A basis for the clinical management of complicated MDR-TB cases Ignacio Monedero and Sandya Holkar summarise best practice in the often lengthy and complex managemenet of multidrug-resistant tuberculosis

Summary Successful multidrug-resistant tuberculosis (MDR-TB) treatment and programme performance is possible even in complex circumstances. Governments are subject to strong pressure from donors concerning both DOTS (directly observed treatment, short course) expansion initiatives and especially MDR management. 1 Nevertheless, anyone assuming an MDR programme can be launched just with money and drugs is probably labouring under a grave misapprehension. A sound understanding of the clinical management of both susceptible and resistant TB is one of the basic fundamentals. The substandard use of second-line drugs is not only measured in low cure rates but in drug resistance amplifi cation in the community, and hence potentially circulating extensively drug-resistant (XDR) TB strains. From a clinical point of view, MDR management is lengthy and complicated, involving the entire range of problems attendant upon chronic disease plus the high toxicity profile of second-line drugs. In addition, in de veloping countries with high HIV/TB co-infection levels, the complexity in terms of clinical and drug management issues increases. Poverty and lack of access to care and treatment can reduce adherence and further complicate the recovery process. This paper provides a brief summary of the best practice in MDR-TB patients including the most frequent side-effects and practical advice on managing TB/HIV co-infection based upon the most recent evidence. Background