The 2016 Treatment of Drug-Susceptible Tuberculosis Guidelines have been released as an update to the previous tuberculosis (TB) guidelines published in 2003. The guidelines have been developed by the American Thoracic Society (ATS), Centers for Disease Control and Prevention (CDC), and the Infectious Diseases Society of America (IDSA).

The updated guidelines include recommendations on the clinical and public health management of TB in children and adults in well-resourced settings. The guidelines also provide evidence-based recommendations that were developed using GRADE methodology, which use structured reviews, analyses, and expert discussion of data. 

Of the nine recommendations for the treatment of drug-susceptible TB, the guidelines include recommendations on the management of patients with TB and HIV co-infection. Further, they include recommendations on TB disease in special cases, such as extrapulmonary TB, culture-negative pulmonary TB, and TB during pregnancy and breastfeeding. 

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In general, the objectives of TB therapy are to: 1) cure the individual patient and minimize risk of death and disability, 2) reduce transmission of M. tuberculosis to other persons; and 3) prevent the development of drug resistance during therapy. Case management interventions should be used while treating patients with TB disease and directly observed therapy (DOT) should be used when treating patients with all forms of TB disease. 

The preferred regimen for treating adults with TB remains a regimen involving an intensive phase of  2 months of isoniazid (INH),rifampin (RIF)pyrazinamide (PZA), and ethambutol (EMB) followed by a continuation phase of 4 months of INH and RIF. It is generally recommended that the once weekly regimen of INH 900/RPT 600 should be avoided; it may be considered in uncommon situations where more than once weekly DOT is difficult to achieve. 

Patients co-infected with HIV who receive antiretroviral therapy (ART) should receive the following TB treatment regimen:

  • 6 month daily regimen for drug susceptible pulmonary TB
    • Intensive Phase: 2 months of INH, RIF, PZA and EMB
    • Continuation Phase: 4 months INH and RIF

ART should be initiated during TB treatment:

  • Ideally, ART should be initiated within the first two weeks of TB treatment with CD4 cell counts <50/mm3 and by 8–12 weeks of TB treatment for patients with CD4 cell counts >50/mm3; however patients with TB meningitis should not start before 8–10 weeks of TB treatment is completed, regardless of CD4 count.

4-month treatment regimen is adequate for the treatment of adult patients who are not infected with HIV and who have AFB smear- and culture-negative pulmonary TB. 

Patients with TB meningitis and TB pericarditis should receive the following treatment regimen:

  • Initial adjunctive corticosteroid therapy with dexamethasone should be given for six weeks for patients with TB meningitis
  • Initial adjunctive corticosteroid therapy should not be routinely used in but should be reserved for selected patients with TB pericarditis

The full guidelines can be found here.

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