Abstract Back ground: Tuberculosis is an infectious (TB) disease caused by M. Tuberculosis. TB generally affects the lung but can also affect other parts of the body. Patients with pulmonary tuberculosis (PTB) spread the disease through tiny airborne droplets into the surrounding air during coughing, sneezing, speaking and laughing from peoples who have active TB in their lungs .The aim of this study was to determine the prevalence of pulmonary tuberculosis using a standard culture method and its drug susceptibility pattern among smear negative presumptive pulmonary tuberculosis (SNPTB) patients at the Felege Hiwot Referral Hospital (FHRH), Bahir Dar, Ethiopia. Methods: Institutional based cross sectional study design was conducted among smear negative presumptive pulmonary tuberculosis (SNPTB) suspected patients visiting FHRH from January 2017 to June 2017. Convenient sampling technique was employed to select the study subjects. Sputum sample was collected from patients who had sputum smear negative result by Auramine O Fluorescence staining method. All smear negative pooled sputum samples were further processed for culture using conventional Lowenstein-Jensen (LJ) solid medium and automated BACTEC MGIT 960 system liquid medium at Amhara public health institute, TB Laboratory. Moreover, molecular line probe assay (LPA) was done for culture positive MTB complex isolates. Descriptive statistics and multivariate logistic regression analysis were done using SPSS version 23. Result: Out of the 242 florescence microscopy negative cases, 20/242 (8.3%) were found to be positive for acid fast bacilli (AFB) using overnight bleach concentration technique. The overall proportion of smear negative but culture positive PTB cases were 27/233 (11.6%). Out of this 2/27 (7.4%) were isolated as Non-Tuberculosis Mycobacterium (NTM). The remaining 9/242 (3.7%) specimens were contaminated and excluded from the analysis. Significant difference was not observed between solid and liquid culture systems in terms of mycobacterial recovery rate. LPA was done for twenty five Mycobacterium tuberculosis complex (MTBC) isolates. Of these, 4/25(16%) of isolates were identified as mono resistance to rifampicin on rpoB gene locus of MTBC. Variables (age 29-39years and >40 years, rural residence, being illiterate, retreatment case, contact history with PTB patients, abnormal chest x-ray finding, fever, hemopityasis and purulent sputum were significantly associated with smear negative culture positive PTB (p<0.05)). Furthermore, mono resistance to rifampicin was significantly associated with retreatment cases (p<0.05). Conclusions: In the studied site, high prevalence of culture positive miss classified PTB cases were documented from smear negative presumptive PTB patients. Fluorescence microscopy sputum examination skill can be one possible reason for this high discrepancy. Therefore, in-service training for laboratory professionals and regular quality assurance is likely to reduce false negative and increase the yield of smear positive results. Moreover, sputum culture should be used at the district level to decrease smear negative cases among presumptive SNPTB patients. Likewise, overnight bleach concentration sputum smear FM is recommended for routine diagnosis of SNPTB in resource limited areas; when culture is not available. Keywords: Culture, Drug susceptibility pattern, Smears negative PTB, FHRH, Bahir Dar.