What is the treatment for Tuberculosis (TB)?

From the Guidelines

Tuberculosis treatment should typically involve a multi-drug regimen taken for 6-9 months, with the standard first-line treatment consisting of four antibiotics: isoniazid, rifampin, ethambutol, and pyrazinamide for the first 2 months, followed by isoniazid and rifampin for 4 more months. The treatment regimen is based on the most recent and highest quality study, which recommends a minimum total treatment period of 6 months 1.

Key Considerations

• The decision to stop therapy should be made on the basis of the number of doses taken within a maximum period, not simply a 6-month period 1.
• For patients with cavitary pulmonary TB disease and positive cultures of sputum specimens at the completion of 2 months of therapy, a longer, 7-month continuation phase of therapy is recommended, resulting in a total duration of 9 months 1.
• Directly observed therapy (DOT) is recommended to ensure adherence, and pyridoxine (vitamin B6) should be given with isoniazid to prevent peripheral neuropathy.
• Regular monitoring for drug side effects is essential, including liver function tests and vision checks for ethambutol.

Drug-Resistant TB

• For drug-resistant TB, treatment regimens are more complex, longer (18-24 months), and require second-line drugs 1.
• The treatment of drug-resistant TB should only include drugs to which the patient’s M. tuberculosis isolate has documented, or high likelihood of, susceptibility 1.
• Drugs known to be ineffective on the basis of in vitro growth-based or molecular DST should not be used 1.

From the FDA Drug Label

Pyrazinamide is indicated for the initial treatment of active tuberculosis in adults and children when combined with other antituberculous agents The current recommendation of the CDC for drug-susceptible disease is to use a six-month regimen for initial treatment of active tuberculosis, consisting of isoniazid, rifampin and pyrazinamide given for 2 months, followed by isoniazid and rifampin for 4 months. Rifampin for Injection, USP is indicated in the treatment of all forms of tuberculosis A three-drug regimen consisting of rifampin, isoniazid, and pyrazinamide is recommended in the initial phase of short-course therapy which is usually continued for 2 months

The recommended tuberculosis treatment regimen is a combination of drugs, typically including isoniazid, rifampin, and pyrazinamide, for an initial period of 2 months, followed by isoniazid and rifampin for 4 months, as recommended by the CDC 2 and supported by rifampicin's drug label 3.

• The treatment regimen may vary depending on the patient's situation, such as drug-resistant disease or HIV infection.
• It is essential to follow the recommended treatment regimen and guidelines to ensure effective treatment and prevent the development of drug-resistant bacteria.

From the Research

Tuberculosis Treatment Overview

• The standard treatment for active tuberculosis (TB) typically involves a combination of isoniazid, rifampin, pyrazinamide, and ethambutol for the initial two-month phase, followed by isoniazid and rifampin for 4 to 7 months 4.
• Directly-observed therapy (DOT) is the standard of care for pulmonary TB, and virtual treatment monitoring using digital technologies is becoming more common 4.
• For latent TB infection (LTBI), rifamycin-based regimens have been successful in preventing progression to TB disease, and once-weekly isoniazid and rifapentine for 12 weeks by DOT has been shown to be safe and effective 4, 5.

Treatment Duration and Regimens

• Attempts to shorten treatment duration have been unsuccessful based on recent clinical trials evaluating the role of fluoroquinolones 4.
• Treatment-shortening trials using higher doses of rifamycins are currently underway 4.
• The standard treatment for latent tuberculosis is nine months of isoniazid taken daily, or twice weekly under direct observation by a healthcare worker 5.
• Initial therapy for patients with active or suspected tuberculosis should include isoniazid, rifampin, pyrazinamide, and ethambutol until susceptibility is known 5.

Drug-Resistant Tuberculosis

• Confirmed multidrug-resistant tuberculosis or extensively drug-resistant tuberculosis should be treated with directly observed therapy in collaboration with a clinician familiar with management of these conditions 5.
• Treatment must include at least 4 drugs to which the organism is susceptible; the duration of therapy should usually be 18-24 months 5.
• Drug-resistant TB is an increasing concern, being met with repurposed drugs and new drugs, including bedaquiline, pretomanid, and delamanid 6.

Treatment Outcomes and Relapse

• A regimen of isoniazid, rifampin, pyrazinamide, and ethambutol given daily for 6 months produced successful outcomes when used in a public health tuberculosis clinic as routine therapy for isoniazid-resistant tuberculosis 7.
• On passive follow-up of at least 2 years on all patients, two patients relapsed, and the single patient with bacteriological relapse did not develop further drug resistance 7.