Treatment of Extensively Drug-Resistant Tuberculosis (XDR TB)

Core Components of XDR TB Treatment Regimen

The American Thoracic Society recommends that treatment for patients with XDR TB should include a regimen of at least five effective drugs in the intensive phase and four drugs in the continuation phase, with bedaquiline and a later-generation fluoroquinolone as core components, for a total duration of 15-24 months after culture conversion 1, 2, 3
The intensive phase of XDR TB treatment should consist of at least 5 effective drugs, according to the American Journal of Respiratory and Critical Care Medicine 1, 3
The continuation phase of XDR TB treatment should consist of at least 4 effective drugs, as recommended by the American Journal of Respiratory and Critical Care Medicine 1, 3
The total treatment duration for XDR TB is 15-24 months after culture conversion, as stated by the American Journal of Respiratory and Critical Care Medicine 1, 2

Bedaquiline is strongly recommended as a core component of any XDR TB regimen by the American Journal of Respiratory and Critical Care Medicine 1, 3
A later-generation fluoroquinolone, such as levofloxacin or moxifloxacin, is strongly recommended if susceptibility is confirmed by the American Journal of Respiratory and Critical Care Medicine 1, 4, 3
Linezolid is suggested as a core component due to its effectiveness against resistant strains, according to the American Journal of Respiratory and Critical Care Medicine 1, 3
Clofazimine is suggested as an important component of XDR TB treatment by the American Journal of Respiratory and Critical Care Medicine 1, 3
Cycloserine is suggested as an effective component of XDR TB treatment by the American Journal of Respiratory and Critical Care Medicine 1, 3

Pyrazinamide should only be included if susceptibility is confirmed, as recommended by the American Journal of Respiratory and Critical Care Medicine 1, 3
Carbapenems, such as imipenem-cilastatin or meropenem, must always be used with amoxicillin-clavulanate, according to the American Journal of Respiratory and Critical Care Medicine 5, 3
Amikacin or streptomycin should only be used if susceptibility is confirmed and oral options are limited, as stated by the American Journal of Respiratory and Critical Care Medicine 5
Delamanid may be considered, though evidence is limited, according to the American Journal of Respiratory and Critical Care Medicine 1, 3

Kanamycin or capreomycin are not recommended due to poor outcomes, as stated by the American Journal of Respiratory and Critical Care Medicine 5, 3
Macrolides, such as azithromycin and clarithromycin, are not recommended due to lack of efficacy, according to the American Journal of Respiratory and Critical Care Medicine 1, 3
Amoxicillin-clavulanate alone should only be used with carbapenems, as recommended by the American Journal of Respiratory and Critical Care Medicine 1, 3
Ethionamide/prothionamide should be avoided if more effective drugs are available, according to the American Journal of Respiratory and Critical Care Medicine 5, 3

Surgical intervention, such as elective partial lung resection, may be considered in selected cases where medical therapy alone may be insufficient, as stated by the American Journal of Respiratory and Critical Care Medicine 5

Using fewer than five effective drugs in the intensive phase leads to poorer outcomes, as recommended by the American Journal of Respiratory and Critical Care Medicine 1
Treating for less than 15 months after culture conversion for XDR TB is associated with higher relapse rates, according to the American Journal of Respiratory and Critical Care Medicine 1, 3

Shorter regimens (9-12 months) are being studied but are not yet recommended for XDR TB, as stated by the American Journal of Respiratory and Critical Care Medicine 5