Active tuberculosis in adults
Pulmonary or extrapulmonary TB, confirmed or strongly suspected. Age 16 years or older. Not for latent TB infection.
All Pathways
Infectious DiseaseManagement
Tuberculosis Treatment (ATS/CDC/ERS/IDSA 2025)
Tuberculosis Treatment (ATS/CDC/ERS/IDSA 2025): Active tuberculosis in adults → Baseline tests, notify and refer → Rifampicin interactions: review every...
Pathway Overview
19 steps
Algorithm Steps
19 total
01Start 02Action Baseline tests, notify and refer
Before the first dose. Notify public health (TB is notifiable in all Australian states and territories) and refer to the state TB service.
- Sputum x3: AFB smear, culture and drug susceptibility testing (DST)
- Rapid molecular test (e.g. Xpert MTB/RIF) for rifampicin resistance
- HIV test for all patients
- ALT, bilirubin, FBC, creatinine (eGFR); hepatitis B and C serology
- HbA1c or fasting glucose if diabetes risk factors
- Visual acuity and colour vision (ethambutol)
- Chest X-ray
03Warning Rifampicin interactions: review every medicine before starting
Rifampicin and rifapentine lower the levels of many drugs.
- Reduces effect of warfarin, DOACs, hormonal contraception, antiretrovirals, immunosuppressants, methadone, azoles
- Hormonal contraception may fail: advise a non-hormonal method
- Adjust or monitor interacting drugs with a pharmacist or TB specialist
04Warning TB meningitis, pregnancy, children, renal or liver disease: specialist regimen
The standard adult regimen below needs changes in these groups. Plan with the state TB service. CrCl <30 mL/min or dialysis: pyrazinamide and ethambutol 3 times a week, dosed by the TB specialist. Existing liver disease: specialist chooses the regimen and LFT schedule.
- TB meningitis: 9-12 months plus corticosteroid (see meningitis step)
- Pregnancy: 4-month rifapentine and BPaL/BPaLM regimens not studied; give pyridoxine
- Children under 16: paediatric TB service (different mg/kg doses)
05Action Pulmonary or laryngeal TB: airborne precautions
Start at suspicion. Follow the local infection control policy.
- Single negative pressure room
- Staff wear a fit-checked P2/N95 respirator
- Patient wears a surgical mask outside the room
- Stop when 3 sputum smears are negative (8-24 hours apart), at least 2 weeks of effective treatment and clinically better. Rifampicin-resistant TB: TB service decides (often culture conversion)
06Action If HIV positive: ART timing and interactions
Plan with an HIV specialist.
- CD4 <50 cells/µL: start ART within 2 weeks of TB treatment
- CD4 50 cells/µL or more: start ART within 2-8 weeks (ATS 2016: by 8-12 weeks)
- TB meningitis: do not start ART early (see meningitis step)
- Rifampicin interacts with many antiretrovirals; rifabutin may replace rifampicin
- Watch for IRIS after ART starts
07Decision Rifampicin susceptible (no resistance on rapid test or DST)?
While culture DST is pending, start the standard regimen unless rifampicin resistance is detected.
- If Yes
- Drug-susceptible
08Warning Isoniazid-resistant TB on DST: stop isoniazid; 6 months RZE plus levofloxacin
Check DST results before the continuation phase. Isoniazid + rifampicin continuation in isoniazid-resistant TB is rifampicin alone and can cause rifampicin resistance. Treat with the state TB service.
- Give 6 months daily rifampicin, ethambutol, pyrazinamide plus levofloxacin
- Levofloxacin 750-1000 mg daily (adults); other drugs at standard doses
- Selected non-cavitary, low-burden disease: pyrazinamide may stop at 2 months
09Decision Drug-susceptible TB: which regimen?
Choose by site of disease and eligibility
- Standard 6-month
10Action Standard regimen, adults: 2 months HRZE
Isoniazid (H), rifampicin (R), pyrazinamide (Z), ethambutol (E), daily for 8 weeks, with DOT. Weight <40 kg or >90 kg: TB specialist to dose. Not for TB meningitis or other CNS TB (see meningitis step).
