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Dilemma of managing asymptomatic children referred with ‘culture-confirmed’ drug-resistant tuberculosis
  1. Marian Loveday1,
  2. Babu Sunkari2,
  3. Ben J Marais3,
  4. Iqbal Master2,
  5. James C M Brust4
  1. 1Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
  2. 2Drug-resistant TB Unit, KwaZulu-Natal Department of Health, King Dinuzulu Hospital, Durban, South Africa
  3. 3Clinical School, Children's Hospital at Westmead, University of Sydney, Sydney, Australia
  4. 4Department of Medicine, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, New York, USA
  1. Correspondence to Dr Marian Loveday, Health Systems Research Unit, South African Medical Research Council, PO Box 19070, Tygerberg 7505, South Africa; marian.loveday{at}


Background The diagnosis of drug-resistant tuberculosis (DR-TB) in children is challenging and treatment is associated with many adverse effects.

Objective We aimed to assess if careful observation, without initiation of second-line treatment, is safe in asymptomatic children referred with ‘culture-confirmed’ DR-TB.

Setting KwaZulu-Natal, South Africa—an area with high burdens of HIV, TB and DR-TB.

Design, intervention and main outcome measures We performed an outcome review of children with ‘culture-confirmed’ DR-TB who were not initiated on second-line TB treatment, as they were asymptomatic with normal chest radiographs on examination at our specialist referral hospital. Children were followed up every other month for the first year, with a final outcome assessment at the end of the study.

Results In total, 43 asymptomatic children with normal chest radiographs were reviewed. The median length of follow-up until final evaluation was 549 days (IQR 259–722 days); most (34; 83%) children were HIV uninfected. Resistance patterns included 9 (21%) monoresistant and 34 (79%) multidrug-resistant (MDR) strains. Fifteen children (35%) had been treated with first-line TB treatment, prior to presentation at our referral hospital. At the final evaluation, 34 (80%) children were well, 7 (16%) were lost to follow-up, 1 (2%) received MDR-TB treatment and 1 (2%) died of unknown causes. The child who received MDR-TB treatment developed new symptoms at the 12-month review and responded well to second-line treatment.

Conclusions Bacteriological evaluation should not be performed in the absence of any clinical indication. If drug-resistant Mycobacterium tuberculosis is detected in an asymptomatic child with a normal chest radiograph, close observation may be an appropriate strategy, especially in settings where potential laboratory error and poor record keeping are constant challenges.

  • DR-TB
  • children
  • Asymptomatic
  • management
  • HIV

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