Received 27 August 2010; received in revised form 9 November 2010; accepted 16 November 2010

Journal of Infection and Public Health (2011) 4, 41 47 First insight into the drug resistance pattern of Mycobacterium tuberculosis in Dohuk, Iraq: Using spoligotyping and MIRU-VNTR to characterize multidrug resistant strains Muayad A. Merza a,b,, Parissa Farnia a, Ahmad M. Salih b, Mohammad Reza Masjedi a, Ali Akbar Velayati a a Mycobacteriology Research Center (MRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University (Medical Campus), Darabad, Tehran, Iran b Azadi Teaching Hospital, College of Medicine University of Dohuk, Dohuk, Kurdistan, Iraq Received 27 August 2010; received in revised form 9 November 2010; accepted 16 November 2010 KEYWORDS Tuberculosis; Multidrug resistant; Iraq; Drug susceptibility testing; Molecular genotyping Summary The objectives of this study were to determine drug resistance pattern in new and previously treated tuberculosis (TB) patients, to assess function of TB control program, and to characterize multidrug resistant TB (MDR-TB) by molecular fingerprinting methods. Anti-micorbial susceptibility testing (AST) to the first line anti-tb drugs was performed on Löwenstein Jensen (middlebrook 7H10) medium according to the proportion method. Molecular fingerprinting of all MDR strains was performed by spoligotyping and MIRU-VNTR. Mycobacterium tuberculosis strains were isolated from 53 Iraqi patients with pulmonary TB. Thirty eight patients (71.7%) tested cases, and 15 (28.3%) were previously treated. Four of the 38 new cases (10.5%) had resistant, of which 3 (7.9%) were MDR. Eight (53.3%) of the 15 previously treated patients had resistant strains, of which 7 (46.7%) were MDR. Spoligotyping of MDR strains showed family (40%) as the predominant genotype. Using MIRU-VNTR typing, all isolates had a unique profile. MDR-TB prevalence is higher among previously treated patients than among the new cases. The many drug resistant strains, in absence of evidence of recent transmission and in combination with the many previously treated cases, highlight the need for an improved control program, coupled with a need to improve detection rate and early diagnosis of MDR-TB. 2010 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved. Corresponding author at: Mycobacteriology Research Center (MRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), WHO Collaborating Center of Tuberculosis, Shaheed Bahonar Ave, Darabad, P.O. Box 19575/154, Tehran 19556, Iran. Tel.: +98 21 8408275; fax: +98 21 2285777. E-mail address: muayadfaily@yahoo.com (M.A. Merza). 1876-0341/$ see front matter 2010 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jiph.2010.11.002

42 M.A. Merza et al. Introduction Despite the adoption of Directly Observed Therapy Short-Course (DOTS) strategy by World Health Organization (WHO), TB prevalence continues to increase worldwide, particularly in developing countries. This has been attributed to the human immunodeficiency virus (HIV) pandemic and emergence of drug resistant strains [1]. Additional reasons for the increase are related to poverty, migration, ethnic conflicts and abuse of narcotic substances. Of great importance are also inadequate health care generally attributed to poor performance of NTPS. These factors may lead to the development of drug resistance, which however, can be counteracted by proper health control measures [2]. The emergence of MDR-TB, that is Mycobacterium tuberculosis strains resistant to at least isoniazid (INH), rifampicin (RMP), poses a significant global and public health concern. Such cases are difficult to cure, requiring the use of second line drugs that are more toxic and expensive than the first line regimen [3]. The recently published WHO report on Global TB Control in 2009 stated that there were an estimated 0.5 million cases of MDR-TB in 2007 [1]. Recently, M. tuberculosis strains that are extensively drug resistant-tb (XDR-TB), i.e. MDR-TB strains resistant to at least three of the six classes of second-line drugs (aminoglycosides, polypeptides, fluoroquinolones, thioamides, cycloserine, and para-aminosalicylic acid) have been described [4,5]. According to a 2000 2004 survey of International TB Laboratories conducted by the WHO and US Centers for Disease Control (CDC), 20% of M. tuberculosis isolates were MDR-TB and 2% were XDR-TB [6]. Anti-TB drug resistance is present everywhere in the world and MDR-TB