Tuberculosis Treatment (ATS/CDC/ERS/IDSA 2025)

Algorithm Steps

1. ▶

   Start

   Active Tuberculosis

   Pulmonary or extrapulmonary TB confirmed or highly suspected

   1. ●

      Action

      Initial Workup

      Before starting treatment

      • Sputum x3 for AFB smear and culture
      • GeneXpert MTB/RIF for rapid detection
      • CXR
      • HIV test (mandatory)
      • Baseline LFTs, CBC, BMP, visual acuity
      1. ●

         Action

         Respiratory Isolation

         Airborne precautions

         • Negative pressure room
         • N95 respirators for staff
         • Until 3 negative smears on treatment
         1. ◆

            Decision

            Drug Susceptibility

            Based on GeneXpert and/or culture

            1. ●

               Action

               Drug-Susceptible TB

               Standard 4-drug regimen

               • Intensive phase (2 months): RIPE
               • R: Rifampin 10mg/kg (max 600mg) daily
               • I: Isoniazid 5mg/kg (max 300mg) daily + B6
               • P: Pyrazinamide 25mg/kg daily
               • E: Ethambutol 15-20mg/kg daily
               1. ●

                  Action

                  Continuation Phase

                  After 2 months intensive

                  • 4 months Rifampin + Isoniazid (total 6 months)
                  • NEW: 4-month regimen option:
                  • HPZM (INH, RIF, PZA, Moxifloxacin) if age ≥12, drug-susceptible
                  • Continue pyridoxine (B6) throughout
                  1. ●

                     Action

                     Monitoring

                     Clinical and laboratory

                     • Monthly sputum until culture negative
                     • LFTs at baseline, then if symptomatic
                     • Visual acuity monthly while on ethambutol
                     • DOT strongly recommended
                     1. ⚠

                        Warning

                        Hepatotoxicity

                        ALT >5x ULN or symptoms

                        • Stop all hepatotoxic drugs
                        • Rechallenge sequentially after normalization
                        • Consider alternative regimen
                     2. ●

                        Action

                        HIV Co-infection

                        Special considerations

                        • Start ART within 2-8 weeks of TB treatment
                        • Watch for IRIS
                        • Drug interactions: Rifabutin may substitute for rifampin
                        • Longer duration may be needed
                        1. ✓

                           Outcome

                           Treatment Complete

                           6+ months, cultures negative

                     3. ⚠

                        Warning

                        Treatment Failure/Relapse

                        Persistent positive cultures, recurrence

                        • Re-test for drug resistance
                        • Ensure DOT compliance
                        • Consider surgical resection if localized
            2. ●

               Action

               MDR-TB (RIF-resistant)

               Specialist consultation required

               • 6-month BPaLM regimen now recommended:
               • Bedaquiline + Pretomanid + Linezolid + Moxifloxacin
               • OR longer regimen based on DST
               • Expert consultation essential