RESEARCH ARTICLE

Drug-resistance patterns of Mycobacterium

tuberculosis strains and associated risk factors
among multi drug-resistant tuberculosis
suspected patients from Ethiopia
Eyob Abera Mesfin1,2*, Dereje Beyene1, Abreham Tesfaye3, Addisu Admasu4,
Desalegn Addise2, Miskir Amare2, Biniyam Dagne2, Zelalem Yaregal2, Ephrem Tesfaye2,
Belay Tessema5

1 Addis Ababa University, Department of Microbial, Cellular and Molecular Biology, Addis Ababa, Ethiopia,
a1111111111
2 Ethiopian Public Health Institute, Addis Ababa, Ethiopia, 3 Addis Ababa City Administration Health Bureau
a1111111111 Health Research and Laboratory Services, Addis Ababa, Ethiopia, 4 St. Peter Hospital, Addis Ababa,
a1111111111 Ethiopia, 5 Department of Medical Microbiology, College of Medicine and Health Sciences, University of
a1111111111 Gondar, Gondar, Ethiopia
a1111111111
* eyob2001@gmail.com

Abstract
OPEN ACCESS

Citation: Mesfin EA, Beyene D, Tesfaye A, Admasu

A, Addise D, Amare M, et al. (2018) Drug- Background
resistance patterns of Mycobacterium tuberculosis
strains and associated risk factors among multi
Multidrug drug-resistant tuberculosis (MDR-TB) is a major health problem and seriously
drug-resistant tuberculosis suspected patients threatens TB control and prevention efforts globally. Ethiopia is among the 30th highest TB
from Ethiopia. PLoS ONE 13(6): e0197737. https:// burden countries for MDR-TB with 14% prevalence among previously treated cases. The
doi.org/10.1371/journal.pone.0197737
focus of this study was on determining drug resistance patterns of Mycobacterium tubercu-
Editor: Seyed Ehtesham Hasnain, Indian Institute losis among MDR-TB suspected cases and associated risk factors.
of Technology Delhi, INDIA

Received: January 7, 2018 Methods

Accepted: May 8, 2018 A cross-sectional study was conducted in Addis Ababa from June 2015 to December 2016.
Published: June 4, 2018 Sputum samples and socio-demographic data were collected from 358 MDR-TB suspected
cases. Samples were analyzed using Ziehl-Neelsen technique, GeneXpert MTB/RIF assay,
Copyright: © 2018 Mesfin et al. This is an open
access article distributed under the terms of the and culture using Lowenstein-Jensen and Mycobacterial growth indicator tube. Data were
Creative Commons Attribution License, which analyzed using SPSS version 23.
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Results
Data Availability Statement: All relevant data are
A total of 226 the study participants were culture positive for Mycobacterium tuberculosis,
within the paper and its Supporting Information among them, 133 (58.8%) participants were males. Moreover, 162 (71.7%) had been previ-
file. ously treated for tuberculosis, while 128 (56.6%) were TB/HIV co-infected. A majority [122
Funding: Financial and material supports required (54%)] of the isolates were resistant to any first-line anti-TB drugs. Among the resistant iso-
for sample collection, laboratory analysis were lates, 110 (48.7%) were determined to be resistant to isoniazid, 94 (41.6%) to streptomycin,
obtained from Addis Ababa University, College of
89 (39.4%) to rifampicin, 72 (31.9%) to ethambutol, and 70 (30.9%) to pyrazinamide. The
Natural Science Department of Microbial Cellular
and Molecular Biology, and Ethiopian Public Health prevalence of MDR-TB was 89 (39.4%), of which 52/89 (58.4%) isolates were resistance to
Institute (EPHI). all five first-line drugs. Risk factors such as TB/HIV co-infection (AOR = 5.59, p = 0.00),

PLOS ONE | https://doi.org/10.1371/journal.pone.0197737 June 4, 2018 1 / 16

 Drug-resistance patterns of MTB strains among MDR-TB suspected patients from Ethiopia

Competing interests: All authors declare that they cigarette smoking (AOR = 3.52, p = 0.045), alcohol drinking (AOR = 5.14, p = 0.001) hospital
have no conflict of interest associated with the admission (AOR = 3.49, p = 0.005) and visiting (AOR = 3.34, p = 0.044) were significantly
publication of this manuscript.
associated with MDR-TB.

Conclusions
The prevalence of MDR-TB in the study population was of a significantly high level among
previously treated patients and age group of 25–34. TB/HIV coinfection, smoking of ciga-
rette, alcohol drinking, hospital admission and health facility visiting were identified as risk
factors for developing MDR-TB. Therefore, effective strategies should be designed consid-
ering the identified risk factors for control of MDR-TB.

1. Background
Tuberculosis (TB) continues to represent as a global major health challenge to the reduction of
morbidity and mortality among millions of people every year. The health of approximately
10.4 million individuals worldwide are impacted annually by TB resulting in approximately
1.8 million TB-related deaths, with the majority (95%) of deaths were reported from resource-
limited countries [1]. In Sub-Saharan countries, the prevalence of MDR-TB is high especially
among previously treated TB cases when contrasted with new cases of TB [2]. Research has
revealed that approximately 500,000 cases of MDR-TB emerge annually every year [3] and that
approximately 3% of these cases receive treatment and that more than 100,000 deaths occur
annually because of MDR-TB. In addition, as many as 10% of MDR-TB cases were extensively
drug-resistant (XDR) [4]. MDR-TB is defined as resistance to both rifampicin and isoniazid;
XDR is defined as MDR-TB with additional resistance to any fluoroquinolone and at least one
of the three second-line injectable drugs: amikacin, capreomycin and kanamycin [5].
According to a recent World Health Organization (WHO) report of high TB-related bur-
den countries, Ethiopia was identified as being among the thirty highest TB-burdened nations
(TB, TB/HIV and MDR-TB) with TB remaining one of the Ethiopia’s leading causes of mortal-
ity. According to the 2017 WHO report, the prevalence of MDR-TB in Ethiopia was reported
to be 2.7% and 14% among new and previously treated cases respectively with the prevalence
of TB/HIV co-infection assessed as being 8% of the affected population [6]. Moreover, several
studies done in Ethiopia showed that the prevalence of MDR-TB was 31.4% in Jimma [7], 28%
in Addis Ababa [8], 46.3% in Addis Ababa [9] and 5% in Northwest Ethiopia [10]. Rapid trans-
mission of MDR-TB is a major public health problem globally especially for resource-limited
countries and represents a major challenge for TB control program. In addition, high preva-
lence of TB, poor treatment, limited access to health care, and several other related factors
have constrained the ability of the sub-Saharan region, including Ethiopia to effectively control
MDR-TB [11]. Finally, the rapid transmission of XDR-TB has recently emerged as yet another
challenge for TB control program [12].
Drug-resistant strains of Mycobacterium tuberculosis (MTB) arise from spontaneous chro-
mosomal mutations at a predictable low frequency, but a study done by Gandh et al. revealed
that selection pressure that is caused by inappropriate utilize of anti-TB drugs results in the
emerging of resistant MTB [13]. Similarly, a study done in Ethiopia identified long treatment,
poor treatment follow up & interruption of treatment were identified as risk factors for signifi-
cant increases in MDR-TB [14]. Other studies done in Ethiopia and China also revealed that
HIV infection, cigarette smoking, alcohol drinking, overpopulated, and weak DOTS (Directly

