Seek expert consultation for all patients with suspected or proven drug-resistant TB. Treatment of active TB disease caused by drug- resistant organisms should be done by or in close consultation with an expert in the management of these difficult situations.

INH-resistant TB is the most common form of drug-resistant TB (with a global prevalence of >10%). Updated ATS/CDC/ IDSA recommendations for the treatment of drug-resistant TB recommend the addition of later generation fluoroquinolones (i.e., levofloxacin or moxifloxacin) to rifampin, pyrazinamide, and ethambutol for the treatment of INH-resistant TB, although there are limited data on the benefit of the addition of the fluoroquinolone in these circumstances.

Multidrug-resistant (MDR)-TB is defined as resistance to at least INH and rifampin. New and repurposed anti-TB drugs included in treatment regimens have provided new options for the treatment of MDR-TB including 6-9 month regimens using BPaL (bedaquiline, pretomanid, and levofloxacin) or BPaLM (BPaL plus moxifloxacin).

As noted, consultation with an expert is required for MDR-TB and other drug-resistant TB cases. Second line treatment regimens often represent the patient’s last best hope for being cured. Inappropriate management can have life-threatening consequences.

If you think, identify, or suspect rifampin-resistant or MDR-TB disease in a person with TB, contact the state consultants by direct email, Dr. Susan Ray sray02@emory.edu or Dr. Marcos Schechter mcoutin@emory.edu, or by telephoning the Georgia Department of Public Health TB Program at 404-657-2597 for diagnostic and treatment support. There are multiple strategies to pursue rapid genotypic assessment for drug resistance.

Additionally, there are several exciting new regimens with strong outcomes that require expert consultation. See Appendix and/or website for making contact with an appropriate expert in your county:https://dph.georgia.gov/district-health-directors