Culture and Next-generation sequencing-based drug susceptibility testing unveils high levels of drug-resistance-TB in Djibouti: results from the first national survey.

Djibouti is a small country in the Horn of Africa with a high TB incidence (378/100,000 in 2015). Suboptimal treatment success and the identification of hundreds of TB patients with multidrug-resistant TB (MDR-TB) - several also resistant to second-line TB agents - suggested that drug-resistance is a major problem in the country.A national survey was conducted to estimate the proportion of MDR-TB among a representative sample of TB patients. Sputum was tested using XpertMTB/RIF and samples with rifampicin resistance underwent first line phenotypic susceptibility testing.301 new and 66 previously treated TB cases were enrolled. MDR-TB was detected in 34 patients. Resistance to pyrazinamide, aminoglycosides and capreomycin was detected in 62%, 18% and 29% of MDR-TB strains respectively, while resistance to fluoroquinolones was not detected. Cluster analysis identified primary transmission of MDR-TB as a critical factor fostering drug resistance in the country. Levels of MDR-TB in Djibouti are among the highest on the African continent. High levels of resistance to pyrazinamide and second-line injectable agents have important implications for treatment regimens.