PLOS ONE | https://doi.org/10.1371/journal.pone.0197737 June 4, 2018 2 / 16

 Drug-resistance patterns of MTB strains among MDR-TB suspected patients from Ethiopia

Observed Treatment Short-course) program were the major risk factors for spread of
MDR-TB infection [7–9, 14, 15].
The global pattern of MDR-TB is not well known and little information is available regard-
ing MDR-TB strains in a high TB/HIV prevalence countries like Ethiopia. MDR-TB is a result
of unsuccessful TB control programs characterized by inappropriate TB treatment, and poor
diagnostic capacity. In resource-limited countries such as Ethiopia, MDR-TB is public health
threat due to poor adherence to treatment, delay of treatment and shortage of diagnostic cen-
ter for MDR-TB [11]. In Ethiopia, an MDR-TB suspected case is defined as a patient who is a
case of treatment failure; a symptomatic patient who had a close contact with confirmed
MDR-TB patient; a patient from known high-risk group such as health workers; a patient who
remains smear positive after 2 months of treatment (new cases); or remains smear positive
after 3 months of retreatment with first-line treatment (retreatment cases such as defaulter,
relapse) [16]. In all such cases, the development of enhanced diagnosis and treatment strategies
are essential for controlling transmission of TB especially MDR-TB. Accordingly, this study
focused on the identification of drug-resistance patterns of Mycobacterium tuberculosis strains
among MDR-TB suspected patients and the associated risk factors for the development of
MDR-TB in the study area.

Materials and methods

Study setting and design
A cross-sectional institution based survey was conducted between June 2015 and December
2016 in health facilities found in Addis Ababa, the capital city of Ethiopia. The study was con-
ducted in selected health facilities. All samples were collected from study participants visiting
the health facilities in Addis Ababa during the study period. Health facilities which provided
laboratory services for MDR-TB diagnosis were selected from Addis Ababa city. Sample analy-
sis was performed at Ethiopia Public Health Institute (EPHI) National TB Reference Labora-
tory, Ethiopia. The sample size was calculated using single population proportion formula
considering the assumptions that at 95% confidence level with 5% precision and z value of 1.96
[17], and the 2014 Ethiopian national TB drug resistance survey report showed that the preva-
lence of drug-resistant TB among previously treated cases was 17.8% [18].
Thus, considering 10% nonresponse rate, the minimum sample size was 248 MDR-TB sus-
pected cases. MDR-TB suspected cases are patients who are a case of treatment failure; a symp-
tomatic patients who had a close contact with confirmed MDR-TB patient; patients from
known high-risk group such as health workers; patients who remain smear positive after 2
months of treatment (new cases); or remain smear positive after 3 months of retreatment with
first-line treatment [16].
In Ethiopia drug-resistant TB diagnosis has been carried out using the GeneXpert MTB/
RIF assay and phenotypic drug susceptibility testing (DST). However, as GeneXpert MTB/RIF
assays and DST are performed in only a few health facilities, MDR-TB suspected cases are
referred to GeneXpert MT/RIF diagnostic sites. Since all MDR-TB suspected cases are referred
to GeneXpert MT/RIF diagnostic sites, GeneXpert MT/RIF diagnostic sites found in Addis
Ababa City were selected as study sites. Therefore, Addis Ababa Health research and Labora-
tory services (Addis Ababa Regional referral Laboratory), Teklehiamnot health center, and
Saint Peter hospital were the study sites to recruit patients for enrollment in this study. Volun-
teer MDR-TB suspected patients who visited the health facilities during a study period were
included as study participants. MDR-TB suspected patients who were seriously ill or uncon-
scious, patients who were below the age of 12 years old, and patients who were not willing to
participate in the study were excluded from the study.

PLOS ONE | https://doi.org/10.1371/journal.pone.0197737 June 4, 2018 3 / 16

 Drug-resistance patterns of MTB strains among MDR-TB suspected patients from Ethiopia

Sputum sample collection and laboratory analysis

Sputum samples from patients with pulmonary tuberculosis were collected into a sterile wide
mouth 50 ml falcon tube a volume of 5 to 10 ml, and all specimens were stored at 2–8 oC at
sample collection sites until transported to EPHI TB laboratory using cold chain. Samples
were analyzed using Ziehl-Neelsen Methods [19] and GeneXpert MTB/RIF assay [20] as the
methods described. Moreover samples were cultured using LJ [21] and MGIT [22] methods
for better yield; briefly, the samples were decontaminated with 4% NaOH-NALC and neutral-
ized with phosphate-buffered saline (PBS), and then inoculated on LJ slants at 37˚C for 8
weeks maximum [21] and in BACTEC™ MGIT 960 tubes (BD Diagnostics, Sparks, MD, USA)
at 37˚C for 42 days maximum [22]. All positive culture results were confirmed by using
MPT64 antigen detection methods (Capilia TB) [23]. Phenotypic drug susceptibility test for
rifampicin (RIF), isoniazid (INH), streptomycin (STR), ethambutol (EMB) and pyrazinamide
(PZA) were performed with the Bactec MGIT 960 method. Briefly, 0.1 ml of a bacterial suspen-
sion with a McFarland standard was inoculated into a vial supplemented with reconstitution
solution, and the concentration of drugs was 1.0 μg/ml for RIF, 0.1 μg/ml for INH, 5.0 μg/ml
for EMB 1.0 μg/ml for STR and 100 μg/ml for PZA [22]. Mycobacterium tuberculosis strain
H37Rv was used as a sensitive control for the susceptibility testing.

Data analysis
Data were entered using Epinfo version 3.1 and exported to SPSS version 23 for analysis. Data
completeness and consistency were checked by running frequencies of each variable. Bivariate
analyses were carried out for categorical variables, and odds ratios were used to quantify the
strength of association between potential risk factors and MDR-TB. Multiple logistic regres-
sions were used to control the confounding effect of different variables while assessing the
effect of each variable on the likelihood of MDR-TB occurrence. A p-value of 0.05 was used as
the cut-off point for statistical significance. Variables having a p-value of at most 0.05 in bivari-
ate analysis were included in the multivariate logistic regression model analysis.

Ethical considerations
Ethical approval was obtained from Research and Ethical Review Committee of the Addis
Ababa University and Ethiopian Public Health Institute. Written and or oral informed consent
was taken from each study participant, and parent/guardian for those who were under age of
18 years old Permission was also obtained from study sites. Data and samples were collected
and analyzed using codes so that the confidentiality of the patients & test result were main-
tained throughout the study period.

