Guideline

WHO consolidated guidelines on tuberculosis: Module 4: treatment - drug-resistant tuberculosis treatment, 2022 update

Year of Publication

2022

Issuing Institution

World Health Organization

Links

Pubmed

Recommendations

40 included recommendations

Health education and counselling on the disease and treatment adherence should be provided to patients on TB treatment

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Moderate

A package of treatment adherence interventions may be offered for patients on TB treatment in conjunction with the selection of a suitable treatment administration option

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

One or more of the following treatment adherence interventions (complementary and not mutually exclusive) may be offered to patients on TB treatment or to health-care providers: a) tracers or digital medication monitor

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

One or more of the following treatment adherence interventions (complementary and not mutually exclusive) may be offered to patients on TB treatment or to health-care providers b) material support to patient

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Moderate

One or more of the following treatment adherence interventions (complementary and not mutually exclusive) may be offered to patients on TB treatment or to health-care providers c) psychological support to patient

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

One or more of the following treatment adherence interventions (complementary and not mutually exclusive) may be offered to patients on TB treatment or to health-care providers d) staff education

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

The following treatment administration options may be offered to patients on TB treatment: a) Community- or home-based treatment support is recommended over health facility-based treatment support or unsupervised treatment

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Moderate

The following treatment administration options may be offered to patients on TB treatment: b) Treatment support administered by trained lay providers or health-care workers is recommended over treatment support administered by family members or unsupported treatment

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

The following treatment administration options may be offered to patients on TB treatment: c) Video-supported treatment (VST) can replace in-person treatment support when the video communication technology is available and can be appropriately organized and operated by health-care providers and patients

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Patients with multidrug-resistant TB (MDR-TB) should be treated using mainly ambulatory care rather than models of care based principally on hospitalization

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

A decentralized model of care is recommended over a centralized model for patients on MDR-TB treatment

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

In TB high-burden settings, decentralized models of care may be used to deliver TB services to children and adolescents with signs and symptoms of TB and/or those exposed to TB

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Family-centred, integrated models of care to deliver TB services may be used in children and adolescents with signs and symptoms of TB and/or those exposed to TB, in addition to standard models of care

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

The 6-month bedaquiline, pretomanid, linezolid and moxifloxacin (BPaLM) regimen for multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB) and pre-extensively drug-resistant tuberculosis (XDR-TB): WHO suggests the use of the 6-month treatment regimen composed of bedaquiline, pretomanid, linezolid (600 mg) and moxifloxacin (BPaLM) rather than 9-month or longer (18-month) regimens in MDR/RR-TB patients.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

The 9-month all-oral regimen for multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB): WHO suggests the use of the 9-month all-oral regimen rather than longer (18-month) regimens in patients with MDR/RR-TB and in whom resistance to fluoroquinolones has been excluded.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

In multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB) patients on longer regimens, all three Group A agents and at least one Group B agent should be included to ensure that treatment starts with at least four TB agents likely to be effective, and that at least three agents are included for the rest of treatment if bedaquiline is stopped. If only one or two Group A agents are used, both Group B agents are to be included. If the regimen cannot be composed with agents from Groups A and B alone, Group C agents are added to complete it.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Kanamycin and capreomycin are not to be included in the treatment of multidrug-resistant tuberculosis or rifampicin-resistant tuberculosis (MDR/RR-TB) patients on longer regimens

Status

Maintained

Recommended against

Conditional

Certainty of evidence

Very low

Levofloxacin or moxifloxacin should be included in the treatment of multidrug-resistant tuberculosis or rifampicin-resistant tuberculosis (MDR/RR-TB) patients on longer regimens.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

Longer regimens for multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB): Bedaquiline should be included in longer multidrug-resistant TB (MDR-TB) regimens for patients aged 18 years or more.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

Bedaquiline should be included in longer multidrug-resistant TB (MDR-TB) regimens for patients aged 18 years or more.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

Longer regimens for multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB): In children with MDR/RR-TB aged below 6 years, an all-oral treatment regimen containing bedaquiline may be used.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Longer regimens for multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB): Linezolid should be included in the treatment of MDR/RR-TB patients on longer regimens.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

