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From magic bullets back to the Magic Mountain: the rise of extensively drug-resistant tuberculosis

Nature Medicine volume 13, pages 295–298 (2007)Cite this article

Extensively drug-resistant tuberculosis (XDR-TB) occurs where health systems have been historically weak; it lays bare the reality of TB as a serious public health problem, especially in areas of high HIV prevalence, and reinforces the need for effective TB control strategies that are coordinated with HIV control. The problem of XDR-TB in high HIV prevalence settings challenges all aspects of the public health and health-care systems, and will require an integrated approach. Failure to act rapidly to contain local outbreaks, develop tools and strategies for identifying and treating XDR-TB, and investing in longer term improvements to TB control could transform the magic bullets for TB into blanks, and assure a return to the grim prospects of the Magic Mountain.

The development of tuberculosis (TB) chemotherapy from the 1940s through the 1970s transformed the deadly 'white plague' into a curable disease, though it was a largely uncelebrated triumph of twentieth century science1. But since the dawn of the antibiotic era, TB treatment has been shadowed by the specter of drug resistance. The very first person treated with streptomycin at the Mayo Clinic in 1944 developed resistance to the drug (but was cured with surgery), as did the majority of those treated with the drug in the famous 1948 British Medical Research Council trial that both established the efficacy of treatment for TB and created the paradigm of the controlled clinical trial2. Fifteen years ago an epidemic of multidrug-resistant tuberculosis, or MDR-TB—TB resistant to rifampin plus isoniazid—in New York City induced panic and alarm, but a massive infusion of funds into the public health infrastructure turned the tide, at least in the United States, and public interest waned3,4. However, the problem of drug resistance has persisted, and efforts to contain it globally have not been sufficient.

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Figure 1: First-line and second-line anti-TB drugs.
Figure 2: Countries with confirmed XDR-TB cases thus far (pink).

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Acknowledgements

Grant support: US National Institutes of Health AI51528 and AI01637, and the Bill & Melinda Gates Foundation.

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  1. Center for Tuberculosis Research, 1550 Orleans Street, Room 1M.08, Johns Hopkins University, Baltimore, 21231, Maryland, USA

    Susan E Dorman & Richard E Chaisson

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Dorman, S., Chaisson, R. From magic bullets back to the Magic Mountain: the rise of extensively drug-resistant tuberculosis. Nat Med 13, 295–298 (2007). https://doi.org/10.1038/nm0307-295

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