Treatment of Tuberculous Meningitis in Adults (Age 18+) Without HIV Co-infection
Clinical Scenario
This protocol addresses hospitalised adults aged 18 years or older presenting with tuberculous meningitis in the absence of HIV co-infection. The HIV status is a decisive factor in both therapy selection and the strength of evidence supporting specific adjunctive treatments in this population.
Defining Conditions
Age ≥ 18 years
No HIV co-infection
The evidence supporting this regimen is rated high-certainty with a strong recommendation specifically for individuals without HIV. For people living with HIV, a separate case-by-case assessment applies.
Treatment Approach
Management involves initiating a multi-drug anti-tuberculosis combination regimen, with an additional agent incorporated at the start for patients at elevated risk of resistance. After the initial induction phase, therapy is stepped down to a two-drug continuation regimen to complete the full treatment course. Adjunctive corticosteroid therapy is given concurrently, with a tapering schedule, alongside pyridoxine supplementation and comprehensive supportive care.
The complete regimen — specific agents, sequencing, dosing, duration, and resistance-adjusted modifications — is available in the full protocol.
References
DOI: 10.1016/S1473-3099(25)00364-0
- Population: adults in hospital requiring treatment for tuberculous meningitis.
- Is there HIV co-infection? High certainty of evidence, strong recommendation for use in individuals without HIV; high certainty of evidence, weak recommendation for use in people living with HIV so the decision to use should be made on a case-by-case basis.
- Adults: RHZE with quinolone if at high risk of isoniazid resistance.
- Step down to rifampicin and isoniazid after 2 months; complete 9–12 months of anti-tuberculosis therapy.
- High certainty of evidence, strong recommendation for use in individuals without HIV.
- Pyridoxine (B6) supplementation.
- Oxygen, fluid balance, temperature, blood pressure; nutrition: swallow assessment and oral or nasogastric feed; mobility: pressure-relieving mattress, thromboembolism prevention.