MDR-/XDR-TB management: what it was, current standards and what is ahead

Despite killing nearly 2 million people every year, TB is arguably the most neglected disease in terms of the funding and research it receives. In many ways, multidrug-resistant TB is a result of this disregard. In high-burden countries, not many improvements have been implemented in the diagnosis and treatment tools of TB since the 1960s. Following this period, fluoroquinolones, developed for other infections, are the only highly active new drugs against TB. Multidrug- and extensively drug-resistant TB is booming worldwide as a result of insufficient control measures. Furthermore, the prevalence of this disease is substantially facilitated by the HIV epidemic. After a deadly and well-reported extensively drug-resistant TB outbreak occurred in HIV-infected patients in South Africa, the threat of an untreatable TB epidemic is receiving increased attention internationally. Nevertheless, drug-resistant management has lacked research and funding over several decades and we are now faced with many controversial issues and little research-based evidence. There are no clinical trials comparing different treatments, and current management is based on personal experiences and agreement between experts. The major challenge for the next few years is to improve the evidence base in order to develop more rational recommendations that adequately address the current problem and avoid making a bad situation worse.