The source population was all DR-TB patients in the Amhara region while the study population were DR-TB patients registered and follow their treatment in the four (University of Gondar, Boru-Meda, Debre-Markos, and Woldia) DR-TB treatment centers of Amhara Regional State, Ethiopia. Over 90% of DR-TB patients in the region started and follow their Second Line ant-TB Drugs (SLD) in these four hospitals [26]. University of Gondar Comprehensive Specialized Hospital is the second-largest hospital giving clinical care and management for DR-TB in the Country, which is found in the Central Gondar zone of Amhara. Boru-Meda generalized hospital is one of the oldest hospitals known to give special care for TB and Leprosy patients historically, now it advanced its care for DR-TB patients, found in the South Wello zone of the Amhara. Debre-Markos referral hospital is serving DR-TB patients in the Easter Gojjam Zone of Amhara that serves patients coming from the catchment. The fourth hospital is Woldia general hospital which is found in the North Wello Zone of Amhara and serves patients from the Northeaster parts of Ethiopia. All four hospitals give services not only for patients who come from their catchment area but also to those coming from the neighboring Regional states (Tigray, Afar, and Benshagul Gumuz) of Ethiopia. Almost all of the DR-TB patients had enrolled in SLD treatment with a bacteriologically confirmed result of a list resistant to rifampicin (RR, MDR, Pre-XDR, or XDR) TB (Fig 1). Culture-based DST and LPA were used alternatively to diagnose DR-TB in Ethiopia to the time 2013. Later in 2013, Xpert MTB/RIF was introduced in the study area to diagnose RR-TB. Currently, only two TB culture-based DST and LPA sites are available in the region, which is located in Bahr-Dar and Gondar. The access of these three diagnosis tests varies from site to site, because of this and some other reasons even after the introduction of Xpert MTB/RIF, culture and LPA were also used as the first test to diagnose DR-TB. Currently, those three tests are done serially. Once the patient was diagnosed to have RR-TB by Xpert MTB/RIF then first and the second line LPA was performed to see further resistance for Isoniazid, Floroqunolols, and injectable ant-TB drugs, and culture was done to monitor the treatment response and when further phenotypic DST is necessary.

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