Treatment of Rifampin-Resistant Tuberculosis

First-Line Approach

The World Health Organization recommends the 6-month BPaLM regimen (bedaquiline, pretomanid, linezolid, and moxifloxacin) for patients without documented resistance to fluoroquinolones or bedaquiline, as it reduces treatment duration from 15-24 months to just 6 months 1
The BPaLM regimen is indicated for confirmed MDR/RR-TB patients with no documented resistance to fluoroquinolones or bedaquiline, including those with extrapulmonary disease and both HIV-infected and uninfected patients, though HIV-positive patients require extended treatment 1

The European Respiratory Society recommends that core drugs in longer regimens (18-20 months) include levofloxacin or moxifloxacin, bedaquiline for patients ≥18 years, and linezolid, with a strong recommendation for each 4
Additional agents in longer regimens should include at least one of clofazimine, cycloserine or terizidone, with supplementary agents such as ethambutol, delamanid, and pyrazinamide used as needed 2, 3, 4

The European Respiratory Society advises against using kanamycin or capreomycin in MDR/RR-TB treatment on longer regimens, as these injectable agents are not recommended in current guidelines 3, 4
Streptomycin or other injectable agents should not be used even in isoniazid-resistant TB when rifampin is susceptible 3, 4

For patients with isoniazid resistance but rifampin susceptibility, a 6-month regimen of rifampin, ethambutol, pyrazinamide, and levofloxacin is recommended, without the addition of streptomycin or other injectable agents 1, 3, 4

Directly observed therapy (DOT) is strongly recommended for all TB patients to ensure adherence and prevent drug resistance, with treatment adherence interventions including digital monitoring, material support, and psychological support 1