Drug-resistant Tuberculosis in India: The Way Forward

Drug-resistant tuberculosis (DR-TB) remains one of the most formidable challenges to tuberculosis (TB) control in India. Despite substantial progress in reducing overall TB incidence, the emergence and persistence of multidrug-resistant TB (MDR-TB) and extensively DR-TB (XDR-TB) threaten to undermine national elimination goals. MDR-TB, defined as resistance to at least isoniazid and rifampicin, and XDR-TB, characterized by additional resistance to fluoroquinolones and second-line agents, are associated with prolonged treatment, increased toxicity, and poorer outcomes. India continues to bear the highest burden of DR-TB globally, contributing nearly one-third of the world’s MDR/rifampicin-resistant TB cases. Epidemiological estimates indicate that MDR-TB occurs in approximately 2%–3% of new TB cases and 12%–13% of previously treated cases.1,2 In absolute terms, this translates to over one lakh MDR-TB cases annually, reflecting both the scale of the problem and ongoing transmission. Although XDR-TB constitutes a smaller proportion of cases, it represents a significant clinical concern due to limited treatment options and high mortality rates. The emergence of pre-XDR TB further complicates management and highlights the evolving spectrum of drug resistance in the country. The management of DR-TB in India has undergone a paradigm shift over the past decade with the transition from injectable-based regimens to all-oral therapies. The availability of newer drugs such as bedaquiline, delamanid, and linezolid has significantly improved treatment outcomes and tolerability. These agents, along with clofazimine and fluoroquinolones like levofloxacin and moxifloxacin, now form the backbone of modern DR-TB regimens. Shorter, standardized regimens such as the BPaL (bedaquiline, pretomanid, and linezolid) and BPaLM regimens have reduced treatment duration to 6–9 months, enhancing adherence and programmatic feasibility. Importantly, these drugs are provided free of cost under India’s National TB Elimination Programme, reflecting a strong policy commitment to DR-TB control. However, challenges remain. Adverse drug reactions, especially with linezolid, require careful monitoring. There is also a growing concern regarding emerging resistance to newer agents, underscoring the need for robust drug susceptibility testing and pharmacovigilance. In addition, gaps in access to diagnostics and treatment persist, particularly in rural and resource-limited settings. The way forward for India requires a multipronged strategy. Early diagnosis through universal drug susceptibility testing must be strengthened, with widespread deployment of rapid molecular diagnostics such as CBNAAT and TrueNat. Ensuring uninterrupted drug supply chains and expanding access to newer regimens are equally critical. Equally important is the integration of private healthcare providers into the national program to ensure standardized treatment and reporting. From a preventive perspective, strict adherence to treatment protocols, infection control measures, and active case finding are essential to curb transmission. Addressing underlying determinants such as malnutrition, diabetes, and overcrowding will also play a pivotal role in reducing disease burden. In conclusion, while India has made commendable progress in the fight against TB, DR-TB remains a significant obstacle. The availability of effective oral regimens offers renewed hope, but sustained efforts in early detection, rational drug use, and prevention are crucial. A coordinated approach combining clinical excellence and public health strategy will be essential for India to achieve its goal of TB elimination.