Treatment of Tuberculosis
Based on the most recent ATS/CDC guidelines from:
Am J Respir Crit Care Med 2003;167:603-662
General:
- Consideration should be given to giving fixed-dose combinations medications [e.g., Rifamate® (INH 150mg+RIF 300mg) or Rifater® (INH 50mg+RIF 120mg+PZA 300mg)] when possible to prevent patients from developing drug resistance due to taking one drug alone.
- Directly Observed Therapy (DOT) is strongly recommended for all patients to ensure adherence to treatment.
For Drug-Susceptible M. tuberculosis:
- Isoniazid + Rifampin + Pyrazinamide + Ethambutol (if INH susceptibility not known) for two months,
- Then Isoniazid + Rifampin for at least 4 months.
Resistance to INH only:
- Same as above except that all drugs shall be continued for at least 6 months.
- Because RIF+EMB are the effective drugs in the regimen, consideration should be given to continuing the regimen for 12 months, with or without PZA, especially in patients with extensive TB disease and/or underlying diseases that impair immunity (e.g., HIV, diabetes mellitus).
- Although 6-month intermittent regimens yielded good results in clinical trials despite resistance to INH, adding a fluoroquinolone and/or an injectable agent (e.g., SM, CM, AK, KM) should be strongly considered for patients with extensive disease.
- INH may be discontinued.
The following tables are found in Section 4B of the TB Control Manual.
TB treatment regimens for drug-susceptible and INH-resistant strains*
| Dosing interval | Induction phase Minimum 2 months (8 weeks) | Continuation phase Minimum 4 months (16 weeks) |
| Drug-susceptible | INH-resistant |
| Daily | INH+RIF+PZA+EMB** | INH+RIF | RIF+PZA+EMB |
| Twice-weekly | INH+RIF+PZA+EMB** daily x 2 weeks, then twice-weekly x 6 weeks | INH+RIF | Not recommended |
| Thrice-weekly | INH+RIF+PZA+EMB | INH+RIF | RIF+PZA+EMB† |
*It is very strongly recommended that all drug treatment be given by DOT
**EMB may be discontinued if the isolate is sensitive to INH and RIF. SM may be used as an alternative to EMB.
†Although 6-month intermittent regimens yielded good results in clinical trials despite resistance to INH, adding a fluoroquinolone and/or an injectable agent (e.g., SM, CM, AK, KM) should be strongly considered for patients with extensive disease.
TB drug treatment dosages in adults
| Drug | Dose, mg/kg (maximum) |
| Daily | Twice-weekly | Thrice-weekly |
| Isoniazid | 5 (300 mg) | 15 (900 mg) | 15 (900 mg) |
| Rifampin | 10 (600 mg) | 10 (600 mg) | 10 (600 mg) |
| Pyrazinamide | 20-25 (2 g) | 40-50 (4 g) | 30-35 (3 g) |
| Ethambutol | 15 | 40-50 | 25-30 |
| Streptomycin | 15 (1 g) | 15 (1 g) | 15 (1 g) |
TB drug treatment dosages in children (under 12 years of age)
| Drug | Dose, mg/kg (maximum) |
| Daily | Twice-weekly | Thrice-weekly |
| Isoniazid | 10-15 (300 mg) | 20-30 (900 mg) | Not recommended |
| Rifampin | 10-20 (600 mg) | 10-20 (600 mg) | Not recommended |
| Pyrazinamide | 15-30 (2 g) | 50 | Not recommended |
| Ethambutol | 15 (2.5 g) | 50 | Not recommended |
| Streptomycin | 20-40 (1 g) | 20 (1 g) | Not recommended |
Follow-Up (See Chapter 5 of the TB Control Manual)
- Monthly Monitoring:
- Symptom Review
- Compliance Assessment
- Sputum Smear and Culture
- Appropriate Blood Tests
- Reassess treatment regimen if the smear or culture is still positive at 3 months.
Multidrug-Resistant TB (MDR-TB) (See Chapter 4 of the TB Control Manual)
- MDR TB requires careful assessment and individual tailoring of treatment regimen. Three or more "good" drugs may be necessary for the best results. Expert consultation is required.
- Drugs that may be of use with MDR-TB: Streptomycin, Capreomycin, Kanamycin, Ethionamide, Cycloserine, Rifabutin, PAS, Clofazimine and Quinolones (levofloxacin). Special drug request forms must be approved by TB Control before these drugs can be dispensed.
HIV/TB Co-infection (See Chapter 4 of the TB Control Manual)
- Treatment of tuberculosis in an HIV positive person is critical. The most effective treatment regimen possible should be used.
- Co-infection with TB and HIV is an absolute indication for Directly Observed Therapy.
- All HIV-infected patients undergoing treatment for TB should be evaluated for antiretroviral therapy because most patients with HIV-related TB are candidates for concurrent administration of antituberculosis and antiretroviral drug therapies.
- However, the use of Rifampin with protease inhibitors or non-nucleoside reverse transcriptase inhibitors is generally contraindicated.
- Rifabutin may be substituted for Rifampin in patients with drug-sensitive TB in certain situations.
- New agents are being introduced and treatment recommendations are changing rapidly.
- Expert consultation is recommended and/or review of recent TB/HIV treatment recommendations in:
