title: Dilemma of managing asymptomatic children referred with 'culture-confirmed' drug-resistant tuberculosis.
abstract: The diagnosis of drug-resistant tuberculosis (DR-TB) in children is challenging and treatment is associated with many adverse effects.
  
  
  
  We aimed to assess if careful observation, without initiation of second-line treatment, is safe in asymptomatic children referred with 'culture-confirmed' DR-TB.
  
  
  
  KwaZulu-Natal, South Africa-an area with high burdens of HIV, TB and DR-TB.
  
  
  
  We performed an outcome review of children with 'culture-confirmed' DR-TB who were not initiated on second-line TB treatment, as they were asymptomatic with normal chest radiographs on examination at our specialist referral hospital. Children were followed up every other month for the first year, with a final outcome assessment at the end of the study.
  
  
  
  In total, 43 asymptomatic children with normal chest radiographs were reviewed. The median length of follow-up until final evaluation was 549 days (IQR 259-722 days); most (34; 83%) children were HIV uninfected. Resistance patterns included 9 (21%) monoresistant and 34 (79%) multidrug-resistant (MDR) strains. Fifteen children (35%) had been treated with first-line TB treatment, prior to presentation at our referral hospital. At the final evaluation, 34 (80%) children were well, 7 (16%) were lost to follow-up, 1 (2%) received MDR-TB treatment and 1 (2%) died of unknown causes. The child who received MDR-TB treatment developed new symptoms at the 12-month review and responded well to second-line treatment.
  
  
  
  Bacteriological evaluation should not be performed in the absence of any clinical indication. If drug-resistant Mycobacterium tuberculosis is detected in an asymptomatic child with a normal chest radiograph, close observation may be an appropriate strategy, especially in settings where potential laboratory error and poor record keeping are constant challenges.
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa.
authors.forename: Marian
authors.initials: M
authors.lastname: Loveday
authors.affiliation: Drug-resistant TB Unit, KwaZulu-Natal Department of Health, King Dinuzulu Hospital, Durban, South Africa.
authors.forename: Babu
authors.initials: B
authors.lastname: Sunkari
authors.affiliation: Clinical School, Children's Hospital at Westmead, University of Sydney, Sydney, Australia.
authors.forename: Ben J
authors.initials: BJ
authors.lastname: Marais
authors.affiliation: Drug-resistant TB Unit, KwaZulu-Natal Department of Health, King Dinuzulu Hospital, Durban, South Africa.
authors.forename: Iqbal
authors.initials: I
authors.lastname: Master
authors.affiliation: Department of Medicine, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, New York, USA.
authors.forename: James C M
authors.initials: JC
authors.lastname: Brust
mesh_terms: D000995:Antitubercular Agents / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D024881:Drug Resistance, Bacterial; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D009169:Mycobacterium tuberculosis / Q000187:drug effects / Q000302:isolation & purification; D013902:Radiography, Thoracic; D012017:Referral and Consultation; D016896:Treatment Outcome; D014376:Tuberculosis / Q000175:diagnosis* / Q000382:microbiology / Q000628:therapy*; D018088:Tuberculosis, Multidrug-Resistant / Q000175:diagnosis / Q000382:microbiology / Q000628:therapy; D057832:Watchful Waiting
chemical_list: D000995:Antitubercular Agents
keywords: Asymptomatic; DR-TB; HIV; children; management