Overview
Rifampicin-resistant tuberculosis (RR-TB) is a form of tuberculosis caused by Mycobacterium tuberculosis strains that are resistant to the drug rifampicin 15. This resistance necessitates alternative treatment regimens 3.Diagnosis
The Xpert MTB/RIF Ultra (Xpert Ultra) assay is a WHO-recommended rapid molecular diagnostic test that simultaneously detects tuberculosis and rifampicin resistance 125.
Xpert Ultra is used for pulmonary tuberculosis and rifampicin resistance detection in adults and adolescents with presumptive pulmonary tuberculosis 15.
In children, Xpert Ultra is used to detect pulmonary tuberculosis, tuberculous meningitis, lymph node tuberculosis, and rifampicin resistance 2.
Reference standards for rifampicin resistance detection include culture-based phenotypic drug susceptibility testing, with or without whole genome sequencing 1.Management
Novel regimens, such as those based on levofloxacin (Lfx) or bedaquiline (Bdq), have demonstrated lower hepatotoxicity compared to the WHO shorter regimen for RR-TB 3.
The WHO shorter regimen for RR-TB was associated with the highest prevalence of hepatotoxicity (26.7%) and drug-induced liver injury (18.3%) in one trial 3.
Close monitoring of liver function is recommended throughout RR-TB treatment 3.Special Populations
Xpert Ultra is used for the diagnosis of pulmonary tuberculosis, tuberculous meningitis, lymph node tuberculosis, and rifampicin resistance in children aged birth to nine years 2.Key Recommendations
The Xpert MTB/RIF Ultra assay is recommended for the simultaneous detection of tuberculosis and rifampicin resistance in adults and adolescents with presumptive pulmonary tuberculosis 15. (Evidence: Moderate)
Novel regimens, such as levofloxacin-based or bedaquiline-based regimens, may be associated with lower hepatotoxicity compared to the WHO shorter regimen for rifampicin-resistant tuberculosis 3. (Evidence: Moderate)
Comprehensive management monitoring, including liver function tests, is recommended during treatment for rifampicin-resistant tuberculosis 3. (Evidence: Expert opinion)References
1 Horne DJ, Zifodya JS, Shapiro AE, Church EC, Kreniske JS, Kay AW et al.. Xpert MTB/RIF Ultra assay for pulmonary tuberculosis and rifampicin resistance in adults and adolescents. The Cochrane database of systematic reviews 2025. link
2 Kay AW, Madison M, Scandrett K, Ness T, Amuge P, Inbaraj LR et al.. Xpert MTB/RIF Ultra assay for tuberculosis disease and rifampicin resistance in children. The Cochrane database of systematic reviews 2025. link
3 Song L, Zhang Y, Sun F, Lan Y, Tong J, Ge S et al.. Assessing hepatotoxicity in novel and standard short regimens for rifampicin-resistant tuberculosis: Insights from the TB-TRUST and TB-TRUST-plus trials. International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases 2024. link
4 Peng TR, Chen JH, Chang YH, Shiang JC, Lee MC, Lee CH et al.. Advantages of short-course rifamycin-based regimens for latent tuberculosis infection: an updated network meta-analysis. Journal of global antimicrobial resistance 2022. link
5 Zifodya JS, Kreniske JS, Schiller I, Kohli M, Dendukuri N, Schumacher SG et al.. Xpert Ultra versus Xpert MTB/RIF for pulmonary tuberculosis and rifampicin resistance in adults with presumptive pulmonary tuberculosis. The Cochrane database of systematic reviews 2021. link