Latest Guidelines for Tuberculosis Treatment
For drug-susceptible tuberculosis, the recommended treatment regimen includes an initial 2-month phase of isoniazid, rifampin, pyrazinamide, and ethambutol, followed by a 4-month continuation phase of isoniazid and rifampin (2HRZE/4HR). 1
Drug-Susceptible Tuberculosis Treatment
Initial Phase (First 2 Months)
- Standard treatment consists of four drugs: isoniazid (H), rifampin (R), pyrazinamide (Z), and ethambutol (E) 1, 2
- Daily dosing is strongly recommended for optimal efficacy 1, 2
- Dosage recommendations:
Continuation Phase (Next 4 Months)
- After completing the initial phase, treatment continues with isoniazid and rifampin for 4 additional months 1, 2
- The continuation phase can be initiated once susceptibility to isoniazid and rifampin is confirmed 1
- Fixed-dose combinations of drugs may provide a more convenient form of administration 1
Special Considerations
Extended Treatment Duration
- For patients with cavitary pulmonary TB who remain culture-positive after 2 months of treatment, the continuation phase should be extended to 7 months (total 9 months) 2, 6
- For TB meningitis and CNS tuberculosis, treatment should be extended to 12 months total 2
- If pyrazinamide cannot be included in the initial regimen, treatment duration should be extended to 9 months total 2
Treatment Monitoring
- Response to therapy in pulmonary TB should be monitored with follow-up sputum smear microscopy and culture 2
- Rifampin blood levels may be monitored if poor response to treatment due to under-dosing or malabsorption is suspected 1
Patient-Centered Approach
- A patient-centered approach to treatment is essential to ensure adherence 1
- Directly observed therapy (DOT) or video-observed treatment (VOT) may be used to enhance treatment adherence 1
- Support services, including financial, social, and psycho-social support, may help improve treatment completion 1
Drug-Resistant Tuberculosis Treatment
Multidrug-Resistant TB (MDR-TB)
- For MDR-TB treatment, the latest guidelines recommend:
- Using at least five drugs in the intensive phase and four drugs in the continuation phase 1
- Including a later-generation fluoroquinolone (levofloxacin or moxifloxacin) 1
- Including bedaquiline 1
- Considering linezolid, clofazimine, and cycloserine 1
- Treatment duration of 15-21 months after culture conversion 1
Newer Short-Course Regimens for MDR-TB
- The BPaLM regimen (bedaquiline, pretomanid, linezolid, and moxifloxacin) for 6 months (26 weeks) is now recommended for eligible patients 1
- The 9-month all-oral bedaquiline-containing regimen is another option for people with MDR/RR-TB without resistance to fluoroquinolones 1
Isoniazid-Resistant TB
- For isoniazid-resistant TB, adding a later-generation fluoroquinolone to a 6-month regimen of daily rifampin, ethambutol, and pyrazinamide is suggested 1
- Pyrazinamide duration can be shortened to 2 months in selected situations (non-cavitary disease or toxicity) 1
Latent TB Infection (LTBI) Treatment
Preferred Regimens
- Three rifamycin-based preferred regimens:
- Alternative regimens: daily isoniazid for 6 or 9 months 1
MDR-TB Contacts
- Treatment for LTBI is suggested for contacts to patients with MDR-TB 1
- Recommended regimen: 6 to 12 months of a later-generation fluoroquinolone alone or with a second drug, based on drug susceptibility of the source case 1
Common Pitfalls and Caveats
- Rifampin and rifapentine are not interchangeable; caution should be taken to ensure patients receive the correct medication 1
- Pyridoxine (vitamin B6) should be administered to patients at risk of peripheral neuropathy when receiving isoniazid 2
- Rifampin interacts with many medications, including oral contraceptives, anticoagulants, and antiretroviral drugs, requiring careful medication review 2
- Consultation with a TB expert is necessary if there is suspicion or confirmation of drug-resistant TB 1, 6
- For HIV co-infected patients, drug interactions with antiretroviral therapy must be carefully managed 2