Ethambutol may be included in the treatment of multidrug-resistant tuberculosis or rifampicin-resistant tuberculosis (MDR/RR-TB) patients on longer regimens

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Delamanid may be included in the treatment of multidrug-resistant tuberculosis or rifampicin-resistant tuberculosis (MDR/RR-TB) patients aged 3 years or more on longer regimens

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Pyrazinamide may be included in the treatment of multidrug-resistant tuberculosis or rifampicin-resistant tuberculosis (MDR/RR-TB) patients on longer regimens

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Longer regimens for multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB): Pyrazinamide may be included in the treatment of MDR/RR-TB patients on longer regimens

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

Longer regimens for multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB): Imipenem–cilastatin or meropenem may be included in the treatment of MDR/RR-TB patients on longer regimens.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Longer regimens for multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB): Amikacin may be included in the treatment of MDR/RR-TB patients aged 18 years or more on longer regimens when susceptibility has been demonstrated and adequate measures to monitor for adverse reactions can be ensured. If amikacin is not available, streptomycin may replace amikacin under the same conditions

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

Longer regimens for multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB): Ethionamide or prothionamide may be included in the treatment of MDR/RR-TB patients on longer regimens only if bedaquiline, linezolid, clofazimine or delamanid are not used, or if better options to compose a regimen are not possible

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

Longer regimens for multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB): P-aminosalicylic acid may be included in the treatment of MDR/RR-TB patients on longer regimens only if bedaquiline, linezolid, clofazimine or delamanid are not used, or if better options to compose a regimen are not possible.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

Longer regimens for multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB): Clavulanic acid should not be included in the treatment of MDR/RR-TB patients on longer regimens.

Status

Maintained

Recommended against

Strong

Certainty of evidence

Low

Longer regimens for multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB): In MDR/RR-TB patients on longer regimens, a total treatment duration of 18–20 months is suggested for most patients; the duration may be modified according to the patient’s response to therapy.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Longer regimens for multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB): In MDR/RR-TB patients on longer regimens, a treatment duration of 15–17 months after culture conversion is suggested for most patients; the duration may be modified according to the patient’s response to therapy.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Longer regimens for multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB): In MDR/RR-TB patients on longer regimens containing amikacin or streptomycin, an intensive phase of 6–7 months is suggested for most patients; the duration may be modified according to the patient’s response to therapy.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Regimen for rifampicin-susceptible and isoniazid-resistant TB: In patients with confirmed rifampicin-susceptible, isoniazid-resistant tuberculosis , treatment with rifampicin, ethambutol, pyrazinamide and levofloxacin is recommended for a duration of 6 months.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

Regimen for rifampicin-susceptible and isoniazid-resistant TB: In patients with confirmed rifampicin-susceptible, isoniazid-resistant tuberculosis, it is not recommended to add streptomycin or other injectable agents to the treatment regimen.

Status

Updated

Recommended against

Conditional

Certainty of evidence

Very low

Monitoring patient response to MDR/RR-TB treatment using culture : In multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB) patients on longer regimens, the performance of sputum culture in addition to sputum smear microscopy is recommended to monitor treatment response. It is desirable for sputum culture to be repeated at monthly intervals.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

Starting antiretroviral therapy in patients on multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB) regimens: Antiretroviral therapy is recommended for all patients with HIV and drug-resistant tuberculosis requiring second-line antituberculosis drugs, irrespective of CD4 cell count, as early as possible (within the first 8 weeks) following initiation of antituberculosis treatment.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Very low

Surgery for patients on MDR/RR-TB treatment: In patients with rifampicin-resistant tuberculosis (RR-TB) or multidrug-resistant TB (MDR-TB), elective partial lung resection (lobectomy or wedge resection) may be used alongside a recommended MDR-TB regimen.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Bedaquiline may also be included in longer multidrug-resistant tuberculosis (MDR-TB) regimens for patients aged 6–17 years

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low