Bedaquiline (BDQ) is a diarylquinoline antimycobacterial drug which specifically inhibits mycobacterial adenosine triphosphate synthase. It is the first new drug class with a novel mechanism of action to become available in forty years. Since October 2014, Sirturo (bedaquiline, BDQ) from Janssen Pharmaceutica, has been registered in South Africa for use in HIV-negative or HIV-infected, ART-naïve patients, 18 years or older who have laboratory-confirmed MDR-TB. Additionally, WHO has issued guidance on the treatment of MDR-TB with BDQ. Surveillance for early detection of BDQ resistance is advised by WHO and is incorporated into the South African policy framework according to which all patients starting BDQ treatment will have samples tested at baseline, week 8 and week 24 using BDQ minimal inhibitory concentration (MIC) determination. Results from the first 61 patients with isolates on which culture and MIC testing had been performed have shown that 47/61 had MIC values below 0.25ug/ml, 7/61 at 0.25ug/ml and 6/61 above 0.25ug/ml. The latter figures are above the EUCAST tentative ECOFF “breakpoint” concentration; however, of these only one had received prior treatment with clofazimine, a drug shown to have the potential to confer cross resistance to BDQ. Of these, none have shown mutations in atpE, the gene shown to be directly associated with resistance, and two have shown mutations in Rv0678, a putative efflux pump encoding gene thought to be associated with BDQ resistance. Monitoring is ongoing for the emergence of resistance and mechanisms associated with resistance in the South African context.