What are the current Ghana tuberculosis (TB) management guidelines, including the recommended first‑line regimen for newly diagnosed drug‑susceptible cases, the Category II regimen for retreatment cases, dosing for children and pregnant women, HIV co‑treatment recommendations, and the approach to multidrug‑resistant (MDR) TB?

Current Ghana TB Management Guidelines

Ghana follows WHO-recommended TB treatment protocols, with first-line therapy consisting of a 2-month intensive phase of isoniazid, rifampicin, pyrazinamide, and ethambutol, followed by a 4-month continuation phase of isoniazid and rifampicin. 1

First-Line Treatment for Drug-Susceptible TB

Standard Regimen

• Intensive phase (2 months): Isoniazid, rifampicin, pyrazinamide, and ethambutol given daily 1
• Continuation phase (4 months): Isoniazid and rifampicin 1
• Fixed-dose combinations are highly recommended to improve adherence 1

Treatment Monitoring

• Sputum microscopy should be performed at completion of the intensive phase (2 months), at 5 months, and at end of treatment 1
• Patients with positive smears at 5 months should be considered treatment failures and have therapy modified 1
• For extrapulmonary TB and children, clinical response is the primary assessment method 1

HIV Co-Infection Management

HIV Testing and Counseling

• In high HIV prevalence areas, HIV counseling and testing are indicated for all TB patients as routine management 1
• In lower prevalence settings, testing is indicated for TB patients with HIV-related symptoms or high-risk exposure history 1

Antiretroviral Therapy Integration

• All TB/HIV co-infected patients should be evaluated for antiretroviral therapy during TB treatment 1
• TB treatment should not be delayed while arranging antiretroviral therapy 1
• Cotrimoxazole prophylaxis should be provided to all TB/HIV co-infected patients 1
• Consultation with an HIV expert is recommended before initiating concurrent treatment due to drug-drug interactions 1

Evidence from Ghana shows TB/HIV integration improved treatment success from 50% to 69%, with particularly dramatic improvements at referral sites (46% to 78%) 2

Pediatric Considerations

Diagnosis in Children

• Diagnosis should be based on chest radiographic abnormalities consistent with TB plus either history of exposure to an infectious case or evidence of TB infection (positive tuberculin skin test) 1
• Sputum specimens should be obtained when culture facilities are available, using expectoration, gastric washings, or induced sputum 1

Treatment Approach

• Children require weight-based dosing with careful tablet splitting or crushing, as pediatric formulations are often unavailable 1
• Spreading daily doses throughout the day can improve tolerability but complicates directly observed therapy 1
• Drugs can be mixed with foods or drinks; nasogastric or gastrostomy feeding may be appropriate in some situations 1

Multidrug-Resistant TB Management

Diagnostic Approach

• Drug susceptibility testing should be performed for isoniazid, rifampicin, and ethambutol when drug resistance is suspected 1
• GenoType MTBDRplus molecular testing has shown 100% sensitivity and specificity for detecting rifampicin and multidrug resistance in Ghana 3
• Resistance assessment should be based on prior treatment history, exposure to drug-resistant source cases, and community prevalence 1

Treatment Regimen Composition

• At least 5 effective drugs should be used during the intensive phase, followed by 4 drugs in the continuation phase 4
• Core drugs must include bedaquiline and a later-generation fluoroquinolone (levofloxacin or moxifloxacin) 4
• Additional drugs may include cycloserine/terizidone, delamanid, pyrazinamide (if susceptible), carbapenems with amoxicillin-clavulanate, and aminoglycosides if susceptible 4

Drugs to Avoid

• Kanamycin and capreomycin should not be used 4
• Macrolides (azithromycin, clarithromycin) should not be used 4
• Ethionamide/prothionamide and p-aminosalicylic acid should only be used when more effective drugs are unavailable 4

Treatment Duration

• Intensive phase: 5-7 months after culture conversion 4
• Total duration: 15-21 months after culture conversion for MDR-TB 4
• For pre-XDR and XDR-TB: 15-24 months after culture conversion 4, 5

Regimen Design Principles

• Regimen composition should be guided by drug susceptibility testing of the patient's isolate or the presumed source case 1
• For treatment failure cases, assume resistance to rifampicin and isoniazid 1
• High-dose isoniazid (15-20 mg/kg) can overcome low-level resistance in children 1
• Never add a single drug to a failing regimen; add at least 2-3 new drugs to which susceptibility can be inferred 5

Treatment Support and Adherence

Directly Observed Therapy

• Patient-centered measures should be used to ensure adherence, with supervision tailored to individual circumstances 1
• Video-observed therapy may replace directly observed therapy when technology is available and appropriately organized 1
• Directly observed therapy by healthcare workers is recommended over family-administered or unsupervised treatment 1

Barriers to Adherence in Ghana

Research from high-burden TB settings in Ghana identified critical barriers: food insecurity, transportation costs, lack of family support, income insecurity, long distances to treatment centers, insufficient TB knowledge, drug side effects, and improvement in health after the intensive phase 6

Model of Care

• Ambulatory care is recommended over hospitalization-based models for MDR-TB patients 1
• Decentralized care is recommended over centralized models 1

Retreatment Cases

Category II Regimen Considerations

• Patients with previous TB treatment history require assessment for drug resistance 1
• Treatment failures and chronic cases should always be assessed for possible drug resistance 1

Pregnant Women

• Standard first-line regimens can be used in pregnancy 1
• For MDR-TB in pregnancy, consultation with experienced providers is essential, as many second-line drugs have limited safety data 1

Contact Investigation

• Children under 5 years and HIV-infected persons in close contact with infectious TB cases should be evaluated for both latent infection and active TB 1
• For MDR-TB contacts, latent TB treatment with a later-generation fluoroquinolone alone or with a second drug based on source-case susceptibility should be considered 4

Reporting Requirements

• All providers must report new and retreatment TB cases and their treatment outcomes to local public health authorities 1
• Written records of all medications, bacteriological response, and adverse reactions should be maintained 1

Common Pitfalls to Avoid

• Do not use fluoroquinolones as broad-spectrum antimicrobials in suspected TB cases, as they can cause transient improvement and delay diagnosis 1
• Do not use fewer than 5 effective drugs in the intensive phase of MDR-TB treatment 4
• Do not treat MDR-TB for less than 15 months after culture conversion 4, 5
• Do not delay TB treatment while arranging HIV services 1

Treatment Outcomes in Ghana

Historical data shows cure rates improved from 43.6% in 1997 to 87.7% in 2010, attributed to improved diagnosis, community TB care, stigma reduction, public-private partnerships, and enablers' packages 7. However, default rates have been problematic, reaching 46.1% in some cohorts, particularly among men and those in suburban areas 8.