Results
Socio-demographic characteristics of the study participants
A total of 358 MDR-TB suspected cases were enrolled in this study, of which 226 (63.1%) were
culture positive for MTB and 5 (1.4%) cases were positive for non-tuberculosis mycobacteria
(NTM). Among MTB culture positive cases, majority 133 (58.8%) of cases were males, and 101
(44.7%) of the respondents were in the age group of 24–34 years with an average age of 34.4
years. Majority 213 (94.2%) of the respondents were living in an urban environment. Married
individuals accounted for the majority 162(60.2%) the cases but 80(35.4%) were never married
at all. Most 152 (67.2%) of the respondents were Orthodox by religion and majority 134
(53.1%) of the cases were from Amhara and Oromo ethnic group. Seventy two (31.8%) of the
respondents attended high schools, and they were employed at private organization and 96

PLOS ONE | https://doi.org/10.1371/journal.pone.0197737 June 4, 2018 4 / 16

 Drug-resistance patterns of MTB strains among MDR-TB suspected patients from Ethiopia

(42.5%) of participants had less than 1000 Birr (50 USD) income per month. More than half,
117 (51.7%) of the participants had 2 rooms in their residence. A majority [174 (77%)] of the
participants lived in families with more than two family members. (Table 1 and Fig 1).

TB and treatment related conditions among MDR-TB suspected case

Among the MDR-TB suspected cases 196 (86.7%) cases were AFB positive and 128 (56.6%)
cases were TB/HIV co-infected. One hundred sixty two (71.7%) cases were previously treated
cases that had a history of TB treatment for more than a month in addition to this, 77(34.1%)
cases had a history of family member infected by TB. Among the previously treated cases
(n = 162), 148 (91.4%) were relapse and the remaining 9 (5.6%), and 5(3.1%) were treatment
failure and defaulter cases, respectively. In addition, 26 (16.0%) cases had discontinued anti-
TB drug during treatment time, of these 16(61.5%) cases had discontinued anti-TB drugs for a
month or more and most 24 (92.3%) of the patients discontinued one time during their treat-
ment period. One hundred and ninety (84.1%) cases were visiting health facilities for other
reasons and 51(26.8%) cases were admitted to hospital. Eight-five (37.6%) cases had an antibi-
otic treatment history for other diseases, of which 32 (37.7%) had interrupted antibiotic treat-
ment for more than once. Moreover, 42(18.6%) participants were self-reported frequent
consumers of alcohol and 27(11.9%) reported themselves as being frequent cigarette smokers
(Table 2).

Mycobacterium tuberculosis identification and drug susceptibility test

results
Among 226 Mycobacterium tuberculosis isolates, the majority 123 (54.4%) of isolates were
resistant to at least one of the five first-line anti TB drugs (RIF, INH, PZA, EMB, and STR),
however, the remaining 104 (46.0%) isolates were susceptible to all first-line anti TB drugs.
Moreover, resistance to INH, STR, RIF, EMB and PZA were 110 (48.7%), 94 (41.6%), 89
(39.4%), 72 (31.9%), and 70 (30.9%), respectively. Furthermore, the proportion of drug-resis-
tance pattern among previously treated cases (n = 162) were 87 (53.7%), 75 (46.3%), 73
(45.1%), 59 (36.4%), and 59 (36.4%), and 57 (35.2%), INH, STR, RIF, EMB and PZA, respec-
tively (Table 3).

Patterns of multidrug-resistance
The prevalence of multi-drug-resistant TB was 89 (39.4%), of which 73 (82.0%), 65 (73.0%)
and 63 (70.8%) were additionally resistant to STR, EMB and PZA anti-TB drugs, respectively.
In addition, among multi-drug-resistant TB cases, 52/89 (58.4%) were resistance for all first-
line anti TB drugs (RIF, INH, PZA, EMB, and STR). Moreover, the prevalence of Multi-drug-
resistant TB among previously treated cases was 73/162 (45.1%) whereas 16/64 (25%) were
among new cases. A higher multi-drug-resistance rate was observed among previously treated
cases 73/89 (82.0%) compared with new cases, and a substantial drug-resistance pattern was
observed on STR, PZA, and EMB drugs with 64 (87.7%), 53 (72.6%) and 50 (68.5%) isolates
respectively. Out of 89 MDR-TB confirmed cases, more than three-fourth, [71 (79.8%)] were
HIV positive patients, and majority 87 (97.8%) of the MDR-TB cases were AFB positive
(Table 2). However, 3 (1.3%) isolates had discordant results from MGIT and GeneXpert meth-
ods; both isolates had RIF susceptible results from MGIT but they were found to be RIF resis-
tant by GeneXpert assay. The other one isolate had a resistant result from MGIT and
susceptible with GeneXpert assay. When we evaluated the performance of GeneXpert method
against MGIT for DST, we found that sensitivity result was 99.1% with 99.6% specificity.

PLOS ONE | https://doi.org/10.1371/journal.pone.0197737 June 4, 2018 5 / 16

 Drug-resistance patterns of MTB strains among MDR-TB suspected patients from Ethiopia

Table 1. Socio-demographic characteristics of MDR-TB suspected cases and MDR-TB confirmed cases, Addis
Ababa, January, 2017(n = 226).
Variable All MDR-TB suspected cases MDR-TB confirmed cases Number (%) (n = 89)
Number (%) (n = 226)
Sex
Male 133 (58.8) 37 (41.6)
Female 93 (41.2) 52 (58.4)
Age Group
15–24 27 (11.9) 4 (4.5)
25–34 101 (44.7) 53 (59.6)
35–44 68 (30.1) 23 (25.8)
45–54 20 (8.8) 6 (6.7)
Above 54 10 (4.4) 3 (3.4)
Marital Status
Married 136 (60.2) 54 (60.7)
Single 80 (35.4) 31 (34.8)
Divorced 7 (3) 2 (2.2)
Widow 3 (1.3) 2 (2.2)
Living Region
AA 208 (92.0) 83 (93.3)
Amhara 1 (0.4) 0 (0)
Dire Dawa 2 (0.9) 2 (2.2)
Oromia 12 (5.4) 4 (4.5)
SPNN 3 (1.3) 0 (0)
Residence
Rural 13 (5.8) 4 (4.5)
Urban 213 (94.2) 85 (95.5)
Education status
College 29 (12.8) 15 (16.9)
High School 72 (31.8) 26 (29.2)
Elementary 57 (25.1) 18 (20.2)
R&W 54 (23.9) 22 (24.3)
Illiterate 14 (6.2) 8 (9.0)
Religion
Muslim 46 (20.4) 19 (21.3)
Orthodox 152 (67.3) 61 (68.5)
Protestant 28 (12.4) 9 (10.1)
Monthly Income in ETB
No Income 3 (1.3) 6 (6.7)
100–1000 47 (20.8) 15 (16.9)
1001–2000 101 (44.7) 32 (36.0)
2001–3000 42 (18.6) 23 (25.8)
3001–4000 26 (11.5) 13 (14.6)
4001–5000 7 (3.1) 0 (0)
Occupation 3 (1.3) 6 (6.7)
Daily Laborer 28 (12.4) 9 (10.1)
Government Worker 30 (13.3) 14 (15.7)
House wife 26 (11.5) 13 (14.6)
Private Worker 72 (31.9) 23 (25.8)
Self-employed 67 (29.6) 29 (32.6)
(Continued)

PLOS ONE | https://doi.org/10.1371/journal.pone.0197737 June 4, 2018 6 / 16

 Drug-resistance patterns of MTB strains among MDR-TB suspected patients from Ethiopia

Table 1. (Continued)

Variable All MDR-TB suspected cases MDR-TB confirmed cases Number (%) (n = 89)
Number (%) (n = 226)
Unemployed 3 (1.3) 1 (1.1)
Number of rooms in residence
1–2 173 (76.5) 64 (71.9)
3–4 52 (23) 24(27)
5–6 1 (0.5) 1 (1.1)

