Treatment Regimen for Pulmonary Tuberculosis

Initial Evaluation and Diagnosis

The Centers for Disease Control and Prevention recommends that patients with suspected pulmonary TB should receive a comprehensive evaluation including medical history, physical examination, chest x-ray, tuberculin skin test, and at least three sputum specimens for acid-fast bacilli smear, culture, and drug susceptibility testing 3
The American Thoracic Society suggests that HIV testing and counseling should be offered to all patients with suspected or confirmed TB 3, 4
Local health departments should be notified immediately when TB is suspected or confirmed to initiate contact investigation, as recommended by the Centers for Disease Control and Prevention 5

The Centers for Disease Control and Prevention recommends a 6-month regimen consisting of isoniazid, rifampin, pyrazinamide, and ethambutol for the first 2 months, followed by isoniazid and rifampin for 4 months 1, 2
The Infectious Diseases Society of America suggests that ethambutol should be included until drug susceptibility results are available, unless there is less than 4% primary resistance to isoniazid in the community 6

For HIV-infected patients, the Centers for Disease Control and Prevention recommends treatment for a minimum of 9 months and for at least 6 months beyond documented culture conversion 3
The American Thoracic Society suggests that patients with TB, HIV, and CD4+ counts <100 cells/mm³ should receive daily therapy during the intensive phase and daily or three times weekly therapy during the continuation phase 4
For culture-negative pulmonary TB when drug resistance is unlikely, the American Thoracic Society recommends a 4-month regimen consisting of isoniazid, rifampin, pyrazinamide, and ethambutol for 2 months followed by isoniazid and rifampin for an additional 2 months 2, 5

If interruption occurs during the intensive phase, the Infectious Diseases Society of America recommends that if the lapse is <14 days, treatment should be continued to complete planned total doses, but if the lapse is ≥14 days, treatment should be restarted from the beginning 7, 8

The Centers for Disease Control and Prevention recommends that patients should be monitored for clinical improvement and sputum conversion 6
The Infectious Diseases Society of America suggests that patients who remain smear-positive at 3 months should be reevaluated for possible treatment failure, nonadherence, or drug resistance 6
Sputum cultures should be obtained monthly until two consecutive negative cultures are documented, as recommended by the Centers for Disease Control and Prevention 1