The WHO/IUATLD diagnostic algorithm for tuberculosis and empiric fluoroquinolone use: potential pitfalls.

According to the current WHO/IUATLD diagnostic algorithm for tuberculosis, to establish the diagnosis of smear-negative pulmonary disease, patients should first demonstrate no clinical response to a course of broad-spectrum antibiotics. The fluoroquinolones have broad-spectrum activity against respiratory pathogens and are generally considered first-line therapy for the treatment of community-acquired pneumonia; they also have bactericidal activity against Mycobacterium tuberculosis. Of note, empiric fluoroquinolone monotherapy has been associated with delays in the initiation of appropriate anti-tuberculosis therapy, and also resistance in M. tuberculosis. Delays in the diagnosis and treatment of tuberculosis are associated with increased morbidity and mortality. Resistance to fluoroquinolones in M. tuberculosis could limit the use of this potentially first-line class of anti-tuberculosis agents. The WHO/IUATLD diagnostic criteria for smear-negative tuberculosis should be revised to ensure that fluoroquinolones are not used inappropriately and that the detrimental effects of empiric fluoroquinolone monotherapy in tuberculosis patients are avoided.