is considered to be widespread today. A high prevalence of MDR-TB cases has been noticed in China, India, and the Russian Federation. China and India carry approximately 50% of the global burden and the Russian Federation a further 7% [7]. Iraq is one of the countries in WHO Eastern Mediterranean Region (WHO-EMR) with a relatively high TB incidence rate (56/100,000) and low case detection rate (45%) [1]. This may be attributed to the unstable situation in society, low socio-economic status, and unsatisfactory treatment. The DOTS strategy has been adopted in Iraq since 1998, except for the three northern Iraq provinces (Dohuk, Erbil and Sulaimani), which implemented DOTS since 2001. In northern Iraq, the management of TB patients is based primarily on smear microscopic examination as there is no culture and antimicrobial susceptibility testing (AST) [8]. In case of treatment failure or suspicion of drug resistance, patients are referred to Baghdad or neighbouring countries for further investigations. The DNA fingerprinting methods have been widely used to characterize drug resistance strains, particularly MDR-TB, in order to better understand the origin and propogation of drug resistant strains in a specific location. The first effective strains genotyping technique, RFLP-IS6110, has gained recognition as the international standard for epidemiological typing of M. Tuberculosis [9]. Recently, spoligotyping, a highly polymorphic direct repeat (DR) locus in the MTB genome has been used to provide epidemiological information of strain relatedness [10]. More recently, mycobacterial interspersed repetitive unit-variable number of tandem repeats (MIRU-VNTR) analysis have been established to track epidemic strains [11]. Because the TB drug resistance patterns and genotype characterization of resistant strains are currently unknown in Dohuk, the goal of the presents study was to determine drug resistance pattern in new and previously treated TB patients, to evaluate TB control programs, to determine risk factors associated with MDR-TB and finally to characterize MDR strains by molecular fingerprinting methods. Materials and methods Specimen collection All smear positive pulmonary specimens were collected between June 2008 and June 2009 at the NTP center of Dohuk province Iraq. Sampling was deemed to be representative at the province level, as all TB cases had attended directly or had been referred from other health centers to the Dohuk NTP. Classical epidemiology data were collected by using standard questionnaires. Information was obtained on sex, age, country of birth, recent smear positivity, previous history of TB, and present address. The specimens were shipped to Mycobacteriology Research Center (MRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Tehran, Iran for culturing and DST. Isolation of M. tuberculosis The pulmonary specimens were processed for culture by digestion, decontamination and concen-

Drug resistance pattern of Mycobacterium tuberculosis in Dohuk, Iraq 43 tration following modified Petroff s method and were inoculated into 2 tubes of LJ media. The slants were examined for growth once weekly up to 8 weeks [12]. The isolates were identified as M. tuberculosis by using biochemical tests, including production of niacin, catalase activity, nitrate reduction, pigment production and growth rate [12]. AST ASTs were performed for INH, RMP, streptomycin (STM), ethambutol (EMB), and pyrazinamide (PZA). Colonies from the surface of LJ medium were transferred into sterile test tubes containing 6 8 glass beads and 3.0 ml of Middlebrook 7H9 broth. The suspension was adjusted to 1 McFarland standard. Thereafter, dilutions of 1/10, 1/1000 and 1/100,000 were prepared and inoculated into drug-containing middlebrook and controls. The drug concentrations were as follows: 0.2 g/ml INH, 40 g/ml RMP, 2 g/ml EMB and 4 g/ml STM by the proportion method [13]. Susceptibility to pyrazinamide (PZA) was tested using a two-phase medium and two different concentration of inocula. DNA fingerprinting DNA of each MDR-TB isolate was extracted and spoligotyping was performed as described by Kamerbeek et al. [10]. For MIRU-VNTR genotyping, 12 loci of the MDR strains were amplified by PCR as described previously [11,14]. Definitions Any drug resistance was defined as resistance to one or more first-line drugs. Monoresistance was defined as resistance to only one of the five firstline drugs (INH, RMP, STM, EMB, and PZA). MDR-TB was defined as M. tuberculosis strains that were resistant to at least INH and RMP. Drug resistance among new cases was defined as the presence of resistant isolates of M. tuberculosis in patients who had not been exposed to anti-tb treatment for as much as 1 month; previously called primary resistance. Drug resistance among previously treated cases was defined as the presence of resistant isolates of M. tuberculosis in patients who had been treated for TB for 1 month or more; previously called acquired resistance [7]. A cluster was defined as two or more isolates obtained from different patients having identical spoligotype or MIRU-VNTR pattern [15]. Statistical analysis The AST results obtained were analyzed by entering the data in a binary format as Microsoft Excel spreadsheet. Frequencies and variables were compared by Chi-square test or Fisher s exact test whenever necessary. A P-value of less than 0.05 was considered statistically significant. The spoligotyping results were compared with those in the international SpolDB4 database [16] and further analyzed with Spotclust, using a mixture model built on the SpolDB3 database [17]. Thereafter, the spoligotypes were assigned to families and subfamilies. The rate of diversity was calculated by dividing the number of spoligotypes by the total number of isolates found. The MIRU-VNTR results were analyzed by using the MIRU-VNTRPlus database [18]. Results Characteristics of patients In total, 86 smear positive pulmonary specimens between June 2008 and June 2009 were included. Out of 86 patients, 30 specimens (34.9%) were excluded because they were either culture negative or had culture contamination. In addition another 3 specimens (3.5%) were excluded because their cultures were mycobacteria other than TB (MOTT). The study therefore consisted of 53 culture positive patients. Of the 53 patients, 38 were new TB cases and 15 were previously treated patients. The mean age of the patients was 49.10 yr (±2.15). There were 37 males (69.8%) and 16 females (30.2%), giving a sex ratio of 2.3:1. AST of M. Tuberculosis Table 1 demonstrates patterns of drug resistance among the strains. Of the M. tuberculosis strains isolated from each of 54 smear positive, 41 (77.4%) were susceptible to all first line drugs investigated, and 12 (22.6%) were resistant to at least one drug. Thirty eight patients (71.7%) were new cases, and 15 (28.3%) were previously treated. Ten patients (18.7%) had MDR-TB, with the most common pattern of resistance to the three drugs INH, RMP and EMB (4, 7.4%) shown in Table 1. There were certain variables associated with MDR-TB cases. Among the 10 MDR-TB patients, 7 (70%) had been previously treated while among the 48 patients with non-mdr-tb only 8 patients (16.7% P-value = 0.003) had been previously treated. MDR- TB was found in patients with mean age 51.3 (±3.3) and was higher in males (8, 80%).

44 M.A. Merza et al. Table 1 Resistance to first-line drugs among M. tuberculosis strains. Type New cases Previously treated cases Total P-value Total strains Investigated 38 15 53 All susceptible 34 (89.5%) 7 (46.7%) 41 (77.4%) <0.001 Any drug resistance 4 (10.5%) 8 (53.3%) 12 (22.6%) 0.013 INH 4 (10.5%) 8 (53.3%) 12 (22.6%) RMP 3 (7.9%) 7 (46.7%) 10 (18.9%) PZA 0 2 (13.3%) 2 (3.8%) EMB 1 (2.6%) 6 (40.0%) 7 (13.2%) STM 0 2 (13.3%) 2 (3.8%) Monoresistance 1 (2.6%) 1 (6.7%) 2 (3.8%) 0.97 INH 1 (2.6%) 1 (6.7%) 2 (3.8%) RMP 0 0 0 PZA 0 0 0 EMB 0 0 0 STM 0 0 0 Multidrug resistance 3 (7.9%) 7 (46.7%) 10 (18.7%) 0.006 INH + RMP 2 (5.3%) 1 (6.7%) 3 (5.6%) INH + RMP + PZA + EMB 0 1 (6.7%) 1 (1.9%) INH + RMP + PZA + STM + EMB 0 1 (6.7%) 1 (1.9%) INH + RMP + EMB 1 (2.6%) 3 (20.0%) 4 (7.4%) INH + RMP + STM + EMB 0 1 (6.7%) 1 (1.9%) Genotypes and transmission analysis of MDR-TB cases To gain insight into the genotypes and transmission patterns of MDR strains, the isolates were subjected to spoligotyping and MIRU-VNTR, respectively. The 10 analyzed MDR strains yielded 9 different spoligopatterns resulting in an overall diversity of 0.90. Based on the spoligotype patterns, there was only one cluster consisting of two patients. The remaining drug resistant TB patients had isolates with unique spoligotype patterns (Fig. 1). Family assignment by use of the SpolDB4 database and Spotclust identified the family as the predominant genotype (n = 4, 40.0%), followed by T1, Haarlem3 and Family33 each (n = 2, 20%). Using