Fluoroquinolone-resistant tuberculosis: implications in settings with weak healthcare systems

•Fluoroquinolones (FQs) are essential anti-tuberculosis drugs, and regimens containing FQs are increasingly explored and are effective.•FQ resistance among Mycobacterium tuberculosis complex isolates is increasing in high-burden countries.•High-burden countries also have weak healthcare systems, which help propagate FQ resistance through omission of regulatory policies and commission of irresponsible drug use.•Drug regulatory agencies as well as other healthcare policymakers and stakeholders must ensure responsible use of FQs to counter increasing drug resistance.•One Health Initiative models work best in preventing FQ misuse in the non-healthcare environment.

SummaryFluoroquinolones (FQ) play an essential role in the treatment and control of multidrug-resistant tuberculosis (MDR-TB). They are also being evaluated as part of newer regimens under development for drug-sensitive TB. As newer FQ-based regimens are explored, knowledge of FQ resistance data from high TB burden countries becomes essential. We examine available FQ resistance data from high TB burden countries and demonstrate the need for comprehensive surveys to evaluate FQ resistance in these countries. The factors driving FQ resistance in such conditions and the cost of such resistance to weak healthcare systems are discussed. The need for a comprehensive policy for addressing the issue of FQ resistance is highlighted.