ETB: Ethiopian Birr

https://doi.org/10.1371/journal.pone.0197737.t001

Seventy-three (82.0%) MDR-TB cases were previously treated cases and the remaining 16
(18.0%) were new cases. Moreover 23 (25.8%) MDR-TB cases had a history of family member
infected by TB. Among the previously treated cases, the majority [63 (86.3%)] of the MDR-TB
cases were relapse cases, and 7 (9.6%) cases had discontinued their use of an anti-TB drug dur-
ing treatment and 5/7 (71.4%) the cases discontinued anti-TB drugs for more than a month.
Moreover 82 (92.1%) MDR-TB cases were visiting health facilities for other reasons and 20
(22.5%) cases were admitted to hospital. More than a quarter, [23 (25.8%)] had an antibiotic
treatment history for other diseases, while 8/23 (34.7%) of these cases had interrupted antibi-
otic treatment more than once. The majority of MDR-TB cases 52 (58.4%) were males and 85
(95.5%) MDR-TB cases were lived in an urban environment. Fifty-three (59.6%) of the
MDR-TB cases were in the age group of 25–34 years and 54 (60.7%) the cases were married
and more than half, [58 (65.2%)] of the cases were from Amhara and Oromo ethnic group
(Tables 1 and 2, Fig 1).

Risk factors associated with multidrug resistance development

In a univariate analysis of different variables with the development of MDR-TB, TB/HIV co-
infection, previously TB infected cases, a family member who had previously TB infected

Fig 1. The proportion of MDR-TB among suspect cases classified by ethnic groups.
https://doi.org/10.1371/journal.pone.0197737.g001

PLOS ONE | https://doi.org/10.1371/journal.pone.0197737 June 4, 2018 7 / 16

 Drug-resistance patterns of MTB strains among MDR-TB suspected patients from Ethiopia

Table 2. TB disease and other related conditions among MDR-TB suspected and MDR-TB confirmed cases,
Addis Ababa, January, 2017(n = 226).
All MDR-TB suspected cases MDR-TB confirmed cases
Variable Number (%) Number (%)
Family member Previously TB infected
No 149 (65.9) 66 (74.2)
Yes 77 (34.1) 23 (25.8)
Treatment history of TB infected families
No 3 (3.9) 0 (0)
Yes 74 (96.1) 23 (100)
Previously TB Infected
No 64 (28) 16 (18)
Yes 162 (71.7) 73 (82)
Treatment history of previously TB infected cases
No 0 (0) 0 (0)
Yes 162 (100) 73 (100)
Treatment interruption previously TB treated cases
No 136 (84.0) 63 (86.3)
Yes 26 (16.0) 10 (13.7)
Duration of treatment interruption in days
7–21 7 (26.8) 2 (20)
30–45 16 (61.5) 7 (70)
150 1 (3.8) 0 (0)
Unknown 2 (7.7) 1 (10)
Frequency of drug interruption
1 24 (92.2) 9 (90)
3 1 (3.9) 0 (0)
Unknown 1 (3.9) 1 (10)
DOT treatment
No 1 (0.6) 1(1.4)
Yes 161 (99.4) 72(98.6)
TB treatment history
New 64 (28.3) 16 (18)
Retreatment 162 (71.7) 73 (82)
TB history
New 64 (28.3) 16 (18)
Defaulter 5 (2.2) 3 (3.4)
Relapse 148 (65.5) 63 (70.8)
Treatment failure 9 (4.0) 7 (7.9)
AFB Results
Negative 30(13.3%) 2(2.2%)
Positive 196(86.7%) 87(97.8%)
HIV status
Positive 128 (56.6) 71 (79.8)
Negative 98 (43.4) 18 (20.2)
Antibiotic treatment history (frequently)
No 141 (62.4) 45 (50.6)
Yes 85 (37.6) 44 (49.4)
Antibiotic treatment interruption
No 53 (62.3) 29 (65.9)
(Continued)

PLOS ONE | https://doi.org/10.1371/journal.pone.0197737 June 4, 2018 8 / 16

 Drug-resistance patterns of MTB strains among MDR-TB suspected patients from Ethiopia

Table 2. (Continued)

All MDR-TB suspected cases MDR-TB confirmed cases

Variable Number (%) Number (%)
Yes 32 (37.7) 15 (34.1)
Alcohol drinking frequently
No 184 (81.4) 61 (68.5)
Yes 42 (18.6) 28 (31.5)
Cigarettes smoking
No 199 (88.1) 73 (82)
Yes 27 (11.9) 16 (18)
Health facility visiting
Yes 190 (74.1) 82(92.1)
No 36 (15.9) 7 (7.9)
Hospital admission
No 175 (77.4) 55 (61.8)
Yes 51 (22.6) 34 (38.2)

AFB: Acid fast Bacilli; DOT: Directly Observed Treatment; HIV: Human Immunodeficiency Virus

https://doi.org/10.1371/journal.pone.0197737.t002

cases, antibiotic taking, alcohol drinking, age group between 25 & 34 years, cigarette smoking,
health facility visits and hospital admission appear to represent significant risk factors for
MDR-TB (p<0.05). Moreover, multivariate analysis indicated that MDR-TB is significantly
associated with hospital admission, (AOR = 3.49, p = 0.005) health facility visit, ((AOR = 3.34,
p = 0.044), TB/HIV co-infection, (AOR = 5.59, p = 0.00) alcohol drinking (AOR = 5.14,
p = 0.001) and cigarette smoking (AOR = 3.52, p = 0.045). Patients admitted to hospital and
visited health facilities and those who were self-reported as being frequent cigarette smokers
were three times more likely to develop MDR-TB when compared to those who did not fit
these profiles. Moreover, TB/HIV co-infection and drinking alcohol were five times more
likely to have MDR-TB when compared with those HIV negative cases and TB patients who
did not drink alcohol (Table 4).

Discussion
In this study, about 72% of cases were previously treated cases that had a history of TB treat-
ment for more than a month and 34.1% cases had a history of a family member infected by
TB. In addition 16.0% of the cases had discontinued anti-TB drug during the treatment period.
More than 56% of the cases were TB/HIV co-infected patients, and about 80% of the TB/
MDR-TB cases were HIV positive patients. The high prevalence in our study could be attrib-
uted to the fact that HIV-positive patients are more likely to develop TB/MDR-TB than HIV
negative patients due to their immunocompromised status. In supporting our finding, several
studies revealed that HIV infection was the major associated risk factor for spread of MDR-TB
infection in population [7–9, 14, 15]. Moreover, the study also found that more than 95% of
the MDR-TB cases lived in an urban environment. Evidence from a previous study showed
that patients who live in an urban area are more likely to develop drug-resistant TB due to
slums/overcrowded area that favor for transmission of TB/MDR-TB [7].
Furthermore, the highest rate of MDR-TB patients were also in the age group of 25–34
years, a finding that is consistent with other studies done in Ethiopia [7, 24, 25]. The highest
rate of MDR-TB in this age group might possibly be due to this age cohort’s high mobility and
high-risk behavior could possibly expose them to greater risk of acquiring TB as well as to a

