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 Table of Contents  
Year : 2020  |  Volume : 9  |  Issue : 3  |  Page : 309-312

High degree of fluoroquinolone resistance among extrapulmonary tuberculosis patients at a tertiary care center in North India

1 Department of Medicine, All India Institute of Medical Sciences, New Delhi; School of Life Sciences, Jaipur National University, Jaipur, Rajasthan, India
2 School of Life Sciences, Jaipur National University, Jaipur, Rajasthan, India
3 Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
4 Department of Medicine, All India Institute of Medical Sciences, New Delhi, India

Date of Submission26-Jun-2020
Date of Decision01-Jul-2020
Date of Acceptance02-Jul-2020
Date of Web Publication28-Aug-2020

Correspondence Address:
Sanjeev Sinha
Department of Medicine, All India Institute of Medical Sciences, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmy.ijmy_116_20

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Background: The treatment of drug-resistant tuberculosis (TB) involves various regimens. Among them, the most promising antibiotic regimens are fluoroquinolone (FQ) drugs. Drug susceptibility testing (DST) for FQs is not included as routine assessment for baseline TB diagnosis. Limited resources are available about FQ resistance among extrapulmonary TB (EPTB) cases. Methods: A total of 447 culture-positive specimens were subjected to DST for first-line anti-TB drugs (FLDs) and second-line anti-TB drugs. DST was performed using automated mycobacterium growth indicator tube-960 liquid culture techniques. The study was carried out during the period of April 2016 to March 2017. In addition, DST of FQs was also performed in FLD-sensitive strains. Results: Mycobacterium tuberculosis was isolated from 447 specimens. Of the 447 culture-positive EPTB specimens, 54 were rifampicin-resistant (RR)/multidrug-resistant TB (MDR-TB) isolates, 45 isolates were resistant to any drug, and the remaining 348 were sensitive to FLDs. Monoresistance of FQs was observed in 20.4% (11/54) among RR/MDR-TB isolates and 4.3% (15/348) among FLD-sensitive isolates. Conclusion: The high degree of FQ resistance observed in EPTB specimens among drug-sensitive and MDR-TB isolates is alarming. This study reflects the need to expand culture and DST for EPTB cases and include FQs within first-line DST in such settings. Furthermore, there should be a rational use of FQs for the treatment of other diseases.

Keywords: Drug susceptibility testing, extensively drug-resistant tuberculosis, extrapulmonary tuberculosis, fluoroquinolone resistance

How to cite this article:
Chaubey J, Shrivastava D, Pawar S, Singh BK, Sharma R, Sinha S. High degree of fluoroquinolone resistance among extrapulmonary tuberculosis patients at a tertiary care center in North India. Int J Mycobacteriol 2020;9:309-12

How to cite this URL:
Chaubey J, Shrivastava D, Pawar S, Singh BK, Sharma R, Sinha S. High degree of fluoroquinolone resistance among extrapulmonary tuberculosis patients at a tertiary care center in North India. Int J Mycobacteriol [serial online] 2020 [cited 2023 Jan 30];9:309-12. Available from: https://www.ijmyco.org/text.asp?2020/9/3/309/293541

  Introduction Top

Antituberculous drug regimens include fluoroquinolones (FQs) as one of the critical components. The treatment of multidrug-resistant tuberculosis (MDR-TB) includes FQs along with the second-line injectable drugs such as amikacin, kanamycin (KAN), and capreomycin. MDR-TB is defined as tuberculosis (TB) caused by those isolates of Mycobacterium tuberculosis (Mtb) that are resistant to isoniazid and rifampicin.[1],[2] DNA topoisomerases are enzymes that introduce temporary single- or double-strand breaks in the DNA, thereby fixing the topological problems associated with DNA replication, transcription, recombination, and chromatin remodeling. The DNA topoisomerases are directly inhibited by FQs by forming a complex with the DNA and topoisomerase, resulting in double-strand DNA breaks that are lethal for the bacteria.[3]

Spontaneous mutations in chromosomal genes are the main cause of drug resistance in Mtb. The most important mechanism of FQ resistance in Mtb is mutations in the quinolone-resistance-determining region (QRDR) of the gyrA gene.[4] A relationship between phenotypic resistance to FQs and mutations in QRDRs was detected among Mtb clinical isolates.[5]

FQs possess broad antimicrobial activity and hence are widely used for the treatment of various bacterial infections.[6] In many countries, FQ-resistant MTB has markedly emerged as a consequence of the exuberant use of FQs in the treatment of community-acquired bacterial infections. FQ exposure before TB diagnosis has been established as an associated factor for FQ resistance, specifically in case when FQ exposure occurs >60 days before TB diagnosis and for a duration of more than 10 days.[7],[8] Furthermore, the diagnosis of pulmonary TB gets complicated by the use of FQs that reduces smear positivity and delays access to treatment.[9],[10] In high-burden TB countries, FQs are also used to treat a variety of other bacterial infections besides TB. Thus, it may prove useful to observe the prevalence of FQ resistance in Mtb isolates, particularly at the baseline.[11] There are limited data available worldwide on FQ resistance among extrapulmonary TB (EPTB) isolates. The aim of the present study was to determine the FQ monoresistance in first-line anti-TB drug (FLD)-sensitive strains and MDR-TB isolates among EPTB cases at baseline.

