.
Bedaquiline is an anti-tuberculous drug of the diarylquinoline class, which inhibits bacterial adenosine triphosphate synthase, and represents the first new class of anti-tuberculous agents for at least four decades. Its unique mechanism means that there is no cross-resistance with other drugs in current use. In phase II clinical trials, in combination with background MDR-TB regimens, bedaquiline resulted in reduced time to sputum culture conversion, reduced emergence of resistance to companion drugs and little additional toxicity compared with background regimens alone [3]. At present it is not yet licensed in Europe and the World Health Organization (WHO) has recently issued interim policy guidance for its use as part of combination therapy for adults with MDR-TB under specific conditions, based on currently available evidence [3].
A 28-year-old, HIV-negative Indian female with no prior history of TB treatment or contact was diagnosed with TB through screening on arrival in the UK. A pre-departure chest radiograph 3 months before assessment in the UK was reported to be normal. A bacille Calmette–Guérin scar was seen on examination. A tuberculin skin …