Drug-resistant tuberculosis treatment

(no change to w
or
ding but c
ombined with s
ection abo
ve called: Section 3: 
Rec
ommendations on the us
e o
f longer r
egimens for multidr
ug/ r
ifampicin 
resist
ant
 
tuber
culosis)
In MDR/RR-TB patients on longer r
egimens, a tr
eatment duration 
of 15–17 months af
ter cultur
e conver
sion is suggested for most 
patients; the duration may be modified accor
ding to the patient’
s 
response to therapy
 (conditional r
ecommendation, ver
y low 
cer
tainty in the estimates o
f
 
effect).
3.16 In MDR/RR-TB patients on longer r
egimens, a tr
eatment duration o
f 
15–17 months af
ter cultur
e conver
sion is suggested for most patients; the 
duration may be modified accor
ding to the patient’
s r
esponse to
therapy
. 
(Conditional r
ecommendation, ver
y low cer
tainty in the estimates o
f effect). 
(no change to w
or
ding but c
ombined with s
ection abo
ve called: Section 3: 
Rec
ommendations on the us
e o
f longer r
egimens for multidr
ug/ r
ifampicin 
resist
ant
 
tuber
culosis)
In MDR/RR-TB patients on longer r
egimens that contain amikacin 
or str
eptomycin, an intensive phase o
f 6–7 months is suggested 
for most patients; the duration may be modified accor
ding to the 
patient’
s r
esponse to therapy
 (conditional r
ecommendation, ver
y 
low cer
tainty in the estimates o
f
 
effect).
3.17 In MDR/RR-TB patients on longer r
egimens containing amikacin or 
str
eptomycin, an intensive phase o
f 6–7 months is suggested for most patients; 
the duration may be modified accor
ding to the patient’
s r
esponse to
therapy
. 
(Conditional r
ecommendation, ver
y low cer
tainty in the estimates o
f effect. 
(no change to w
or
ding but c
ombined with s
ection abo
ve called: Section 2.2: 
Rec
ommendations on the us
e o
f longer r
egimens for multidr
ug/ r
ifampicin 
resist
ant
 
tuber
culosis)
Section 4: Use o
f the standar
dized shor
ter MDR-TB r
egimen
 
Section 2: Shor
ter
, all-oral, bedaquiline-containing r
egimen for 
multidrug-/ rifampicin-r
esistant tuber
culosis
In MDR/RR-TB patients who have not been pr
eviously 
treated for mor
e than 1 month with second- line medicines 
used in the shor
ter MDR-TB r
egimen or in whom r
esistance 
to fluor
oquinolones and second-line injectable agents has 
been excluded, a shor
ter MDR-TB r
egimen o
f 9–12 months 
may be used instead o
f the longer r
egimen
s (conditional 
recommendation, low cer
tainty in the estimates o
f effect). 
2.1 A shor
ter all-oral bedaquiline-containing r
egimen o
f 9–12 months duration 
is r
ecommended in eligible patients with confir
med multidrug- or rifampicin-
resistant tuber
culosis (MDR/RR-TB) who have not been exposed to tr
eatment 
with second-line TB medicines used in this r
egimen for mor
e than 1 month, and 
in whom r
esistance to fluor
oquinolones has been
excluded.
(Conditional r
ecommendation, ver
y low cer
tainty in the evidence). 
(updat
ed
 
rec
ommendation)

---

WHO consolidated 
guidelines 
on
tuberculosis: 
drug-resistant tuberculosis treatment
95
Recommendations in the 2019 updat
e
Recommendations in the curr
ent updat
e
Not included in 2019 guidelines 
Section 4: The bedaquiline, pr
et
omanid and linezolid (BP
aL) r
egimen for 
MDR-TB with additional fluor
oquinolone r
esistance
Not included in 2019 guidelines
4.1. A tr
eatment r
egimen lasting 6–9 months, composed o
f bedaquiline, 
pr
etomanid and linezolid (BP
aL), may be used under operational r
esear
ch 
conditions in multidrug-r
esistant tuber
culosis (MDR-TB) patients with TB that 
is r
esistant to fluor
oquinolones, who have either had no pr
evious exposur
e to 
bedaquiline and linezolid or have been exposed for no mor
e than 2 weeks. 
(Conditional r
ecommendation, ver
y low cer
tainty in the estimates o
f effect). 
(new
 
rec
ommendation)
Section 5: Monit
oring p
atient r
esponse t
o MDR-TB 
tr
eatment using cultur
e 
Section 5: Monit
oring p
atient r
esponse t
o MDR-TB tr
eatment using 
cultur
e
In MDR/RR-TB patients on longer r
egimens, the per
for
mance 
of sputum cultur
e in addition to sputum smear micr
oscopy is 
recommended to monitor tr
eatment r
esponse. It is desirable 
for sputum cultur
e to be r
epeated at monthly inter
vals
 (str
ong 
recommendation, moderate cer
tainty in the estimates o
f 
test
 
accuracy).
5.1. In multidrug- or rifampicin-r
esistant tuber
culosis (MDR/RR-TB) patients 
on longer r
egimens, the per
for
mance o
f sputum cultur
e in addition to sputum 
smear micr
oscopy is r
ecommended to monitor tr
eatment r
esponse 
(str
ong 
recommendation, moderate cer
tainty in the estimates o
f test accuracy).
It is 
desirable for sputum cultur
e to be r
epeated at monthly inter
vals.

