Shorter Drug-Resistant TB Regimens: Current Evidence

Introduction to Shorter Regimens

• The American Thoracic Society, Centers for Disease Control and Prevention, European Respiratory Society, and Infectious Diseases Society of America could not recommend for or against the 9-12 month standardized regimen in 2019 because it included kanamycin and drugs for which resistance was likely 1, 2, 3

Composition of Shorter Regimens

• The 2025 guidelines recommend the BPaLM regimen for MDR/RR-TB with extrapulmonary involvement, including intestinal TB, composed of bedaquiline, pretomanid, linezolid, and moxifloxacin 4, 5
• The BPaLM regimen has a duration of 6 months, compared to 9-12 months for the older standardized regimen or 15-24 months for conventional longer regimens 4, 5

Indications for Shorter vs. Longer Regimens

• The 6-month BPaLM regimen is indicated for MDR/RR-TB patients with confirmed disease, including extrapulmonary disease like intestinal TB, and no documented resistance to fluoroquinolones or bedaquiline 4, 5
• Individualized longer oral regimens are recommended when resistance to fluoroquinolones or other key drugs in shorter regimens exists, or when the patient is ineligible for the shorter regimen based on drug susceptibility testing 5

Composition of Longer Oral Regimens

• Longer regimens should include at least 5 effective drugs, with core drugs including bedaquiline, a later-generation fluoroquinolone, and linezolid 5
• Additional agents may include clofazimine, cycloserine, pyrazinamide, and delamanid, while injectable agents like amikacin or streptomycin should only be used when necessary 5

Special Populations

• For isoniazid-resistant TB, a 6-month regimen including a later-generation fluoroquinolone, rifampin, ethambutol, and pyrazinamide is recommended 1, 4
• For patients with HIV and drug-resistant TB, treatment duration should be extended to at least 9 months and for at least 6 months beyond culture conversion 4

Monitoring and Support

• Monthly sputum cultures are recommended to monitor treatment response, and directly observed therapy is strongly recommended to ensure adherence 4, 5
• Treatment adherence interventions, including digital monitoring, material support, and psychological support, should be implemented, and adjunctive surgery may be considered in select cases with high risk of treatment failure 1, 4, 5