Updated Guidelines on the Treatment of Drug-Susceptible and Drug-Resistant TB

Dear Colleague Letter

Dear Colleagues,

Treating tuberculosis (TB) disease improves individual health, minimizes risk for death and disability, and reduces transmission of TB to others. On December 31, 2024, the American Thoracic Society (ATS), the Centers for Disease Control and Prevention (CDC), the European Respiratory Society (ERS), and the Infectious Diseases Society of America (IDSA) published "Updates on the Treatment of Drug-Susceptible and Drug-Resistant Tuberculosis: An Official ATS/CDC/ERS/IDSA Clinical Practice Guideline" in the American Journal of Respiratory and Critical Care Medicine.

A panel of experts from ATS, CDC, ERS, IDSA, and We Are TB authored the updates, incorporating clinical guidance resulting from the results of recent clinical treatment trials, including CDC's TB Clinical Trials Consortium. The updated guidelines offer patients and health care providers shorter, safer, and more effective regimens with fewer pills and injections.

Highlights

Adults and adolescents with drug-susceptible pulmonary TB disease can be treated in four months instead of six.

The panel recommends two months of isoniazid (H), rifapentine (P), pyrazinamide (Z), moxifloxacin (M), followed by two months of isoniazid, rifapentine, and moxifloxacin (2HPZM/2HPM) for people aged 12 years or older.

Most children with non-severe TB disease can be treated in four months instead of six.

The panel recommends two months of isoniazid (H), rifampin (R), pyrazinamide (Z), and ethambutol (E), followed by two months of isonaizid and rifampin (2HRZE/2HR) for children and adolescents between three months and 16 years of age with non-severe pulmonary TB disease.

New all-oral regimens for multidrug- and rifampin-resistant TB disease shorten treatment duration from fifteen months to six months.

• The panel recommends a six-month treatment regimen (BPaLM) of bedaquiline (B), pretomanid (P), linezolid (L), and moxifloxacin (M) for people aged 14 years or older with rifampin-resistant, fluoroquinolone-susceptible pulmonary TB disease.
• The panel recommends a six-month treatment regimen (BPaL) of bedaquiline (B), pretomanid (P), and linezolid (L) for people aged 14 years or older with rifampin-resistant pulmonary TB disease and fluoroquinolone resistance or intolerance.
• These regimens are also treatment options for people with an intolerance of rifampin.

The guidelines are meant for low-incidence settings where mycobacterial cultures, molecular and phenotypic drug susceptibility tests, and radiographic studies, among other diagnostic tools, are available on a routine basis. Directly observed therapy (DOT) and integrated case management remain the standard of care.

I encourage you to read the guidelines for information about patient eligibility, clinical evaluation and monitoring, and regimen administration. State and local TB programs, and the TB Centers of Excellence for Training, Education, and Medical Consultation can provide assistance and support in treating people with TB disease.

Thank you for your work and commitment to eliminate TB in the United States.

Sincerely,

Philip LoBue, MD, FACP, FCCP
Director
Division of Tuberculosis Elimination
National Center for HIV, Viral Hepatitis, STD, and TB Prevention