Treatment of Drug-Susceptible Tuberculosis

Publication Date: August 10, 2016
Last Updated: December 16, 2022

Treatment

Organization and Supervision of Treatment

See Recommendation Grading.
Recommendation 1: The panel suggests using case management interventions during treatment of patients with tuberculosis. (C, VL)
620
Recommendation 2: The panel suggests using DOT rather than SAT for routine treatment of patients with all forms of tuberculosis. (C, L)
620

Recommended Treatment Regimens

Recommendation 3a: The panel recommends the use of daily rather than intermittent dosing in the intensive phase of therapy for drug susceptible pulmonary tuberculosis. (S, M)
620
Recommendation 3b: Use of thrice-weekly therapy in the intensive phase (with or without an initial 2 weeks of daily therapy) may be considered in patients who are not HIV infected and are also at low risk of relapse (pulmonary tuberculosis caused by drug-susceptible organisms, that at the start of treatment is non-cavitary and/or smear negative). (C, L)
620
Recommendation 3c: In situations where daily or thrice-weekly DOT therapy is difficult to achieve, use of twice-weekly therapy after an initial 2 weeks of daily therapy may be considered for patients who are not HIV-infected and are also at low risk of relapse (pulmonary tuberculosis caused by drug-susceptible organisms, that at the start of treatment is non-cavitary and/or smear negative). (C, VL)
Note: If doses are missed in a regimen using twice-weekly dosing, then therapy is equivalent to once weekly, which is inferior (See below).
620
Recommendation 4a: The panel recommends the use of daily or thrice weekly dosing in the continuation phase of therapy for drug susceptible pulmonary tuberculosis. (S, M)
620
Recommendation 4b: If intermittent therapy is to be administered in the continuation phase, then the panel suggests use of thrice-weekly instead of twice-weekly therapy. (C, L)
This recommendation allows for the possibility of some doses being missed. With twice-weekly therapy, if doses are missed then therapy is equivalent to once weekly, which is inferior.
620
Recommendation 4c: The panel recommends against INH 900 mg and rifapentine 600 mg in the continuation phase. (S, H)
In uncommon situations where more than once-weekly DOT is difficult to achieve, once-weekly continuation phase therapy with INH 900 mg plus rifapentine 600 mg may be considered for use only in HIV-uninfected persons without cavitation on chest radiography.
620

Treatment in Special Situations

Recommendation 5a: For HIV-infected patients receiving ART, the panel suggests using the standard 6-month daily regimen consisting of an intensive phase of 2 months of INH RIF, PZA, and EMB followed by a continuation phase of 4 months of INH and RIF for the treatment of drug-susceptible pulmonary tuberculosis. (C, VL)
620
Recommendation 5b: In uncommon situations in which HIV-infected patients do NOT receive ART during tuberculosis treatment, the panel suggests extending the continuation phase with INH and RIF for an additional 3 months (ie, a continuation phase of 7 months in duration, corresponding to a total of 9 months of therapy) for treatment of drug susceptible pulmonary tuberculosis. (C, VL)
620
Recommendation 6: The panel recommends initiating ART during tuberculosis treatment. ART should ideally be initiated by 8–12 weeks of tuberculosis treatment initiation for patients with CD4 counts ≥50 cells/μL. ART should ideally be initiated within the first 2 weeks of tuberculosis treatment for patients with CD4 counts <50* cells/μL. (S, H)
*An exception is patients with HIV infection and tuberculous meningitis
(see Immune Reconstitution Inflammatory Syndrome in the full text Guidelines).
620

Extrapulmonary Tuberculosis

Recommendation 7: The panel suggests initial adjunctive corticosteroid therapy NOT be routinely used in patients with tuberculous pericarditis. (C, VL)
620
Recommendation 8: The panel recommends initial adjunctive corticosteroid therapy with dexamethasone or prednisolone tapered over 6–8 weeks for patients with tuberculous meningitis. (S, M)
620

Culture-Negative Pulmonary Tuberculosis in Adults

Recommendation 9: The panel suggests that a 4-month treatment regimen is adequate for treatment of HIV-uninfected adult patients with AFB smear- and culture-negative pulmonary tuberculosis. (C, VL)
620

Recommendation Grading

Overview

Title

Treatment of Drug-Susceptible Tuberculosis

Authoring Organizations

American Thoracic Society

Centers for Disease Control and Prevention

Infectious Diseases Society of America

Publication Month/Year

August 10, 2016

Last Updated Month/Year

October 4, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

This guideline provides recommendations on the clinical and public health management of tuberculosis in children and adults in settings in which mycobacterial cultures, molecular and phenotypic drug susceptibility tests, and radiographic studies, among other diagnostic tools, are available on a routine basis.

Target Patient Population

Adult and pediatric patients with tuberculosis

PICO Questions

  1. Does adding case management interventions to curative therapy improve outcomes compared to curative therapy alone among patients with tuberculosis?

  2. Does self-administered therapy (SAT) have similar outcomes compared to directly observed therapy (DOT) in patients with various forms of tuberculosis?

  3. Does intermittent dosing in the intensive phase have similar outcomes compared to daily dosing in the intensive phase for treatment of drug-susceptible pulmonary tuberculosis?

  4. Does intermittent dosing in the continuation phase have similar outcomes compared to daily dosing in the continuation phase in patients with drug-susceptible pulmonary tuberculosis patients?

  5. Does extending treatment beyond 6 months improve outcomes compared to the standard 6-month treatment regimen among pulmonary tuberculosis patients coinfected with HIV?

  6. Does initiation of ART during tuberculosis treatment compared to at the end of tuberculosis treatment improve outcomes among tuberculosis patients coinfected with HIV?

  7. Does the use of adjuvant corticosteroids in tuberculous pericarditis provide mortality and morbidity benefits?

  8. Does the use of adjuvant corticosteroids in tuberculous meningitis provide mortality and morbidity benefits?

  9. Does a shorter duration of treatment have similar outcomes compared to the standard 6-month treatment duration among HIV-uninfected patients with paucibacillary tuberculosis (ie, smear negative, culture negative)?

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Ambulatory

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Treatment, Management

Diseases/Conditions (MeSH)

D014376 - Tuberculosis

Keywords

tuberculosis, Mycobacterium tuberculosis, antitubercular agents, Drug-Susceptible Tuberculosis, TB, TB, tb, Tuberculosis

Source Citation

Payam Nahid, Susan E. Dorman, Narges Alipanah, Pennan M. Barry, Jan L. Brozek, Adithya Cattamanchi, Lelia H. Chaisson, Richard E. Chaisson, Charles L. Daley, Malgosia Grzemska, Julie M. Higashi, Christine S. Ho, Philip C. Hopewell, Salmaan A. Keshavjee, Christian Lienhardt, Richard Menzies, Cynthia Merrifield, Masahiro Narita, Rick O'Brien, Charles A. Peloquin, Ann Raftery, Jussi Saukkonen, H. Simon Schaaf, Giovanni Sotgiu, Jeffrey R. Starke, Giovanni Battista Migliori, Andrew Vernon, Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis, Clinical Infectious Diseases, Volume 63, Issue 7, 1 October 2016, Pages e147–e195, https://doi.org/10.1093/cid/ciw376

Supplemental Methodology Resources

Data Supplement