(no
 
change)
Section 6: S
tar
t o
f antir
etr
oviral therapy in p
atients on 
second-line antituber
culosis r
egimens
 
Section 6: S
tar
t o
f antir
etr
oviral therapy in p
atients on second-line 
antituber
culosis r
egimens
Antir
etr
oviral therapy is r
ecommended for all patients with 
HIV and DR-TB r
equiring second-line antituber
culosis drugs, 
irr
espective o
f CD4 cell count, as early as possible (within the fir
st 
8 weeks) following initiation o
f antituber
culosis tr
eatment
 (str
ong 
recommendation, ver
y low-quality
 
evidence).
6.1. Antir
etr
oviral therapy is r
ecommended for all patients with HIV and drug-
resistant tuber
culosis r
equiring second-line antituber
culosis drugs, irr
espective o
f 
CD4 cell count, as early as possible (within the fir
st 8 weeks) following initiation o
f 
antituber
culosis
treatment
.
(Str
ong r
ecommendation, ver
y low quality evidence). 
(no
 
change)

---

Supplementary Table
96
Recommendations in the 2019 updat
e
Recommendations in the curr
ent updat
e
Section 7: Sur
ger
y for p
atients on MDR-TB tr
eatment
 
 Section 7: Sur
ger
y for p
atients on MDR-TB tr
eatment
In patients with RR-TB or MDR-TB, elective par
tial lung r
esection 
(lobectomy or wedge r
esection) may be used alongside a 
recommended MDR-TB r
egimen 
(conditional r
ecommendation, 
ver
y low cer
tainty in the
 
evidence).
7.1. In patients with rifampicin-r
esistant tuber
culosis (RR-TB) or multidrug-
resistant TB (MDR-TB), elective par
tial lung r
esection (lobectomy or wedge 
resection) may be used alongside a r
ecommended MDR-TB r
egimen.
 
(Conditional r
ecommendation, ver
y low cer
tainty in the evidence). 
 
(no
 
change)
Section 8: Car
e and suppor
t for p
atients with MDR/RR-TB
Section 8: Car
e and suppor
t for p
atients with MDR/RR-TB
Health education and counselling on the disease and tr
eatment 
adher
ence should be pr
ovided to patients on TB tr
eatment 
(str
ong r
ecommendation, moderate cer
tainty in the
 
evidence).
8.1 Health education and counselling on the disease and tr
eatment adher
ence 
should be pr
ovided to patients on tuber
culosis (TB) tr
eatment.
(Str
ong r
ecommendation, moderate cer
tainty in the evidence) 
(no
 
change)
A package o
f tr
eatment adher
ence inter
ventions
71
may be o
ffer
ed 
to patients on TB tr
eatment in conjunction with the selection 
of a suitable tr
eatment administration option
 (conditional 
recommendation, low cer
tainty in the evidence).
72
8.2 A package o
f tr
eatment adher
ence inter
ventions
71 
may be o
ffer
ed to patients 
on TB tr
eatment in conjunction with the selection o
f a suitable tr
eatment 
administration option.
72 
(no
 
change)
71
Tr
eat
m
ent adhe
renc
e int
er
ve
ntions inc
lude
soc
ial suppor
t suc
h as m
at
erial suppor
t (e
.g. f
ood, financ
ial inc
ent
ive
s, t
ranspor
t f
ee
s), psyc
hologic
al suppor
t, t
rac
er
s suc
h as hom
e visit
s or digit
al healt
h c
om
m
unic
ations
(e.g. 
SMS, 
telephone 
calls), 
medication 
monitor 
and 
staff 
education. 
The 
inter
ventions 
should 
be 
selected 
based 
on 
an 
assessment 
of 
the 
individual 
patient’
s 
needs, 
pr
ovider
’s 
resour
ces 
and
conditions
for
implementation.
72
Tr
eatment administration options include dir
ectly obser
ved tr
eatment (DO
T), non-daily DO
T, video-obser
ved tr
eatment (V
O
T), or unsuper
vised
treatment.

---

WHO consolidated 
guidelines 
on
tuberculosis: 
drug-resistant tuberculosis treatment
97