Joint guidelines issued for drug-susceptible pulmonary tuberculosis

A 4-drug regimen of isoniazid, rifampin, pyrazinamide, and ethambutol for 2 months, followed by a continuation phase of 4 months of isoniazid and rifampin, remains the preferred initial treatment for drug-susceptible pulmonary tuberculosis.


Newly released guidelines for treating drug-susceptible pulmonary tuberculosis maintain the existing 4-drug regimen but add certainty of evidence and endorsement by more medical societies to bolster their use.

The guidelines provide recommendations on the clinical and public health management of Mycobacterium tuberculosis in children and adults in settings in which cultures, molecular and phenotypic drug susceptibility tests, and radiographic studies, among other diagnostic tools, are available on a routine basis.

For the first time, the guideline authors noted, recommendations are based on the certainty or quality of evidence assessed by the GRADE methodology. Also, more medical societies were involved in the development, or have endorsed the results, expanding the applicability of the guidance beyond North America to include Europe and other low-incidence settings. Last, practice guidelines for drug-resistant tuberculosis are no longer included and will be covered in a separate practice guideline currently under development.

A 4-drug regimen of isoniazid, rifampin, pyrazinamide, and ethambutol for 2 months, followed by a continuation phase of 4 months of isoniazid and rifampin, remains the preferred initial treatment for drug-susceptible pulmonary tuberculosis. Treatment should be initiated promptly even before acid-fast bacilli, smear microscopy, molecular tests, and mycobacterial culture results are known in patients with high likelihood of having tuberculosis or those seriously ill with a disorder suspicious for tuberculosis. Treatment should not be delayed because of negative acid-fast bacilli smears for patients with suspected tuberculosis who have a life-threatening condition.

The guidelines were published online Aug. 10 by Clinical Infectious Diseases and developed by the American Thoracic Society, CDC, and Infectious Diseases Society of America.

The 9 recommendations advise clinicians on use of case management interventions, directly observed therapy, daily and thrice-weekly dosing, antiretroviral therapy, adjunctive corticosteroid therapy, and appropriate length of a treatment regimen. The guidelines conclude, “Treatment of tuberculosis is focused on both curing the individual patient and minimizing the transmission of M. tuberculosis to other persons, thus, successful treatment of tuberculosis has benefits both for the individual patient and the community in which the patient resides.”