PLOS ONE | https://doi.org/10.1371/journal.pone.0197737 June 4, 2018 9 / 16

 Drug-resistance patterns of MTB strains among MDR-TB suspected patients from Ethiopia

Table 3. Drug resistance pattern in Mycobacterium tuberculosis complex isolates among retreatment and new MDR-TB suspected cases Addis Ababa, January,
2017(n = 226).
All case (n = 226) Previously treated cases (n = 162) Number (%) New cases (n = 64)
Drug Resistance Pattern Number (%) Number (%)
Any Resistance 123 (54.4) 95 (58.6) 28 (43.8)
EMB 72 (31.9), 59 (36.4) 13 (20.3)
INH 110 (48.7), 87 (53.7) 23 (35.9)
STR 94 (41.6) 75 (46.3) 19 (29.7)
PZA 70 (30.9) 57 (35.2) 13 (20.3)
RIF 89 (39.4) 73 (82) 16 (25.0)
Mono Resistance 20 (8.8) 12 (7.4) 8 (12.5)
EMB 4 (1.8) 4 (2.5) 0 (0.0)
INH 7 (3.1) 4 (2.5) 3 (4.7)
STR 7 (3.1) 3 (1.9) 4 (6.3)
PZA 2 (0.9) 1 (0.6) 1 (1.6)
Multi drug Resistance(MDR) 89 (39.4) 73 (45.1) 16 (25.0)
RIF + INH 5 (2.2) 5 (3.1) 0 (0)
RIF + INH + EMB 3 (1.3) 2 (1.2) 1 (1.6)
RIF + INH + STR 10 (4.4) 8 (4.9) 2 (3.1)
RIF + INH + PZA 2 (0.9) 1 (0.6) 1 (1.6)
RIF + INH + EMB + STR 6 (2.7) 6 (3.7) 0 (0)
RIF + INH + EMB + PZA 4 (1.8) 3 (1.9) 1 (1.6)
RIF + INH + STR + PZA 5 (2.2) 4(2.5) 1 (1.6)
RIF + INH + EMB + STR + PZA 52 (23.0) 43 (26.5) 9 (14.1)
Poly Resistance (Non MDR) 13 (5.8) 9 (5.6) 4 (6.3)
EMB + INH 2 (0.9) 1 (0.6) 1 (1.6)
INH + STR 6 (2.7) 3 (1.9) 3 (4.7)
EMB + INH + STR 1 (0.4) 1 (0.6) 0 (0.0)
INH + STR + PZA 3 (1.3) 3 (1.9) 0 (0.0)
EMB + INH + STR + PZA 1 (0.4) 1 (0.6) 0 (0.0)

INH: Isoniazid, RIF: Rifampicin, STR: Streptomycin, EMB: Ethambutol, PZA: Pyrazinamide

Poly Resistance is a drug resistance to two and more drugs without the combination of INH and RIF

https://doi.org/10.1371/journal.pone.0197737.t003

tendency to interrupt TB treatment. In another finding, this study identified that 54% of the
study’s population was resistant to any first-line anti-TB drug, a finding that was lower than
previous studies done in Addis Ababa (72.9%) [9] and Southwest, Ethiopia (58.6%) [7]. In
accounting for this difference, it is possible that, as our study included both previously treated
and new cases, a new TB patient is less likely to develop drug resistant TB.
The highest proportion of drug resistance was observed for INH (49%). This is comparable
to the studies done in Southwest Ethiopia (51%) [7] and Addis Ababa (56.1%) [9]. However, as
our finding on 49% INH resistance was slightly higher than previous studies done in Ethiopia
such as 44% [8] and 42.7% [9]), the high proportion of isoniazid resistance has significant
implications since it is an essential drug during the course of TB treatment and a prophylaxis
for latent TB infected individuals, HIV/AIDS patients and household contacts of smear-posi-
tive pulmonary TB cases. In addition, our study found that, at a rate of 41.6%, streptomycin
resistance was comparable with a study done in Southwest, Ethiopia (42.9%) [7], although
appreciably higher than other Ethiopian studies such as 21% [9] and 28% [8]. The high

PLOS ONE | https://doi.org/10.1371/journal.pone.0197737 June 4, 2018 10 / 16

 Drug-resistance patterns of MTB strains among MDR-TB suspected patients from Ethiopia

Table 4. Univariate and multivariate logistic regression result of risk factors for development of MDR-TB, Addis Ababa, January, 2017 (n = 226).
Variable MDR-TB N (%) Crude Odd ratio (95%) P-Value Adjusted Odd ratio (95%) P-Value
Yes No
Age Group
15–24 4 (14.8) 23 (85.2) 1 1
25–34 53 (52.5) 48 (47.5) 6.35 (2.05 19.70) 3.73 (0.51 27.37) 0.261
35–44 23 (33.8) 45 (66.2) 2.94 (0.91 9.51) 0.001 0.65 (0.13 3.27)
45–54 6 (30.0) 14 (70.0) 2.46 (0.59 10.29) 0.78 (0.34 9.28)
55 3 (30.0) 7 (70.0) 2.46 (0.44 13.75) 2.29 (0.34 15.36)
Cigarettes smoking
Yes 73 (36.7) 126 (63.3) 2.51 (1.11 5.70) 0.045 3.52 (1.03 12.05) 0.045
No 16 (59.3) 11 (40.7)
Alcohol drinking
Yes 61 (33.2) 123 (66.8) 4.03 (1.98 8.12) 0.000 5.14 (1.98 13.33) 0.001
No 28 (66.7) 14 (33.3) 1
HIV Status
Positive 71 (55.5) 57 (44.5) 5.54 (2.98 10.28) 0.000 5.59 (2.65 11.75) 0.000
Negative 18 (18.4) 80 (81.6) 1
Antibiotic treatment history
Yes 45 (31.9) 96 (68.1) 2.29 (1.32 3.98) 0.000 1.83 (0.88 3.80) 0.106
No 44 (51.8) 41 (48.2) 1
TB treatment history
Retreatment 73 (45.1) 89 (54.9) 2.46 (1.91 4.69) 0.000 2.21 (0.80 5.89) 0.110
New 16 (25.0) 48 (75.0) 1
TB History
New 16 (25.0) 48(75.0) 1 1
Defaulter 3 (60.0) 2 (40.0) 4.50 (0.69 29.38) 0.012 8.26 (0.86 78.95) 0.067
Relapse 63 (42.6) 85 (57.4) 2.22 (1.16 4.27) 3.56 (0.26 50.16)
Treatment failure 7 (77.8) 2 (22.2) 10.5 (1.97 55.8) 2.78 (0.48 16.14)
Previously TB infected family member
Yes 66 (44.3) 83 (55.7) 0.54 (0.30 0.96) 0.037 0.67 (0.18 2.45) 0.541
No 23 (29.9) 54 (70.1) 1 1
Health facility Visit
Yes 7 (19.4) 29 (80.6) 3.15 (1.31 7.54) 0.019 3.34 (1.03 10.78) 0.044
No 82 (43.2) 108 (56.8) 1
Hospital admitted
Yes 55 (31.4) 120 (68.6) 4.36 (2.25 8.48) 0.000 3.49 (1.45 8.40) 0.005
No 34 (66.7) 17 (33.3) 1

