ABSTRACTSince the discovery of streptomycin's bactericidal activity againstMycobacterium tuberculosis, aminoglycosides have been utilized to treat tuberculosis (TB). Today, the aminoglycosides kanamycin and amikacin are used to treat multidrug-resistant (MDR) TB, and resistance to any of the second-line injectable antibiotics, including kanamycin, amikacin, or capreomycin, is a defining characteristic of extensively drug-resistant (XDR) TB. Resistance to kanamycin and streptomycin is thought to be due to the acquisition of unlinked chromosomal mutations. However, we identified eight independent mutations in the 5′ untranslated region of the transcriptional activatorwhiB7that confer low-level resistance to both aminoglycosides. The mutations lead to 23- to 145-fold increases inwhiB7transcripts and subsequent increased expression of botheis(Rv2416c) andtap(Rv1258c). Increased expression ofeisconfers kanamycin resistance in these mutants, while increased expression oftap, which encodes an efflux pump, is a previously uncharacterized mechanism of low-level streptomycin resistance. Additionally, high-level resistance to streptomycin arose at a much higher frequency inwhiB7mutants than in a wild-type (WT) strain. AlthoughwhiB7is typically associated with intrinsic antibiotic resistance inM. tuberculosis, these data suggest that mutations in an uncharacterized regulatory region ofwhiB7contribute to cross-resistance against clinically used second-line antibiotics. As drug resistance continues to develop and spread, understanding the mechanisms and molecular basis of antibiotic resistance is critical for the development of rapid molecular tests to diagnose drug-resistant TB strains and ultimately for designing regimens to treat drug-resistant cases of TB.