  Methods Top


The present study was approved by the Institutional Ethics Committee (Ref. no. IECPG-AA-2/March 30, 2016) on March 30, 2016, and written informed consent was obtained from all the patients.

Study design

A total of 2215 specimens from 2145 patients including both treatment-naive and treatment-experienced cases with clinical diagnosis of EPTB received at the Intermediate Reference Laboratory (IRL), Department of Internal Medicine, AIIMS, New Delhi, between April 2016 to March 2017 were included in the study [Figure 1]. Various specimens included cerebrospinal fluid (n = 582), pleural fluid (n = 425), lymph node biopsies and aspirates (n = 423), cold abscess (n = 253), bone marrow (n = 115), peritoneal fluid (n = 159), urine (n = 54), colon/ileal biopsy (n = 76), pericardial fluid (n = 52), endometrial aspirates (n = 40), skin biopsy (n = 20), and synovial fluid (n = 16).
Figure 1: Schematic diagram of study profile

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The standard decontamination protocol (NALC-NAOH method) was followed for processing all nonrespiratory specimens. The processed sample was used for culture inoculation in BACTEC mycobacterium growth indicator tube (MGIT) for liquid culture.[12] Sterile body fluids were centrifuged, and the pellet was directly used as inoculum. All culture-positive isolates were subjected to drug susceptibility testing (DST) against ofloxacin (OFX) at a concentration of 2.0 μg/mL and Kanamycin (KM) at a concentration of 2.5 μg/mL.

OFX and KM were obtained in powdered form from M/s Sigma-Aldrich Co. The isolates were subjected to DST for these drugs using BACTEC MGIT-960 system according to the manufacturer's instructions. DST was performed according to the standard 1% proportionate method as per the manufacturer's instructions (Becton Dickinson, Sparks, MD).

Briefly, MGIT BBL tubes were supplemented with 0.8 ml of oleic acid–albumin–dextrose–catalase. Culture suspension for drug vials, inoculum was diluted to 1:5 with sterile saline from 3 to 5 days old positive vial whereas direct inoculation was done from 0–2 days old positive vial. About 100 μL drugs were added to the MGIT tubes to have final concentrations of 2.0 μg/mL OFX and 2.5 μg/mL of KM. A growth control (GC) tube was prepared without antibiotic; culture suspension for GC tube was diluted to 1:100 with sterile saline from drug inoculum. The drug tubes were inoculated with 0.5 ml of the inoculum diluted to 1:5. For GC tube, the drug tubes were inoculated with 0.5 ml of the inoculums diluted to 1:100.

  Results Top

Emergence of ofloxacin monoresistance among drug-sensitive and drug-resistant tuberculosis patients

A total of 2145 patients were enrolled in the present study. The male: female ratio was 1.3 (1203/943), and the mean age was 34.7 ± 15 years. The overall culture positivity rate was 20.2% (447/2215) which is quite similar to our previous study.[13] For the detection of FQ resistance among Mtb isolates, the DST of OFX drug was carried out both with FLDs and second-line anti-TB drugs (SLDs). Out of the 447 Mtb isolates, 348 were sensitive to FLDs, 54 were rifampicin-resistant (RR)/MDR-TB isolates, and the remaining 45 isolates were any drug resistant among FLDs. FQ monoresistance was observed in 4.3% (15/348) and 20.4% (11/54) among FLD-sensitive strains and RR/MDR-TB isolates, respectively. The emergence of preextensively drug-resistant (XDR) TB among drug-sensitive and drug-resistant Mtb isolates was 4.3% (15/348) and 22.2% (12/54), respectively [Table 1].
Table 1: Ofloxacin monoresistance among drug-sensitive and drug-resistant (RR/MDR-TB) TB patients

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Prevalence of preextensively drug resistant and extensively drug resistant among rifampicin-resistant/multidrug-resistant tuberculosis isolates

About 54 RR/MDR-TB isolates on phenotypic DST were subjected to second-line DST. Out of these, FQ monoresistance (OFX) was found in 11/54 (20.4%) isolates, whereas KM monoresistance was found in 01/54 (1.8%) isolates. The remaining 40/54 (74.1%) isolates were sensitive to all SLDs. The overall prevalence of pre-XDR was 12/54 (22.2%), and XDR-TB was detected in two isolates (3.7%) [Table 2].
Table 2: Profiling of drug resistance pattern of secondline anti-TB drugs in extrapulmonary RR/MDR-TB isolates