MIRU-VNTR typing, all isolates had a unique profile, and all of them showed differences in at least one locus (Fig. 1). The 2 strains of the only spoligotyped cluster exhibited identical spoligopatterns, but they had MIRU-VNTR patterns that differed by two repeats at MIRU10, two repeats at MIRU23 and three repeats at MIRU26. The two patients in this cluster were relatives lived in same district and had been diagnosed and treated in the same Dohuk NTP. Discussion Although the social situation is unstable and insecure in Iraq, the TB control services continue to be provided according to DOTS program whenever and wherever possible [1]. The WHO assumed that the incidence rate of TB in Iraq is stable (56/100,000), but there is no reliable data from which to assess incidence trends [1]. Iraq has a higher incidence of TB than the majority of neighbouring countries [1], but knowledge of resistance patterns and trends has not yet been studied. Such information is essential in order to ascertain appropriate treatment strategies. To our knowledge, the present analyses is the first prospective study about anti-tb drug resistance pattern and molecular epidemiology of MDR-TB strains in Iraq. In this study, we found that the rate of any drug resistance and MDR-TB was (22.6%) and (n = 12 and 10 respectively) (18.7%), respectively. The rate is higher compared to figures from Turkey [19], and Qatar [20], whereas the rate is lower than those reported from Iran [21]. In the present study, the most common drug resistance pattern INH resistance (12, 22.6%), followed by RMP resistance (10, 18.9%). In a study from Riyadh, the same resistance pattern was reported [22]. However, other resistance patterns have also been reported. In some studies [19,20], resistance to INH and STM was more frequently reported, whereas in a 15 years surveillance study in Saudi Arabia [23], resistance to INH and EMB was the most common pattern. One possible explanation of our relatively high rate of RMP resistance is attributed to its use in

Drug resistance pattern of Mycobacterium tuberculosis in Dohuk, Iraq 45 Phylogene tic clade Spoligotyping Octal number no (%) Spoligopatterns MIRU-VNTR profile 4 (40) 703727740003771 236426153433 234426153433 503727740003771 2 (20)) 236424183433 503767400005771 232424143322 T 2 (20) T1 747727777740771 234326143323 T1 747767777740771 232124142323 Haarlem 2 (20) Haarlem3 547727737700771 235424143323 Haarlem3 547727437600771 235324143323 F33 2 (20) F33 547737777603771 233226142322 F33 555767437610771 233426123223 Figure 1 Fingerprinting results (spoligotyping and MIRU-VNTR) of MDR-TB cases. the treatment of non-specific infections as well as for certain infectious diseases like brucellosis. STM resistance (2, 3.8%) was less common in this study since the widely used EMB as a fourth drug in the WHO standard regimen for new cases, and the use of STM occurs only during the first 2 months in the WHO standard retreatment regimen. Further, we found that all RMP resistant strains also were resistant to INH. This is a common condition and has e.g. been reported by Al-Orainey et al. who found that majority of isolates from patients with acquired resistance to RMP were also resistant to INH [22]. It is well known that monoresistance to RMP is rare, whereas monoresistance to INH is common [24]. Thus, we propose to apply this fact in our TB laboratories, since there are limited resources for detecting MDR-TB strains in Iraq. In the present study, the rate of MDR-TB in new and previously treated cases was 3 (7.9%) and 7 (46.7%), respectively. Similarly, a high prevalence rate of MDR-TB was seen in Iran, whereas lower rate was reported from other countries in the region [19,20]. Overall, lower MDR-TB rates, 2% for new cases and 29.4% for previously treated cases, were reported from WHO-EMR in 2004 [25]. The high rates of resistance among previously treated cases are serious problems, and may indicate ineffective DOTS implementation in Iraq. Although our treatment success rate (86%) is in line with