The odds ratio indicated that there was significant association between dependent variable (MDR-TB) and independent variables; N: number

https://doi.org/10.1371/journal.pone.0197737.t004

resistance to streptomycin could be due to the common use of the drug for treatment of any
bacterial infections, poor treatment practice and early introduction for treatment [26].
The proportion of drug resistance for rifampicin drug was rated third with 39.4% and all
rifampicin drug-resistant cases were also resistant to Isoniazid which are MDR-TB cases. This
finding concurs the present practice of TB programs to use RIF resistance as a surrogate
marker for MDR-TB diagnosis and second line anti-TB drugs treatment initiation. Our find-
ing was higher than the findings of previous studies done in Addis Ababa (33.3%) [8] and
Southwest, Ethiopia (32.9%) [7]. The high prevalence in our finding might be that the study

PLOS ONE | https://doi.org/10.1371/journal.pone.0197737 June 4, 2018 11 / 16

 Drug-resistance patterns of MTB strains among MDR-TB suspected patients from Ethiopia

was conducted on population of MDR-TB suspected patients. Furthermore, the ethambutol

drug resistance was ranked fourth with 31.9%. It is comparable with a study done in South-
west, Ethiopia that the proportion of any ethambutol resistance was about 29% [7]. Although
it is the first-line drug, it is also included in the regimen of second-line drugs for MDR-TB
treatment. Hence the high rate of ethambutol resistance could be a challenge for MDR-TB
treatment in the future [27]. Furthermore, resistance to PZA was 30.9%, it is well known that
PZA is a cornerstone anti TB drug because of its unique ability to eradicate persistent bacilli,
that allowed treatment shortening from 9 months to 6 months [28] and it is continuing as an
important drug for susceptible and MDR-TB treatment [29]
In terms of prevalence of MDR-TB, the prevalence of MDR-TB was 39.4%, our finding was
somewhat higher than the previous study done in Southwest, Ethiopia 31.4% [7], and com-
pared with Ethiopian national prevalence for previously treated cases, it was twofold higher
(17.8%) [6]. In addition, the proportion of MDR-TB among previously treated was 45.1%.
This finding is in agreement with a study done in Addis Ababa, Ethiopia (46.3%) [9] and India
(47.1%) [30]. However, it was higher than other studies conducted in Ethiopia (28%) [8] and
Northwest Ethiopia (13.9%). The plausible reasons for high prevalence in our finding might be
that the study was conducted among population of MDR-TB suspected patients;, the nature of
this population included in the studies, and there might also be geographical variation in the
level of drug resistance. Our assumption was supported by Mekonnen and colleagues [31].
In another finding, the percentage of MDR-TB among previously treated cases was signifi-
cantly higher (45.1%) compared to new TB cases (25%) It is well documented that previously
treated cases are more likely to develop MDR–TB than new patients [32]. High rates of
MDR-TB among previously treated cases can be influenced by the acquisition of resistance in
the intensive and continuation phases of treatment or by the rate of primary MDR-TB infec-
tion [33]. In addition, the rate of MDR-TB among new cases was 25% was higher than Ethio-
pian national prevalence for new cases was 2.7% [6], and in other studies done in Ethiopia
including those in Debre Markos (10.7%) [34], Northwest Ethiopia (2.3%) [31], and East Goj-
jam (1.29%) [32]. This finding might indicate a significant public health threat given that there
would appear to be a progressive MDR-TB transmission in the population. So this finding
could be a good indicator for a need to strengthen the health system towards a more effective
TB treatment, diagnostic, and prevention and control Program.
Furthermore, while it is well known that the drug-resistant TB is a result of chromosomal
alterations due to mutations or deletions, there are several factors related to TB control pro-
gram that have a significant impact on the increasing and transmission of drug-resistant TB
[35]. Our study revealed that MDR-TB infection had a statistically significant association with
patients admitted to hospital (p<0.005), patients who visited health facilities (p<0.005), HIV
positive patients (p<0.005), patients who were frequent cigarette smokers (p<0.005) and
patients who frequently drink alcohol (p<0.005). All of these factors would appear to be pre-
dictors for MDR-TB. This finding is in agreement with studies done in Addis Ababa, Ethiopia
[8, 9] and China [36]. Moreover, several pieces of evidence revealed HIV/AIDS, overcrowding
and lack of compliance with DOTS program, are also the potential risk factors for the develop-
ment of MDR-TB infection [7, 14, 15, 37]
In another part of this study, we tried to evaluate the performance of GeneXpert method
against MGIT, which is a standard method, for DST, we found that 3 isolates had discordant
results from MGIT and GeneXpert methods (99.1% sensitivity and 99.6% specificity), two iso-
lates had RIF susceptible results from MGIT with GeneXpert resistance results. This situation
might be due to the existence of Mycobacterium tuberculosis strains with borderline of suscep-
tible [38]. Moreover, one isolate was found to be resistance from MGIT and susceptible with
GeneXpert assay, It is well documented that about 5% RIF resistance isolates did not have any

PLOS ONE | https://doi.org/10.1371/journal.pone.0197737 June 4, 2018 12 / 16

 Drug-resistance patterns of MTB strains among MDR-TB suspected patients from Ethiopia

mutation in the rpoB gene, and the mechanism of resistance could be due to intrinsic drug
resistance mechanism in which it is attributed to its unique cell wall properties, including the
presence of mycolic acids, which constitute a very hydrophobic barrier responsible for resis-
tance to certain antibiotics [39]. So this might be preliminary finding for further study on the
performance of GeneXpert assay among MDR-TB suspected cases in Ethiopia.
In general, the findings presented in this paper would tend to confirm that patient progres-
sive acquisition of drug resistance during TB treatment is a significant contributor to higher
rates of MDR-TB since anti-TB drug treatment suppress the growth of susceptible TB isolates
while, at the same time, favor the multiplication of the existing drug-resistant isolates as
described by Mekonnen et al. [31]. MDR-TB control programs currently focus on factors
implementing the guidelines for TB control programs such as early case detection, treatment
adherence, infection prevention and administrative and logistic issues [40]. As this study pro-
vides information on patterns of drug-resistant TB and associated risk factors among previ-
ously treated and new cases, it is proposed that this study’s findings could be applied to an
increased understanding of factors associated with the development of MDR-TB in the popu-
lation and, hence, to ways in which to improve planning associated with ways by which to
reduce MDR-TB.

Conclusion
In conclusion, the present study has revealed that the prevalence of multidrug-resistant tuber-
culosis in the study area was higher compared to WHO data and previous studies done in Ethi-
opia and that the proportion of MDR-TB among previously treated patients and young age
group was also higher than previous studies. The major risk factors for the development of
MDR-TB were TB/HIV co-infection, frequent cigarette smoking, frequent consumption of
alcohol, hospital admission, and a history of visits to health facilities. Finally, this study would
conclude that, as a major public health threat is represented by the finding that there is a pro-
gressive MDR-TB transmission in the population especially in the productive age group of the
population, actions should be taken to improve outreach to populations at risk of MDR-TB if
Ethiopia is to avoid an environment in which MDR-TB continues to increase its impact on the
health of the nation.
Therefore, TB patients suspected for MDR-TB should be identified in a timely manner and
treated according to treatment guideline, and the country should focus its efforts on develop-
ing a strategy designed toward early detection and treatment of MDR-TB cases in the popula-
tion, and monitoring systems to investigate the trend of MDR-TB incidence and efficacy of
MDR-TB treatment regimens. Moreover, further studies should be supported to determine
the transmission dynamics of multidrug-resistant strains using genotyping tools as well as
studies devoted to increasing and refining the public health community’s understanding of
risk factors for the development of MDR-TB in the population.

