Treatment of Drug-Susceptible and Drug-Resistant Tuberculosis

Publication Date: December 30, 2024
Last Updated: January 6, 2025

Summary of Recommendations

In people aged 12 years or older with drug-susceptible pulmonary tuberculosis, we conditionally recommend the use of a 4-month regimen of isoniazid, rifapentine, moxifloxacin, and pyrazinamide. (C, M )
See Table 1 for dosing details.
620
In children and adolescents between 3 months and 16 years of age with nonsevere TB (without suspicion or evidence of multidrug-resistant [MDR]/rifampin-resistant [RR]-TB), we recommend the use of a 4-month treatment regimen of 2HRZ(E)/2HR rather than the 6-month drug-susceptible TB regimen of 2HRZ(E)/4HR. (S, M )
Remarks: Nonsevere TB is defined as peripheral lymph node TB; intrathoracic lymph node TB without airway obstruction; uncomplicated TB pleural effusion; or paucibacillary and noncavitary disease confined to one lobe of the lungs or without a miliary pattern. Children and adolescents who do not meet the criteria for nonsevere TB should receive the standard 6-month treatment regimen (2HRZE/4HR) or recommended treatment regimens for severe forms of extrapulmonary TB. Some children may be eligible for the 4-month rifapentine-moxifloxacin regimen. Dosing is found in Table 1.
620
In adolescents aged 14 and older and adults with rifampin-resistant pulmonary TB with resistance or patient intolerance to fluoroquinolones, who either have had no previous exposure to bedaquiline and linezolid or have been exposed for less than 1 month, we recommend the use of the 6-month treatment BPaL regimen, rather than more than 15-month regimens. (S, VL )
See Table 1 for dosing details.
620
In adolescents aged 14 and older and adults with rifampin-resistant, fluoroquinolone-susceptible pulmonary TB, we recommend the use of a 6-month BPaLM treatment regimen, rather than the 15-month or longer regimens in patients with MDR/RR-TB. (S, VL )
See Table 1 for dosing details.
620

Table 1. Recommended Drug Regimens

* Using actual body weight. Medications should be administered 7 d/wk with food, avoiding milk, antacids, or other cationic items, with DOT 5 of 7 days per week.
† Pyridoxine (vitamin B6), 25–50 mg/d, should be given with isoniazid to all patients.
‡ Using actual body weight and DOT 5 of 7 days per week.
§ To avoid potential ocular toxicity, some clinicians exclude ethambutol for children who are HIV-uninfected, have no prior TB treatment history, live in an area of low prevalence of DR-TB, and have no exposure to an individual from an area of high prevalence of DR-TB. Prevalence and risk factors can be difficult to ascertain; therefore, the American Academy of Pediatrics and most experts include ethambutol as part of the intensive phase regimen for children with TB.
‖ Medications should be administered 7 d/wk with food, with DOT 5 of 7 days per week.
¶ Medications should be administered 7 d/wk with food, avoiding milk, antacids, or other cationic items with DOT 5 of 7 days per week.
d = day; kg = kilograms; mg = milligrams; wk = week.

Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Treatment of Drug-Susceptible and Drug-Resistant Tuberculosis

Authoring Organizations

American Thoracic Society

Centers for Disease Control and Prevention

European Respiratory Society

Infectious Diseases Society of America

Publication Month/Year

December 30, 2024

Last Updated Month/Year

January 6, 2025

Document Type

Guideline

Country of Publication

US

Document Objectives

On the basis of recent clinical trial data for the treatment of drug-susceptible and drug-resistant tuberculosis (TB), the American Thoracic Society, U.S. Centers for Disease Control and Prevention, European Respiratory Society, and Infectious Diseases Society of America have updated clinical practice guidelines for TB treatment 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. New drug-susceptible TB recommendations include the use of a novel 4-month regimen for people with pulmonary TB and a shortened 4-month regimen for children with nonsevere TB. Drug-resistant TB recommendation updates include the use of novel regimens containing bedaquiline, pretomanid, and linezolid with or without moxifloxacin.

PICO Questions

  1. In adolescents and adults with drug-susceptible pulmonary tuberculosis (TB), is a 4-month regimen composed of 2 months of isoniazid, rifapentine, pyrazinamide, and moxifloxacin followed by 2 months of isoniazid, rifapentine, and moxifloxacin (2HPZM/2HPM) as efficacious and safe as the standard 6-month drug-susceptible TB regimen of 2 months of isoniazid, rifampin, pyrazinamide, and ethambutol (2HRZE) followed by 4 months of isoniazid, and rifampin (4HR) endorsed by the American Thoracic Society (ATS)/U.S. Centers for Disease Control and Prevention (CDC)/European Respiratory Society (ERS)/Infectious Diseases Society (IDSA) guidelines?

  2. In children and adolescents with nonsevere, drug-susceptible pulmonary TB, is a 4-month regimen composed of standard-dose 2 months of isoniazid, rifampin, pyrazinamide, and ethambutol followed by 2 months of isoniazid and rifampin (2HRZE/2HR) as efficacious and safe as the standard 6-month drug-susceptible TB regimen of 2 months of isoniazid, rifampin, pyrazinamide, and ethambutol followed by 4 months of isoniazid and rifampin (2HRZE/4HR) endorsed by the ATS/CDC/ERS/IDSA guidelines?

  3. In adolescents aged 14 and older and adults with rifampin-resistant pulmonary TB, is a 6-month BPaL regimen as efficacious and safe as the current 15-month or longer drug-resistant TB regimens composed according to current ATS/CDC/ERS/IDSA drug-resistant (DR)-TB treatment guidelines?

  4. In adolescents aged 14 and older and adults with rifampin-resistant, fluoroquinolone-susceptible pulmonary TB, is a 6-month BPaLM regimen as effective and safe as the 15-month or longer drug-resistant TB regimens composed according to current ATS/CDC/ERS/IDSA DR-TB treatment guidelines?

Inclusion Criteria

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

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Treatment, Management

Diseases/Conditions (MeSH)

D014376 - Tuberculosis, D018088 - Tuberculosis, Multidrug-Resistant

Keywords

tuberculosis, Drug-Susceptible Tuberculosis, Drug-Resistant Tuberculosis

Source Citation

Https://doi.org/10.1164/rccm.202410-2096ST

Supplemental Methodology Resources

Data Supplement