A few decades ago, the idea that a treatise on chemotherapy, to be published in this millennium, could include a chapter on antimycobacterial agents was probably considered acceptable mainly to illustrate the history of a strong successful fight against some human diseases present in the world since antiquity, such as tuberculosis and leprosy. In fact, starting from the middle of the last century, the introduction of chemotherapy for mycobacterial infections, together with improvements in the hygienic and nutritional conditions, brought about a dramatic decrease in the mortality and morbidity of these illnesses, with a trend toward their elimination. Unfortunately, these successes notwithstanding, mycobacterial infections still require particular attention as a worldwide, challenging health problem. In particular, in the last few years, an unexpected resurgence of tuberculosis has occurred in industrialized countries, probably because of the spread of HIV infection and the increasing and uncontrolled waves of immigration. Moreover, the emergence of multidrug resistant strains of
Mycobacterium tuberculosis
has made the older therapies largely ineffective. This chapter has been written for the medicinal chemist who wants to be updated on the situation in this area. The present knowledge of the biology of the pathogens, the mycobacteria, has been reviewed, taking into account the recent information on the genome sequence of
M. tuberculosis
and
M. leprae.
It also will review the information on the pathogenesis and epidemiology of the mycobacterial diseases. The antimycobacterial drugs used in therapy have been described in detail, mentioning some aspects of their discovery, but particularly their
in vitro
and
in vivo
activity, their mechanism of action, their side effects, and the general structure‐activity relationships in the frame of the chemical class to which they belong. Their use in therapy has been considered and evaluated when combined with other antimycobacterial drugs, when the combination is important for an improvement of efficacy and a decrease of probability of resistant strains selection. Some products in the early stage of development, as a starting point for new drugs that are needed, possibly acting on novel targets of the pathogens are also discussed.