Guideline

WHO consolidated guidelines on tuberculosis: module 4: treatment and care

Year of Publication

2025

Issuing Institution

World Health Organization

Links

WHO IRIS

Recommendations

56 included recommendations

New patients with pulmonary TB should receive a regimen containing 6 months of rifampicin: 2HRZE/4HR

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

Wherever feasible, the optimal dosing frequency for new patients with pulmonary TB is daily throughout the course of therapy

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

In all patients with drug-susceptible pulmonary TB, the use of thrice-weekly dosing is not recommended in both the intensive and continuation phases of therapy, and daily dosing remains the recommended dosing frequency

Status

Maintained

Recommended against

Conditional

Certainty of evidence

Very low

The use of fixed-dose combination (FDC) tablets is recommended over separate drug formulations in the treatment of patients with drug-susceptible TB

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

In patients treated with the regimen containing rifampicin throughout treatment, if a positive sputum smear is found at completion of the intensive phase, the extension of the intensive phase is not recommended

Status

Maintained

Recommended against

Strong

Certainty of evidence

High

Patients aged 12 years or older with drugsusceptible pulmonary TB, may receive a 4-month regimen of isoniazid, rifapentine, moxifloxacin and pyrazinamide

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Moderate

In children and adolescents between 3 months and 16 years of age with non-severe TB (without suspicion or evidence of MDR/RR-TB), a 4-month treatment regimen (2HRZ(E)/2HR) should be used

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

It is recommended that TB patients who are living with HIV should receive at least the same duration of TB treatment as HIV-negative TB patients

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

ART should be started as soon as possible within two weeks of initiating TB treatment, regardless of CD4 cell count, among people living with HIV. Adults and adolescents

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

ART should be started as soon as possible within two weeks of initiating TB treatment, regardless of CD4 cell count, among people living with HIV. Children and infants

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

In patients with tuberculous meningitis, an initial adjuvant corticosteroid therapy with dexamethasone or prednisolone tapered over 6-8 weeks should be used

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

In patients with tuberculous pericarditis, an initial adjuvant corticosteroid therapy may be used

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

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

WHO suggests the use of a 6-month treatment regimen composed of bedaquiline, delamanid, linezolid (600 mg), levofloxacin, and clofazimine (BDLLfxC) in MDR/RR-TB patients with or without fluoroquinolone resistance.

Status

Updated

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

WHO suggests using the 9-month all-oral regimens (BLMZ, BLLfxCZ and BDLLfxZ) over currently recommended longer (>18 months) regimens in patients with MDR/RR-TB and in whom resistance to fluoroquinolones has been excluded. Amongst these regimens, using BLMZ is suggested over using BLLfxCZ, and BLLfxCZ is suggested over BDLLfxZ

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

WHO suggests against using 9-month DCLLfxZ or DCMZ regimen compared with currently recommended longer (>18 months) regimens in patients with fluoroquinolone-susceptible MDR/ RR-TB.

Status

Updated

Recommended against

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

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 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

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

Clofazimine and cycloserine or terizidone 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

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

Imipenem–cilastatin or meropenem 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

Amikacin may be included in the treatment of multidrug-resistant tuberculosis or rifampicin-resistant tuberculosis (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

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Ethionamide or prothionamide may be included in the treatment of multidrug-resistant tuberculosis or rifampicin-resistant tuberculosis (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

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

p-aminosalicylic acid may be included in the treatment of multidrug-resistant tuberculosis or rifampicin-resistant tuberculosis (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

Maintained

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

In multidrug-resistant TB or isoniazid-resistant, rifampicin-resistant 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

In multidrug-resistant tuberculosis or rifampicin-resistant tuberculosis (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

In multidrug-resistant tuberculosis or rifampicin-resistant tuberculosis (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

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

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

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

Status

Maintained

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

Antiretroviral therapy is recommended for all patients with HIV and DR-TB 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

Maintained

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

In patients with MDR/RR-TB and HCV co-infection, the WHO suggests the co-administration of HCV and TB treatment over delaying HCV treatment until after treatment of MDR/RR-TB is completed.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

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

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

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

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

A package of treatment adherence interventions may be offered to 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: tracers and/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: material support to the 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: psychological support to the 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: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 tuberculosis (MDR-TB) should be treated using mainly ambulatory care rather than models of care based principally on hospitalization

Status

Maintained

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