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  Discussion Top

Drug resistance has emerged as a major problem in TB management research for new drugs and development of efficacious drug combinations, and regimens are the need of the hour. Newer-generation FQ shaves the potential to become an integral part of the treatment regimen against TB, especially drug-resistant TB. However, these drugs being broad-spectrum antibiotics are also used in the management of a variety of community-acquired infections because of the free availability of these drugs on the counter in the Indian market. FQs accounted for 43% of prescriptions in a study conducted in the USA between November 2000 and January 2001 on the outpatient prescriptions for the treatment of community-acquired pneumonia.[14] A similar audit in India was conducted by ORG IMS, a joint venture between ACNielsen ORG-MARG and IMS Health in India, which conducts prescription audits, attitudinal surveys, and disease-specific studies. They reported that the two most frequently prescribed antibiotics were CFX and OFX, with gatifloxacin and levofloxacin being the sixth and the eighth most frequently prescribed drugs, respectively.[15]

Increasing use of FQs has resulted in an increase in resistance to these antimicrobials. Some studies suggested that FQ resistance may develop as a result of FQ exposure for a small duration as 13 days among treatment-naïve and treatment-experienced TB patients.[16] Reduced susceptibility to one quinolone likely confers reduced susceptibility to all FQs; such cross-resistance within the FQ class was also observed.[17]

The present study illustrates the FLD and SLD resistance including FQ (OFX) monoresistance among FLD-sensitive EPTB cases. An alarmingly higher rate of FQs monoresistance was reported from Mumbai, India,[18] showing an increase from 3% in 1996 to 35% in 2004. The authors attributed such high OFX monoresistance to the widespread use of these vital drugs in the treatment of community-acquired infections. In the present study, OFX resistance was found in 20.4% from 54 RR/MDR-TB isolates studied for SLD pattern. Findings of the present study are slightly lower than a prospective study conducted by Jain et al. 2012[11] in Lucknow, India, who reported 26.3% of OFX resistance among MDR-TB isolates. This might be justified as they analyzed the prevalence from treatment-experienced TB patients only. For detection of FQ resistance among Mtb isolates, the DST of OFX was carried out with FLDs and SLDs. According to the Global TB Report 2015, the proportion of MDR-TB cases having resistance to any FQ, including OFX, levofloxacin, and moxifloxacin, was 21% (95% confidence intervals: 8.3%–34%), whereas in the present study, we observed OFX monoresistance to be 20.4%. Recently, a study from Tamil Nadu, India, by Selvakumar et al. 2015[19] reported 29% of OFX monoresistance in treatment-experienced cases. Among drug-sensitive Mtb isolates, OFX monoresistance of 4.3% (15 of 348) was reported in the present study; this is also a matter of great concern. A DRS study conducted by Ramachandran et al. in 2009[16] reported 24% FQ monoresistance among MDR-TB isolates.

In recent years, the emergence of XDR-TB has appeared as a cause of great concern. Furthermore, limited data are available on XDR-TB among EPTB patients. The present study reported only two treatment-experienced patients with MDR-TB who had XDR-TB (prevalence: 3.7%); this finding is a bit higher than the previous study (2.7%).[20] Such discrepancy could be attributed to the large sample size of the present study as compared to other studies. Earlier studies contradict the present study where large subsets of MDR-TB isolates (22.2%) had pre-XDR-TB (defined as resistance to FQ or injectable aminoglycoside in addition to rifampicin and Isoniazid (INH). Other FQs were not tested due to the high prevalence of cross-resistance.[21] Early identification of these patients is important as they pose the highest risk for developing XDR-TB. Rising FQ resistance in India can be largely attributed to poor knowledge, poor drug adherence to short-course chemotherapy, unregulated prescription of these drugs, their easy availability, and use as an empirical antitubercular treatment by private practitioners.

To avoid this alarming situation of FQ resistance, we should adopt more restrictive policies to control the counter availability of FQs and prevent their rational use by clinicians.[22] More resources, rapid DST implementation, and regular drug resistance surveillance are required to control aggressive TB.[23]

The strength of this study lies in the large sample size with inclusion of all possible types of EPTB samples, and the limitation includes the use of OFX alone for DST. Other FQs (levofloxacin and moxifloxacin) were not tested as a high degree of cross-resistance has been observed (WHO Global TB report 2016).

It can be concluded that the situation of high degree of FQ resistance as observed in EPTB specimens among drug-sensitive and MDR-TB isolates is alarming. This study reflects the need to expand culture and DST for EPTB cases and include FQs within the first-line DST in such settings. Furthermore, the use of FQs should be monitored, and these drugs should be used rationally for the treatment of other diseases. Several other countries such as Canada have adopted the FQ restriction policy; we also support the adoption of such policy in India. If not controlled, the alarming increase in FQ resistance globally could be a threat to TB control programs.


The authors are thankful to the All India Institute of Medical Sciences administration for providing the appropriate infrastructure; Central TB Division, Ministry of Health and Family Welfare, Government of India; State TB Cell, Foundation for Innovative New Diagnostics, India, for logistic support. The authors acknowledge the help of the staff at IRL, AIIMS, New Delhi, for sample collection and processing.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2]


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