Supporting information
S1 File. All Socio-demographic and drug susceptibility test result data xls File.
(XLSX)

Acknowledgments
The authors of this study acknowledge with gratitude the willingness of study subjects to par-
ticipate in this study and the participation, administrative support and cooperation of collabo-
rating health facilities and staff. We would like also to thank Dr. Aster Shewamare, EPHI

PLOS ONE | https://doi.org/10.1371/journal.pone.0197737 June 4, 2018 13 / 16

 Drug-resistance patterns of MTB strains among MDR-TB suspected patients from Ethiopia

National TB Reference Laboratory Staffs, Addis Ababa Health Research and Laboratory Ser-
vices staffs for their technical assistance and guidance. Moreover, we would like to acknowl-
edge with gratitude Dr. William L. R. Emmet for his devotion for editing and advice on the
preparation of this manuscript.

Author Contributions
Conceptualization: Eyob Abera Mesfin, Dereje Beyene, Abreham Tesfaye, Addisu Admasu,
Zelalem Yaregal, Belay Tessema.
Data curation: Eyob Abera Mesfin, Dereje Beyene, Abreham Tesfaye, Addisu Admasu, Desa-
legn Addise, Miskir Amare, Biniyam Dagne, Zelalem Yaregal, Ephrem Tesfaye, Belay
Tessema.
Formal analysis: Eyob Abera Mesfin, Dereje Beyene, Abreham Tesfaye, Addisu Admasu,
Desalegn Addise, Miskir Amare, Biniyam Dagne, Zelalem Yaregal, Ephrem Tesfaye, Belay
Tessema.
Investigation: Eyob Abera Mesfin, Desalegn Addise, Miskir Amare, Biniyam Dagne, Zelalem
Yaregal, Ephrem Tesfaye.
Methodology: Eyob Abera Mesfin, Dereje Beyene, Abreham Tesfaye, Addisu Admasu, Desa-
legn Addise, Miskir Amare, Biniyam Dagne, Ephrem Tesfaye, Belay Tessema.
Writing – original draft: Eyob Abera Mesfin, Dereje Beyene, Abreham Tesfaye, Belay
Tessema.
Writing – review & editing: Eyob Abera Mesfin, Dereje Beyene, Abreham Tesfaye, Addisu
Admasu, Desalegn Addise, Miskir Amare, Biniyam Dagne, Zelalem Yaregal, Ephrem Tes-
faye, Belay Tessema.

References
1. World Health Organization (WHO), Global tuberculosis report 2016. Geneva, Switzerland; WHO
Press; 2016. Available from: http://www.who.int/tb/publications/global_report/en
2. Berhan A, Berhan Y, Yizengaw D. A meta-analysis of drug-resistant tuberculosis in Sub-Saharan Africa:
how strongly associated with previous treatment and HIV co-infection?. Ethiopian journal of health sci-
ences. 2013; 23(3): 271–282. PMID: 24307827
3. Anthony SF. Multidrug-Resistant and Extensively Drug-Resistant Tuberculosis: The National Institute
of Allergy and Infectious Diseases Research Agenda and Recommendations for Priority Research. J of
Inf Dis. 2008; 197:1493–1498.
4. Falzon D, Jaramillo E, Schünemann HJ, Arentz M, Bauer M, Bayona J, Blanc L, et al. WHO guidelines
for the programmatic management of drug-resistant tuberculosis: 2011 update. Geneva, Switzerland;
WHO Press; 2011.
5. Parsons LM, Somoskövi Á, Gutierrez C, Lee E, Paramasivan CN, Abimiku AL,et al. Laboratory diagno-
sis of tuberculosis in resource-poor countries: challenges and opportunities. Clinical microbiology
reviews. 2011 Apr 1; 24(2): 314–350. https://doi.org/10.1128/CMR.00059-10 PMID: 21482728
6. World Health Organization (WHO), Global tuberculosis report 2017. Geneva, Switzerland; WHO
Press; 2017. Available from: http://www.who.int/tb/publications/global_report/en/
7. Abdella K, Abdissa K, Kebede W, Abebe G. Drug resistance patterns of Mycobacterium tuberculosis
complex and associated factors among retreatment cases around Jimma, Southwest Ethiopia. BMC
public health. 2015 Jul 2; 15(1): 599.
8. Meskel DW, Abate G, Lakew M, Goshu S, Aseffa A. Anti-tuberculosis drug resistance among retreat-
ment patients seen at St Peter Tuberculosis Specialized Hospital. Ethiop Med J. 2008; 46(3): 219–225.
PMID: 19271385
9. Abate D, Taye B, Abseno M, Biadgilign S. Epidemiology of anti-tuberculosis drug resistance patterns
and trends in tuberculosis referral hospital in Addis Ababa, Ethiopia. BMC Res Notes. 2012; 5:462.
https://doi.org/10.1186/1756-0500-5-462 PMID: 22929063

PLOS ONE | https://doi.org/10.1371/journal.pone.0197737 June 4, 2018 14 / 16

 Drug-resistance patterns of MTB strains among MDR-TB suspected patients from Ethiopia