- Rifampicin 10 mg/kg daily (max 600 mg)
- Isoniazid 5 mg/kg daily (max 300 mg) plus pyridoxine 25-50 mg daily
- Pyrazinamide daily: 40-55 kg 1000 mg; 56-75 kg 1500 mg; 76-90 kg 2000 mg
- Ethambutol daily: 40-55 kg 800 mg; 56-75 kg 1200 mg; 76-90 kg 1600 mg
- Stop ethambutol when the isolate is susceptible to isoniazid and rifampicin
11Action Standard regimen: then 4 months isoniazid + rifampicin
After the 2-month intensive phase, only if the isolate is susceptible to isoniazid and rifampicin. Total 6 months for pulmonary TB.
- Same isoniazid, rifampicin and pyridoxine doses, daily
- Cavitation on chest X-ray and culture positive at 2 months, or HIV not on ART: add 3 months (9 months total)
- Bone and joint TB: 6-9 months total
- TB meningitis: see meningitis step
12Action Monitoring during treatment
Clinical review at least monthly. Directly observed therapy (DOT) recommended.
- Sputum smear and culture monthly until 2 consecutive cultures are negative. BPaL/BPaLM: every 1-2 weeks until smear conversion, every 2 weeks until culture conversion, then monthly
- Ethambutol: ask about vision and test colour vision monthly
- Repeat LFTs if symptoms, abnormal baseline, liver disease, alcohol, HIV or pregnancy
- Check adherence, weight and adverse effects at each visit
13Warning Stop first-line TB drugs: ALT ≥3x ULN with symptoms or jaundice, or ≥5x ULN
Stop isoniazid, rifampicin or rifapentine and pyrazinamide at once and contact the TB specialist. BPaL/BPaLM: stop all drugs if ALT or AST rise with bilirubin >2x ULN, or ALT or AST >8x ULN, or >5x ULN for more than 2 weeks; TB specialist decides.
- Check hepatitis A, B, C serology, alcohol and other hepatotoxic drugs
- Reintroduce drugs one at a time when ALT <2x ULN, with specialist advice
- Severe or smear-positive TB: specialist may give a non-hepatotoxic interim regimen
14Decision Culture positive after 4 months of treatment, or relapse?
Review culture results and clinical response
- If Yes
15Warning Yes: treatment failure or relapse
Refer to the TB specialist service.
- Repeat culture and DST, including a rapid molecular test
- Never add a single new drug to a failing regimen
- Check adherence, absorption and drug interactions
If No16Outcome No: treatment complete
Full course taken and cultures negative. Report the outcome to public health. BPaL/BPaLM: review with sputum and chest imaging at 3, 6, 12, 18 and 24 months after treatment.
- TB meningitis
17Action TB meningitis: 9-12 months treatment plus corticosteroid
Drug-susceptible TB meningitis or other CNS TB. Treat with TB and infectious diseases specialists.
- 2 months HRZE (standard doses), then 7-10 months isoniazid + rifampicin
- Add dexamethasone or prednisolone at the start, tapered over 6-8 weeks
- HIV: no ART in the first 2 weeks. HIV specialist sets timing: when meningitis is controlled (NIH 2026) or after 8 weeks (ATS 2016)
- Not eligible for the 4-month regimen
- Path rejoins step 12Shared downstream outcome
- 4-month option
18Action Option: 4-month rifapentine-moxifloxacin regimen (pulmonary TB)
TB specialist only. Replaces the standard regimen from day 1. Pulmonary TB susceptible to isoniazid, rifampicin and fluoroquinolones. Not studied in CNS, bone or joint, miliary or pericardial TB, pregnancy, or weight <40 kg.
- Isoniazid 300 mg (plus pyridoxine), rifapentine 1200 mg, moxifloxacin 400 mg: daily for 17 weeks
- Plus pyrazinamide daily for the first 8 weeks: 40 to <55 kg 1000 mg; 55-75 kg 1500 mg; >75 kg 2000 mg
- HIV: studied only with CD4 100 cells/µL or more on efavirenz-based ART; check ART interactions
- Moxifloxacin: ECG if older, heart disease, long QT or other QT-prolonging drugs
- Rifapentine is supplied through the state TB service
- Path rejoins step 12Shared downstream outcome
If No- Rifampicin-resistant
19Action Rifampicin-resistant TB: refer to the state TB service now
Rifampicin resistance detected. Adults with pulmonary TB. Treat only with TB specialist. Not eligible for BPaL/BPaLM (individualised regimen): pregnancy, breastfeeding, severe extrapulmonary TB, resistance or intolerance to bedaquiline, pretomanid or linezolid, or prior use of these for 1 month or more.
