Whole genome sequencing-based detection of extensively drug-resistant tuberculosis from Ethiopia

Rapid and accurate detection of extensively drug-resistant tuberculosis is crucial for effective intervention. Next-generation sequencing technologies have been recommended to rapidly and accurately detect resistance to second-line anti-TB drugs. We deployed whole-genome sequencing to detect mutations associated with drug resistance in pre-extensively drug-resistant tuberculosis and extensively drug-resistant tuberculosis strains in Ethiopia. This report is part of the routine laboratory-based drug-resistance surveillance in Ethiopia. Among 15 pre-extensively drug-resistant tuberculosis and extensively drug-resistant tuberculosis isolates identified during the study period, eleven isolates were retrieved by Whole-genome sequencing. Illumina NextSeq 550 instruments were used to generate genomic data. Lineage and drug-resistance prediction were performed with Tuberculosis Profiler, while phylogeny was conducted by IQ-tree. Of the genotyped isolates, whole-genome sequencing identifies five extensively drug-resistant tuberculosis and four pre-extensively drug-resistant tuberculosis strains. It detects fluoroquinolone resistance mutations gyrA (Ala90Val, Asp94Tyr, Asp94Gly). Bedaquiline resistance mutations are found in atpE (Glu61Asp) and Rv0678 (139dupG, 141 and 142dupTC). Cross-resistance is identified between bedaquiline and clofazimine (n = 4) and delamanid and pretomanid (n = 1). Concordance result is observed between phenotypic drug-susceptibility testing and whole-genome sequencing for eight cases, while three cases are discordant (fluoroquinolones, delamanid, and pretomanid). Phylogenetic analysis reveals three major lineages: Lineage 4 (Euro-American, n = 6 isolates), Lineage 3 (East African-Indian, n = 3 isolates), and Lineage 1 (Indo-Oceanic, n = 2 isolates). Whole-genome sequencing identifies dominant mutations in genes such as gyrA, atpE, and Rv067 that are associated with resistance to second-line anti-tuberculosis drugs. Significant cross-resistance is observed between key second-line drugs, bedaquiline and clofazimine, as well as delamanid and pretomanid. This finding highlights the need for routine genomic surveillance to detect drug resistance early, improve treatment outcomes, and prevent transmission. Drug-resistant tuberculosis (TB) is becoming harder to treat and cure. Genetic testing is being recommended for finding drug resistance in Mycobacterium, a bacterium that causes TB. Here, we isolated bacteria from patients presenting with TB in Ethiopia and found that genetic changes made the bacteria more resistant to new TB drugs, such as bedaquiline, pretomanid, and linezolid. Some of these genetic changes made the bacteria resistant to more than a single drug. Importantly, some highly drug-resistant TB strains were found in people who had been diagnosed for the first time, suggesting that the drug resistance is being passed from person to person. Our findings highlight the urgent need for genetic monitoring of TB in Ethiopia, which could help detect resistance, improve treatment, and prevent the spread of untreatable TB. Diriba, Mollalign et al., use whole-genome sequencing to investigate drug resistance mutations in extensively drug-resistant tuberculosis (XDR-TB) and pre-XDR-TB isolates from Ethiopia. Genomic sequencing identifies resistance-associated variants and mycobacterial lineages beyond conventional testing, supporting more effective treatment and enhanced surveillance.