Fate or missed opportunities - challenges in diagnosing paediatric drug resistant tuberculosis in Germany

<b>Background:</b> Diagnosis and treatment of paediatric tuberculosis resistant to both isoniazid and rifampicin (MDR-pTB) remain challenging due to paucibacillary disease, low sensitivity and specificity of diagnostic tools and frequently changing guidelines <b>Aims and objective:</b> This study aimed to describe epidemiology, clinical characteristics and outcome of MDR-TB among children and adolescents in Germany. <b>Methods:</b> We collected all cases of MDR-pTB registered in Germany from 2010 to 2020 and compared their data to&nbsp;an adequate control sample with drug-sensitive TB. <b>Results:</b> 52 subjects with MDR-pTB (24 active MDR-TB, 28 MDR-LTBI) and 56 controls were included. The annual incidence of MDR-TB rose from two in 2010 to nine in 2020. Time to diagnosis was longer in MDR-pTB compared to drug-sensitive TB (43 vs. 8 days, p &lt;0.001) and did not change during the observational period while the time to diagnose drug-sensitive TB decreased. Most children with MDR-TB were born in countries of the former Soviet Union (48% vs. 8%, p &lt;0.001) and have an index with drug-resistant-TB (97.7% vs. 2.8%, p &lt;0.001). Most patients (85%)&nbsp;recovered, but 20% of MDR patients suffered from long-term side effects. <b>Conclusions:</b> Early diagnosis, identification of potential MDR index, appropriate treatment and follow-up are essential in MDR-pTB. Therefore, better cooperation between clinics and public health care is required in Germany. In children with an MDR-TB index case or in those born in a MDR high-incidence country, bacteriological confirmation including PCR-based susceptibility testing should always be initiated.&nbsp;The individual drug regimen has to be adapted to the patients’ or index’ susceptibility testing results.