Dilemmas in the management of fluoroquinolone-resistant tuberculosis

Dr Marieke’s (name changed to protect privacy) stomach sinks as she views the x-rays of a mother and her daughter aged 5 years. Both of them have rifampicin-resistant tuberculosis (RR-TB) with additional fluoroquinolone resistance (pre-extensively drug-resistant tuberculosis [pre-XDR-TB]). The mother has multiple pulmonary cavities. Dr Marieke’s tuberculosis clinic in a township outside of Cape Town, South Africa, is busy, but she tries to discuss the recommended treatment plan with every patient. For those with pre-XDR-TB, it is challenging to review the different options.