46 M.A. Merza et al. the WHO s target (85%), the 45% case detection rate is under the WHO target (70%) [1], which is another indicator of poor TB control performance. Dye and Williams stated that case detection and cure rates are two variables that act synergistically [26]. When either is low, the other cannot succeed alone resulting in emergence of drug resistance. With respect to risk factors of MDR-TB, we documented that a was significantly (P-value = 0.003) associated with MDR-TB, which has also been documented in other publications [27,28]. Further, we demonstrated that patients with mean age 51.3 yr (±3.3), and male sex were associated risk factors for infection by MDR-TB, but these findings were not statistically significant. The explanation for increase risk of MDR-TB in this age group may be attributed to recent decreases in circulating drugresistant strains or it could reflect the year in which effective anti-tb drugs such as RMP were introduced. In a review by Faustini et al. it was found that MDR-TB was more common in patients under 65 years, but the association was weak and more heterogeneous in patients under 45 [29]. They also stated that MDR-TB incidence was not affected by gender. It has otherwise been hypothesized that women are more compliant with treatment and therefore less likely to receive inadequate treatment [29]. In this study, molecular genotyping of MDR isolates found the family to be the predominant genotype (n = 4, 40.0%). In contrast to our finding, global MDR-TB outbreaks have been associated with Beijing and Haarlem families [30]. The family is essentially localized in Central and Middle Eastern Asia [16]. It belongs to ancient TB and its prevalence is steadily decreasing from South Asia to Western Asia [31]. This genotype might be an ancestor of the Beijing lineage since it clusters close to Beijing when analyzed by a combination of MIRU- VNTR and spoligotyping [32]. Among the 10 MDR-TB patients with fingerprinting information, 2 were part of a single cluster with a similar spoligopattern ( family), but with different MIRU-VNTR profile (234426153433 and 236424183433) (Fig. 1). Based on this finding, further studies with larger sample size are warranted to understand molecular epidemiology of MDR strains in this geographical location. Assuming that clustering represents recent transmission, the low clustering rate of MDR strains in this study suggests that recent transmission in Dohuk plays a lesser role in the occurrence of MDR-TB, and the most MDR strains in Dohuk are due to flawed patient management; effective TB control measures have not yet been achieved in Iraq. The small sample size is the main limitation to this study. Another limitation is that no strains from smear negative pulmonary TB, extra-pulmonary TB, and TB cases from private sector were included, although the study included almost all smear positive specimens for 1 year at a governmental NTP center in Dohuk province. In conclusion, the rate of drug-resistance in pulmonary TB cases, especially MDR-TB, was higher among previously treated patients than among the new cases. This is likewise the consequence of repeated treatments. The many drug resistant strains in absence of evidence of recent transmission in combination with the many previously treated cases highlight the need for an improved control program. This must be coupled with improving case detection rate and early diagnosis of MDR-TB. This is especially important for high-risk patients, in order to reduce the spread and development of resistance. Further prospective studies encompassing all NTPs in Iraq are warranted with the implementation of AST and molecular analysis of drug resistance strains, to better understand the prevalence, pattern and transmission trends of drug resistance. Conflict of interest Funding: This work was supported by grant from MRC, NRITLD (2009-2010), Tehran, Iran. Competing interests: None declared. Ethical approval: The study was approved by the ethics committee of University of Dohuk, College of Medicine and NRITLD in Tehran. Acknowledgements We would like to thank Dr. Abdulla Saeed A. (Director General of Health/Dohuk), Dr. Abdulrahman Islam (Director of Dohuk NTP), and all other NTP staff in Dohuk province for their kind help and support in establishing this study. We are highly grateful to staff of MRC, NRITLD, Tehran, Iran for their valuable help and support in performing routine and research procedures of these specimens. This work was fully supported by NRITLD-Tehran-Iran. References [1] World Health Organization. WHO report 2009. Global tuberculosis control: epidemiology, strategy, financing. WHO/HTM/TB/2009.411. Geneva: WHO; 2009. [2] Antunes ML, Aleixo-Dias J, Antunes AF, Pereira MF, Raymundo E, Rodrigues MF. Anti-tuberculosis drug resistance in Portugal. Int J Tuberc Lung Dis 2000;4:223 31.

