Drug Resistance and Risk Factors of Bacteriologically Confirmed Tuberculosis Cases in 10 Sites — Hunan Province, China, 2018–2025

What is already known about this topic?: Tuberculosis (TB) is a deadly global infectious disease, and China has a high burden of rifampicin-resistant (RR) and multidrug-resistant (MDR) TB, according to the World Health Organization. Prior treatment, Regional disparities, demographics (age/sex), and comorbidities (e.g., diabetes) are associated with an elevated risk of drug-resistant TB. What is added by this report?: We analyzed 25,978 bacteriologically confirmed pulmonary TB (PTB) cases in 10 sites in Hunan Province and found lower first-line drug resistance rates than national/provincial estimates (2018-2025). Retreatment, age 25-44 years, diabetes, and Lengshuitan residence were independent predictors of resistance. Resistance declined during the pandemic, rebounded slightly thereafter, and displayed a 4.0% annual decrease (statistically significant). There was notable inter-county heterogeneity (intraclass correlation coefficient=0.11). Hunan shifted to molecular testing (82.79% of susceptibility tests in 2021-2025). What are the implications for public health practice?: Surveillance should be intensified for groups at high risk of drug-resistant TB, including retreatment patients, those aged 25-44 years, patients with diabetes and TB, and Lengshuitan residents. A scale-up of molecular diagnostic technologies and increased testing panels to cover isoniazid resistance for accurate resistance assessment should be included. Post-pandemic TB control interventions should continue to optimize the quality of routine surveillance data, and in-depth research on non-laboratory factors that lead to regional disparities in drug resistance rates should be performed.