10. Tessema B, Beer J, Emmrich F, Sack U, Rodloff AC. First-and second-line anti-tuberculosis drug resis-
tance in Northwest Ethiopia. The International Journal of Tuberculosis and Lung Disease. 2012 Jun 1;
16(6): 805–811. https://doi.org/10.5588/ijtld.11.0522 PMID: 22390880
11. World Health Organization (WHO), Multidrug and extensively drug-resistant TB (M/XDR-TB): Global
report on surveillance and response. Geneva, Switzerland; WHO Press; 2010. Available from: http://
www.who.int/tb/publications/global_report/en/
12. World Health Organization (WHO). Rapid Implementation of the Xpert MTB/ RIF diagnostic test. Tech-
nical and operational ‘How-to’ Practical considerations. Geneva, Switzerland; WHO Press; 2011.
Available from: http://whqlibdoc.who.int/publications/2011/9789241501569_eng.pdf.
13. Gandhi NR, Moll A, Sturm AW, Pawinski R, Govender T, Lalloo U, et al. Extensively drug-resistant
tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of
South Africa. The Lancet. 2006 Nov 10; 368(9547): 1575–1580.
14. Hirpa S, Medhin G, Girma B, Melese M, Mekonen A, Suarez P,et al. Determinants of multidrug-resistant
tuberculosis in patients who underwent first-line treatment in Addis Ababa: a case control study. BMC
Public Health. 2013 Aug 28; 13(1): 782.
15. Deressa MA, Demissie M. Risk Factors of Multi-Drug-resistant Tuberculosis in Addis Ababa, Ethiopia:
A Matched Case–control Study. Open Access Library Journal. 2014; 1(3): 1–8.
16. Federal Ministry of Health (FMOH): Guideline for program and clinical management of drug-resistant
tuberculosis. FMOH. Addis Ababa; 2009.
17. Barlett JE, Kotrlik JW, Higgins CC. Organizational research: Determining appropriate sample size in
survey research. Information technology, learning, and performance journal. 2001 Apr 1; 19(1):43.
18. World Health Organization (WHO). WHO Ethiopia UPDATE sheet on TB programme in 2014. Addis
Ababa, Ethiopia; WHO Press; 2015. Available from: www.afro.who.int/en/ethiopia/who-country-office-
ethiopia.html.
19. World Health Organization (WHO). Laboratory Service in Tuberculosis Control: Part II. Microscopy.
Geneva, Switzerland; WHO Press; 1998.
20. Barnard M, van Pittius NG, Van Helden PD, Bosman M, Coetzee G, Warren RM. The diagnostic perfor-
mance of the GenoType MTBDRplus version 2 line probe assay is equivalent to that of the Xpert MTB/
RIF assay. Journal of clinical microbiology. 2012 Nov 1; 50(11): 3712–3716. https://doi.org/10.1128/
JCM.01958-12 PMID: 22972826
21. Kent PT, Kubica GP. Public Health Mycobacteriology. A Guide for the Level III laboratory. Atlanta, GA,
US Department of Health and Human Services USA, Centers for Disease Control Press; 1985.
22. Siddiqi SH, Rüsch-Gerdes S. MGIT procedure manual. Geneva, Switzerland: Foundation for innova-
tive new diagnostics. Geneva, Switzerland FIND Press; 2006.
23. Shen GH, Chen CH, Hung CH, Wu KM, Lin CF, Sun YW, et al. Combining the Capilia TB assay with
smear morphology for the identification of Mycobacterium tuberculosis complex. The International Jour-
nal of Tuberculosis and Lung Disease. 2009 Mar 1; 13(3): 371–376. PMID: 19275799
24. Deribew A, Negussu N, Melaku Z, Deribe K. Investigation outcomes of tuberculosis suspects in the
health centers of Addis Ababa, Ethiopia. PLoS One. 2011 Apr 19; 6(4): e18614. https://doi.org/10.
1371/journal.pone.0018614 PMID: 21526179
25. Yohanes A, Abera S, Ali S. Smear positive pulmonary tuberculosis among suspected patients attending
Metehara sugar factory hospital; eastern Ethiopia. African health sciences. 2012; 12(3): 325–330.
PMID: 23382747
26. Gillespie SH. Evolution of drug resistance in Mycobacterium tuberculosis: clinical and molecular per-
spective. Antimicrobial agents and chemotherapy. 2002 Feb 1; 46(2): 267–274. https://doi.org/10.
1128/AAC.46.2.267-274.2002 PMID: 11796329
27. Hoek KG, Schaaf HS, Gey van Pittius NC, van Helden PD, Warren RM. Resistance to pyrazinamide
and ethambutol compromises MDR/XDR-TB treatment. SAMJ: South African Medical Journal. 2009
Nov; 99(11): 785–787. PMID: 20218473
28. Mitchison DA. The action of antituberculosis drugs in short-course chemotherapy. Tubercle. 1985 Sep
1; 66(3):219–25. PMID: 3931319
29. Shi W, Chen J, Feng J, Cui P, Zhang S, Weng X,et al. Aspartate decarboxylase (PanD) as a new target
of pyrazinamide in Mycobacterium tuberculosis. Emerging microbes & infections. 2014 Aug 1; 3(8):
e58.
30. Hanif M, Malik S, Dhingra VK. Acquired drug resistance pattern in tuberculosis cases at the State
Tuberculosis Centre, Delhi, India. The International Journal of Tuberculosis and Lung Disease. 2009
Jan 1; 13(1): 74–78. PMID: 19105882

PLOS ONE | https://doi.org/10.1371/journal.pone.0197737 June 4, 2018 15 / 16

 Drug-resistance patterns of MTB strains among MDR-TB suspected patients from Ethiopia

31. Mekonnen F, Tessema B, Moges F, Gelaw A, Eshetie S, Kumera G. Multidrug-resistant tuberculosis:

prevalence and risk factors in districts of metema and west armachiho, Northwest Ethiopia. BMC infec-
tious diseases. 2015 Oct 26; 15(1): 461.
32. Adane K, Ameni G, Bekele S, Abebe M, Aseffa A. Prevalence and drug resistance profile of Mycobacte-
rium tuberculosis isolated from pulmonary tuberculosis patients attending two public hospitals in East
Gojjam zone, northwest Ethiopia. BMC public health. 2015 Jun 20; 15(1): 572.
33. Sharma SK, Kumar S, Saha PK, George N, Arora SK, Gupta D, et al. Prevalence of multidrug-resistant
tuberculosis among Category II pulmonary tuberculosis patients. Indian J Med Res. 2011; 133: 312–
315. PMID: 21441686
34. Mulu W, Abera B, Yimer M, Hailu T, Ayele H, Abate D. Rifampicin-resistance pattern of Mycobacterium
tuberculosis and associated factors among presumptive tuberculosis patients referred to Debre Markos
Referral Hospital, Ethiopia: a cross-sectional study. BMC research notes. 2017 Jan 3; 10(1): 8. https://
doi.org/10.1186/s13104-016-2328-4 PMID: 28057041
35. Migliori GB, Dheda K, Centis R, Mwaba P, Bates M, O’Grady J, et al. Review of multidrug-resistant and
extensively drug-resistant TB: global perspectives with a focus on sub-Saharan Africa. Tropical Medi-
cine & International Health. 2010 Sep 1; 15(9): 1052–66.
36. Liang L, Wu Q, Gao L, Hao Y, Liu C, Xie Y, et al. Factors contributing to the high prevalence of multi-
drug-resistant tuberculosis: a study from China. Thorax BMJ. 2012; 67(7): 632–638.
37. Barroso EC, Mota RM, Santos RO, Sousa AL, Barroso JB, Rodrigues JL. Risk factors for acquired mul-
tidrug-resistant tuberculosis. Jornal de Pneumologia. 2003 Apr; 29(2): 89–97.
38. Van Rie A, Victor TC, Richardson M, Johnson R, Van Der Spuy GD, Murray EJ,et al. Reinfection and
mixed infection cause changing Mycobacterium tuberculosis drug-resistance patterns. American jour-
nal of respiratory and critical care medicine. 2005 Sep 1; 172 (5):636–42. https://doi.org/10.1164/rccm.
200503-449OC PMID: 15947286
39. Karakousis PC, Yoshimatsu T, Lamichhane G, Woolwine SC, Nuermberger EL, Grosset J, et al. Dor-
mancy phenotype displayed by extracellular Mycobacterium tuberculosis within artificial granulomas in
mice. Journal of Experimental Medicine. 2004 Sep 6; 200(5): 647–57 https://doi.org/10.1084/jem.
20040646 PMID: 15353557
40. Sosa AD, Amábile-Cuevas CF, Byarugaba DK, Hsueh PR, Kariuki S, Okeke IN, editors. Antimicrobial
resistance in developing countries. New York: Springer; 2010: 249–256.

PLOS ONE | https://doi.org/10.1371/journal.pone.0197737 June 4, 2018 16 / 16