Drug resistance pattern of Mycobacterium tuberculosis in Dohuk, Iraq 47 [3] Gupta R, Kim JY, Espinal MA, Caudron JM, Pecoul B, Farmer PE, et al. Responding to market failures in tuberculosis control: a model to increase access to drugs and treatment. Science 2001;293:1049 51. [4] Masjedi MR, Farnia P, Sorooch S, Pooramiri MV, Mansoori SD, Zarifi AZ, et al. Extensively drug resistant tuberculosis: 2 years of surveillance in Iran. Clin Infect Dis 2006;43:840 7. [5] Shah NS, Wright A, Bai GH, Barrera L, Boulahbal F, Martín-Casabona N, et al. Worldwide emergence of extensively drug resistant tuberculosis. Emerg Infect Dis 2007;13:380 7. [6] Centers for Disease Control and Prevention. Emergence of Mycobacterium tuberculosis with extensive resistance to second line drugs-worldwide, 2000 2004. Morb Mortal Wkly Rep 2006;55:301 5. [7] World Health Organization/International Union Against Tuberculosis and Lung Disease (WHO/IUATLD). Antituberculosis drug resistance in the world. The WHO/IUATLD global project on anti-tuberculosis drug resistance surveillance 2002 2007. WHO/HTM/TB/2008.394. Geneva: WHO/IUATLD; 2008. [8] Merza MA, Farnia P, Masjedi MR, Ridell M. Anti-tuberculosis drug resistance in Duhok, Iraq. Int J Tuberc Lung Dis 2010;14:1213 4. [9] Van Embden JD, Cave MD, Crawford JT, Dale JW, Eisenach KD, Gicquel B, et al. Strain identification of Mycobacterium tuberculosis by DNA fingerprinting: recommendations for a standardized methodology. J Clin Microbiol 1993;31:406 9. [10] Kamerbeek J, Schouls L, Kolk A, van Agterveld M, van Soolingen D, Kuijper S, et al. Simultaneous detection and strain differentiation of Mycobacterium tuberculosis for diagnosis and epidemiology. J Clin Microbiol 1997;35:907 14. [11] Supply P, Lesjean S, Savine E, Kremer K, van Soolingen D, Locht C. Automated high-throughput genotyping for study of global epidemiology of Mycobacterium tuberculosis based on mycobacterial interspersed repetitive units. J Clin Microbiol 2001;39:3563 71. [12] Kent PT, Kubica GP. Public health mycobacteriology: a guide for level II laboratory. Atlanta, GA: Public Health Services, US Department of Health and Human Services; 1985. [13] World Health Organization. Laboratory services in tuberculosis control. WHO/TB/98.255. Geneva: WHO; 1999. [14] Supply P, Mazars E, Lesjean S, Vincent V, Gicquel B, Locht C. Variable human minisatellite-like regions in the Mycobacterium tuberculosis genome. Mol Microbiol 2000;36:762 71. [15] Filliol I, Driscoll JR, van Soolingen D, Kreiswirth BN, Kremer K, Valétudie G, et al. Snapshot of moving and expanding clones of M. tuberculosis and their global distribution assessed by spoligotyping in an international study. J Clin Microbiol 2003;41:1963 70. [16] Brudey K, Driscoll J, Rigouts L, Prodinger W, Gori A, Al- Hajoj S, et al. Mycobacterium tuberculosis complex genetic diversity: mining the fourth international spoligotyping database (SpolDB4) for classification, population genetics and epidemiology. BMC Microbiol 2006;6:23. [17] Vitol I, Driscoll J, Kreiswirth B, Kurepina N, Bennett KP. Identifying Mycobacterium tuberculosis complex strain families using