Multidrug-resistant tuberculosis (MDR-TB) is a global public health threat associated with high mortality and challenging treatment regimens. The UK, like many countries, faces a growing incidence of MDR-TB, with 105 (1.9% of all notified cases) treated as MDR-resistant or rifampicin-resistant TB in 2024. Recent clinical trials have demonstrated the efficacy and safety of shorter, all-oral regimens such as BPaLM (bedaquiline, pretomanid, linezolid, moxifloxacin), yet their implementation in the UK presents unique challenges, particularly around the antimicrobial stewardship (AMS) agenda, such as the lack of licensed drugs, pharmacokinetic/dynamic concerns, fragile supply chains and high cost of second-line antituberculosis drugs. This narrative review outlines how the UK has addressed implementation hurdles through coordinated efforts by the British Thoracic Society MDR-TB Clinical Advice Service and National Health Service England. This collaboration has facilitated the adoption of new regimens, with 54 out of 60 requests for using pretomanid-containing regimens approved in the UK up to January 2026. Furthermore, resources like the TB Drug Monographs and the shift to video-observed therapy have streamlined care delivery. The UK has effectively navigated the transition to shorter, all-oral MDR-TB regimens, significantly enhancing patient care and operational efficiency. The integration of clinical guidance, AMS principles, policy reform and specialised monitoring tools provides a robust framework for managing evolving treatment landscapes and delivering patient-centred care.

Tuberculosis is treated mainly in secondary care, but patients commonly present to primary care for investigation of initial symptoms and treatment monitoring. This article discusses the most frequently used anti‐tuberculosis drugs, their monitoring requirements and how to manage drug interactions and adverse reactions.

IntroductionSystemic biologic agents can increase the risk of reactivation of latent tuberculosis (TB). Prior to initiation, screening for latent TB using an interferon-γ (IFN-γ) release assay (IGRA) is recommended. There is concern that false negative IGRAs may be more likely in this context.MethodsThis retrospective analysis of IGRA, specifically TSPOT.TB, results and outcomes of patients already on or due to start biologics identifies the rate of TB reactivation in a low TB incidence setting. Additionally, we estimate the negative predictive value (NPV) of IGRAs in this population.ResultsPatients on biologics were more likely to have a negative IGRA result than patients not on biologics. There was no statistically significant change in conversion or reversion rates between groups. Of 9263 patients on biologics, 19 developed active TB after starting biologics at an incidence of 55.1 per 100 000 patient years. This occurred despite screening in half of the 16 patients for whom we were able to review medical records. Most drugs implicated were known to be high risk, although rituximab and natalizumab were being taken by 5 patients and 1 patient respectively. The TSPOT.TB NPV was 99.20% and dropped only slightly to 99.17% when we simulated an approach where all borderline IGRA results were regarded as being negative.ConclusionNegative IGRA results confer a low risk of subsequent active TB in patients on biologics in a low incidence setting. However, continued awareness is needed given that a number of active TB cases will have had a prior negative result.

BackgroundSystemic biologic agents can increase the risk of re-activation of latent tuberculosis (TB). Prior to initiation, screening for latent TB using an interferon-γ release assay (IGRA) is recommended. There is concern that false-negative IGRAs may be more likely in this context.MethodsThis retrospective analysis of IGRAs, specifically T-SPOT.TB, results and outcomes of patients already on or due to start biologics identifies the rate of TB re-activation in a low TB incidence setting. Additionally, we estimate the negative predictive value (NPV) of IGRAs in this population.ResultsPatients on biologics were more likely to have a negative IGRA result than patients not on biologics. There was no statistically significant change in conversion or reversion rates between groups. Of 9263 patients on biologics, 19 developed active TB after starting biologics at an incidence rate of 55.1 per 100 000 patient-years. This occurred despite screening in half of the 16 patients for whom we were able to review medical records. Most drugs implicated were known to be high risk, although rituximab and natalizumab were being taken by five patients and one patient, respectively. The T-SPOT.TB NPV was 99.20% and dropped only slightly to 99.17% when we simulated an approach where all borderline IGRA results were regarded as being negative.ConclusionsNegative IGRA results confer a low risk of subsequent active TB in patients on biologics in a low TB incidence setting. However, continued awareness is needed given that a number of active TB cases will have had a prior negative result.