- Test fluoroquinolone susceptibility. Susceptible: 6 months BPaLM (bedaquiline, pretomanid, linezolid, moxifloxacin). Resistant or intolerant: 6 months BPaL
- Doses: bedaquiline 400 mg daily for 2 weeks, then 200 mg 3 times a week for 24 weeks; pretomanid 200 mg, linezolid 600 mg, moxifloxacin 400 mg daily for 26 weeks
- Safety: ECG (QTcF) at baseline, weeks 2, 12 and 24 (monthly on BPaLM; more often if long QT or heart disease); stop all drugs if QTcF >500 ms. Avoid efavirenz. Review antidepressants, MAOIs and QT-prolonging drugs
- Linezolid: FBC every 1-2 weeks for 6-8 weeks, then monthly; vision and neuropathy checks monthly. Correct low K+, Mg2+, Ca2+ before starting; LFTs and electrolytes monthly
- Bedaquiline and pretomanid are supplied through the state TB service
- Path rejoins step 12Shared downstream outcome
Guideline Source
Updates on the Treatment of Drug-Susceptible and Drug-Resistant Tuberculosis: ATS/CDC/ERS/IDSA Clinical Practice Guideline (2025)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults with active TB. Children, pregnancy, TB meningitis, renal or liver disease, isoniazid-resistant and rifampicin-resistant TB need the state TB service.
- Doses are for daily regimens in adults 40-90 kg; other weights need specialist dosing.
- Not for latent TB infection. TB is notifiable: notify public health and manage with the state TB service.
- Rifapentine, bedaquiline and pretomanid are supplied through state TB services in Australia.
- ART timing in HIV differs between ATS 2016 and NIH 2026 (especially TB meningitis); the HIV specialist decides.
Contraindicated Populations
Children under 16 years (paediatric TB service)Latent TB infection (use a latent TB pathway)
Applicable Regions
AUUSEUGlobal
AU: TB is notifiable in all states and territories. Treat with the state TB service. Rifapentine, bedaquiline and pretomanid had no ARTG entry on 27 Sep 2026; supply is through the TB service. Australian name: rifampicin (US: rifampin).
Global: ATS/CDC/ERS/IDSA 2025 update (4-month regimens, BPaL, BPaLM) with ATS/CDC/IDSA 2016 drug-susceptible TB guideline
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Tuberculosis Treatment (ATS/CDC/ERS/IDSA 2025)?
The Tuberculosis Treatment (ATS/CDC/ERS/IDSA 2025) is a management clinical algorithm for Infectious Disease. It provides a structured decision tree to guide clinical decision-making, based on Updates on the Treatment of Drug-Susceptible and Drug-Resistant Tuberculosis: ATS/CDC/ERS/IDSA Clinical Practice Guideline (2025).
What guideline is the Tuberculosis Treatment (ATS/CDC/ERS/IDSA 2025) based on?
This algorithm is based on Updates on the Treatment of Drug-Susceptible and Drug-Resistant Tuberculosis: ATS/CDC/ERS/IDSA Clinical Practice Guideline (2025) (DOI: 10.1164/rccm.202410-2096ST).
What are the limitations of the Tuberculosis Treatment (ATS/CDC/ERS/IDSA 2025)?
Known limitations include: Adults with active TB. Children, pregnancy, TB meningitis, renal or liver disease, isoniazid-resistant and rifampicin-resistant TB need the state TB service.; Doses are for daily regimens in adults 40-90 kg; other weights need specialist dosing.; Not for latent TB infection. TB is notifiable: notify public health and manage with the state TB service.; Rifapentine, bedaquiline and pretomanid are supplied through state TB services in Australia.; ART timing in HIV differs between ATS 2016 and NIH 2026 (especially TB meningitis); the HIV specialist decides.. Individual patient factors may require deviation from these recommendations.
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