spoligotypes. Infect Genet Evol 2006;6:491 504. [18] Allix-Béguec C, Harmsen D, Weniger T, Supply P, Niemann S. Evaluation and user-strategy of MIRU-VNTRplus, a multifunctional database for on-line analysis of genotyping data and phylogenetic identification of Mycobacterium tuberculosis complex isolates. J Clin Microbiol 2008;46:2692 9. [19] Surucuoglu S, Ozkutuk N, Celik P, Gazi H, Dinc G, Kurutepe S, et al. Drug-resistant pulmonary tuberculosis in western Turkey: prevalence, clinical characteristics and treatment outcome. Ann Saudi Med 2005;25:313 8. [20] Al-Marri MR. Pattern of mycobacterial resistance to four anti-tuberculosis drugs in pulmonary tuberculosis patients in the state of Qatar after the implementation of DOTS and a limited expatriate screening programme. Int J Tuberc Lung Dis 2001;5:1116 21. [21] Shamaei M, Marjani M, Chitsaz E, Kazempour M, Esmaeili M, Farnia P, et al. First-line anti-tuberculosis drug resistance patterns and trends at the national TB referral center in Iran eight years of surveillance. Int J Infect Dis 2009;13:236 40. [22] Al-Orainey IO, Saeed ES, El-Kassimi FA, Al-Shareef A. Resistance to antituberculosis drugs in Riyadh, Saudi Arabia. Tubercle 1989;70:207 10. [23] Al-Tawfiq JA, Al-Muraikhy AA, Abed MS. Susceptibility pattern and epidemiology of Mycobacterium tuberculosis in a Saudi Arabian hospital: a 15-year study from 1989 to 2003. Chest 2005;128:3229 32. [24] Vareldzis BP, Grosset J, de Kantor I, Crofton J, Laszlo A, Felten M, et al. Drug-resistant tuberculosis: laboratory issues. World Health Organization recommendations. Tuber Lung Dis 1994;75:1 7. [25] Zignol M, Hosseini MS, Wright A, Weezenbeek CL, Nunn P, Watt CJ, et al. Global incidence of multidrug-resistant tuberculosis. J Infect Dis 2006;194:479 85. [26] Dye C, Williams BG. Criteria for the control of drug-resistant tuberculosis. Proc Natl Acad Sci U S A 2000;97:8180 5. [27] Suárez-García I, Rodríguez-Blanco A, Vidal-Pérez JL, García-Viejo MA, Jaras-Hernández MJ, López O, et al. Risk factors for multidrug-resistant tuberculosis in a tuberculosis unit in Madrid, Spain. Eur J Clin Microbiol Infect Dis 2009;28:325 30. [28] Caminero JA. Management of multidrug-resistant tuberculosis and patients in retreatment. Eur Respir J 2005;25:928 36. [29] Faustini A, Hall AJ, Perucci CA. Risk factors for multidrug resistant tuberculosis in Europe: a systematic review. Thorax 2006;61:158 63. [30] Mardassi H, Namouchi A, Haltiti R, Zarrouk M, Mhenni B, Karboul A, et al. Tuberculosis due to resistant Haarlem strain, Tunisia. Emerg Infect Dis 2005;11:957 61. [31] Merza MA, Farnia P, Salih AM, Masjedi MR, Velayati AA. The most predominant spoligopatterns of Mycobacterium tuberculosis isolates among Iranian, Afghan-Immigrant, Pakistani and Turkish tuberculosis patients: a comparative analysis. Chemotherapy 2010;56:248 57. [32] Sola C, Filliol I, Legrand E, Lesjean S, Locht C, Supply P, et al. Genotyping of the Mycobacterium tuberculosis complex using MIRUs: association with VNTR and spoligotyping for molecular epidemiology and evolutionary genetics. Infect Genet Evol 2003;3:125 33. Available online at www.sciencedirect.com