Pulmonary multidrug-resistant (MDR) or rifampicin-resistant (RR) tuberculosis requires a distinct treatment strategy from drug-susceptible TB. This protocol applies to adults and adolescents aged 14 years and older and accounts for the presence or absence of additional fluoroquinolone resistance.

Clinical Scenario

Confirmed pulmonary MDR-TB or RR-TB in a patient aged 14 years or older, with or without documented fluoroquinolone resistance, and who is not pregnant or breastfeeding. WHO recommends a 6-month regimen for this population over longer 9-month or 18-month alternatives.

Treatment Approach (partial overview)

A 6-month oral combination regimen forms the basis of this protocol. The composition is adjusted depending on whether fluoroquinolone resistance has been documented — one agent is omitted when resistance is confirmed, yielding a slightly different combination. The complete regimen, including all components and the criteria governing each variant, is available in the full protocol.

Treatment goals: culture conversion and clinical/radiological response by month 4; monthly sputum culture monitoring to confirm and sustain conversion to negative.

References

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.
Adults and adolescents aged 14 years and older.
It is not recommended during pregnancy.
In cases of documented resistance to FQ, BPaL without moxifloxacin should be initiated or continued.
This extension of the BPaL regimen would be needed only in cases where there is a lack of culture conversion or clinical response (based on the radiological response and clinical judgement of the treating physician) by month 4.

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Treatment of Pulmonary Tuberculosis with Multidrug- or Rifampicin-Resistance (MDR/RR-TB) in Patients Aged 14 and Older

References