We read the BTS guidelines on the management of tuberculosis1 with great interest. For the most part the paper is an excellent summary of best practice and a good reference for a number of difficult situations. We were, however, less happy about the recommendation to move to a four drug regimen for most patients. We wonder if it is legitimate to generalise a practice which may be sensible in London with a significant refugee problem but which may be unnecessary in other parts of the UK.

The recommendation for a four drug regimen is graded as A (requires at least one randomised control trial). Two references are given for the statement. One, a conference report,2 lists ethnic risk factors for single and multidrug resistance drawn from the UK reference laboratory reporting service for tuberculosis. The other3is the report on the 1993 tuberculosis survey in England and Wales and draws attention inter alia to the small but rising incidence of drug resistance between 1988 and 1993. Neither is a controlled …