Treatment of Tuberculosis of Bones or Joints in Rifampicin-Resistant or Multidrug-Resistant TB
When tuberculosis affects bone or joint tissue in the setting of rifampicin-resistant (RR-TB) or multidrug-resistant (MDR-TB) disease, standard first-line TB regimens are not appropriate. Osteoarticular involvement with MDR/RR-TB constitutes a distinct and complex clinical scenario requiring a dedicated treatment strategy.
This protocol applies to patients with confirmed rifampicin-resistant or multidrug-resistant tuberculosis who have osteoarticular (bone or joint) involvement. Osteoarticular TB is classified as severe extrapulmonary TB, alongside miliary TB, TB meningitis, and pericardial TB. Cases of this type often necessitate longer treatment regimens and inpatient care.
Management requires a longer, individualized all-oral regimen. Agents are drawn from prioritized drug-effectiveness groups, with the specific composition determined by each patient's susceptibility profile and the agents available for use.
The complete regimen structure — including which agent groups apply, how they are combined, and the criteria for group selection — is detailed in the full protocol.
Severe extrapulmonary TB: presence of miliary TB, TB meningitis, osteoarticular or pericardial TB.
These cases often necessitate longer regimens, inpatient care and, where there is CNS involvement, the inclusion of additional medicines with demonstrated efficacy in penetrating the blood–brain barrier.
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 the 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.
The total length of a long treatment regimen is 18 to 20 months.
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