by American Thoracic Society

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Tuberculosis remains a public health crisis. The World Health Organization’s Global Tuberculosis Report released in November 2024 painted a sobering picture; approximately 8.2 million people were newly diagnosed with TB in 2023, the highest number since the organization began global TB monitoring in 1995. A major challenge in tuberculosis treatment has been the long duration needed to effectively treat the disease.

In the latest clinical practice guidelines from the American Thoracic Society, the Centers for Disease Control and Prevention, European Respiratory Society and Infectious Diseases Society of America, an expert panel shared new recommendations for all-oral, shorter treatment regimens for TB in eligible children and adults. The guidelines were released online on Dec. 30, 2024 in the American Journal of Respiratory and Critical Care Medicine.

“There has been a quest and concerted effort to develop shorter treatments for TB, after decades of little drug development,” said Jussi Saukkonen, MD, ATSF, one of the lead authors of the guidelines. “Wipmen durations for both drug-susceptible and drug-resistant TB for most patients, down to four and six months, respectively.”

However, the panel notes that “For those who are not eligible for these shorter regimens, the 2016 and 2019 recommendations should be consulted.”

Using the thorough, evidence-based Grading of Recommendations, Assessment, Development and Evaluation or GRADE framework, the expert panel made the following recommendations for patients with tuberculosis:

In adolescents and adults with drug-susceptible pulmonary tuberculosis, is a four-month regimen composed of two months of isoniazid, rifapentine, pyrazinamide, and moxifloxacin followed by two months of isoniazid, rifapentine, and moxifloxacin (2HPZM/2HPM) as efficacious and safe as the standard six-month drug-susceptible TB regimen of two months of isoniazid, rifampin, pyrazinamide, and ethambutol (2HRZE) followed by four months of isoniazid, and rifampin (4HR)?

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 (conditional recommendation, moderate certainty of evidence).

In children and adolescents with non-severe, drug-susceptible pulmonary TB, is a four-month regimen composed of standard-dose two months of isoniazid, rifampin, pyrazinamide, and ethambutol followed by two months of isoniazid and rifampin (2HRZE/2HR) as efficacious and safe as the standard 6-month drug-susceptible TB regimen of two months of isoniazid, rifampin, pyrazinamide, and ethambutol followed by four months of isoniazid and rifampin (2HRZE/4HR)?

In children and adolescents between 3 months and 16 years of age with non-severe TB (without suspicion or evidence of multidrug-resistant rifampin-resistant 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 (strong recommendation, moderate certainty of evidence).

In adolescents aged 14 and older and adults with rifampin-resistant pulmonary TB, is a 6-month bedaquiline, pretomanid, and linezolid (BPaL) regimen as efficacious and safe as the current 15-month or longer drug-resistant TB regimens?

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 (strong recommendation, very low certainty of evidence).

In adolescents aged 14 and older and adults with rifampin-resistant, fluoroquinolone-susceptible pulmonary TB, is a 6-month bedaquiline, pretomanid, linezolid, and moxifloxacin (BPaLM) regimen as effective and safe as the 15-month or longer drug-resistant TB regimens?

In adolescents aged 14 and older and adults with rifampinresistant, 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 (strong recommendation, very low certainty of evidence).

“While these new regimens have allowed significant treatment shortening, it is important to recognize that drug-resistance in TB isolates could emerge with incomplete adherence to these regimens,” cautioned Dr. Saukkonen. “Directly observed treatment, close monitoring for safety and effectiveness of regimens, and drug-susceptibility testing are essential to the effective treatment of TB and for the overall success of TB programs.”

More information: Visit the ATS website to read the current TB clinical practice guidelines in full.

Journal information:American Journal of Respiratory and Critical Care Medicine

Provided by American Thoracic Society

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