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Drug-resistant tuberculosis is a significant contributor to antimicrobial resistance globally. Despite tuberculosis (TB) being endemic in Malaysia, there is limited published data from Malaysia on anti-TB drug resistance. This study aims to determine the patterns and trends in first-line anti-TB drug resistance in a major Malaysian tertiary teaching hospital. A retrospective observational study was conducted on all patients who were diagnosed with culture-confirmed tuberculosis at the University of Malaya Medical Centre, Kuala Lumpur, Malaysia, between 1 January 2017 – 31 December 2020. Patients were identified from the microbiology laboratory database. The medical records of the patients were reviewed, and the following data were collected using a standardised data collection form: demographic data and first-line anti-TB drug resistance patterns. Over the 4-year study period, a total of 675 non-duplicate Mycobacterium tuberculosis isolates were identified from the clinical specimens of 675 patients, of whom the majority were men (64.3%) and between 18-40 years of age (39.9%). Only 8.3% of the isolates were resistant to at least one of the first-line anti-TB drugs tested. The most common form of first-line anti-TB drug resistance was resistance to streptomycin (4.0%), followed by resistance to isoniazid (3.6%), resistance to ethambutol (2.7%) and resistance to rifampicin (1.5%). Multidrug-resistant TB (MDR-TB) accounted for only 0.9% of the isolates. Between 2017 and 2020, there was an overall increase in the prevalence of resistance to at least one of the first-line anti-TB drugs (7.4% to 12.0%), rifampicin-resistant TB (RR-TB) (1.3% to 3.3%) and isoniazid-resistant TB (Hr-TB) (3.9% to 4.3%). However, there was no increase in the prevalence of MDR-TB (1.3%). The prevalence of MDR-TB in our study cohort remained low and stable over the 4-year study period. However, given the increase in RR-TB and Hr-TB rates, active and continuous surveillance of trends in anti-TB drug resistance is warranted. [ABSTRACT FROM AUTHOR]