Tuberculosis (TB) is a disease caused by mycobacteria tuberculosis. It often infects the lungs, but can also affect other organ systems. Symptoms include prolonged cough, weakness, fatigue, weight loss, fever, or night sweats. TB is easily transmitted through droplets in the air when an infected person coughs or sneezes. People living in crowded or unsanitary living conditions or who are immunocompromised are more likely to be infected with TB.
Successful treatment of TB requires taking multiple antibiotics for months and in some cases more than a year. Many patients struggle with the number of daily pills they need to take and the prolonged length of time treatment has to continue to cure the illness. Drug-resistant TB further complicates the predicament by adding to the number of medications and increasing the duration of treatment. Some newer treatment guidelines suggest that shorter regimens may improve compliance while still providing effective treatment.
In this guidelines side-by-side comparison, we compare the latest clinical practice guidelines from the American Thoracic Society (ATS), U.S. Centers for Disease Control and Prevention (CDC), European Respiratory Society (ERS), and the Infectious Disease Society of America (IDSA) to the National Institute for Health and Care Excellence (NICE) on the treatment of pulmonary tuberculosis.
Guidelines for Comparison
| Authoring Organization(s) | National Institute for Health and Care Excellence (NICE) | ATS/CDC/ERS/IDSA |
|---|---|---|
| Publication Date | 2016, updated 2024 | 2024 |
| Graded Recommendations | Yes | Yes |
| Uses GRADE | Yes | Yes |
| Links | Overview / Full Text | Overview / Full Text |
Key Takeaways
Recommendations from these two guidelines differ in 3 key areas: age of patient, duration of treatment, and the choice of drug used in each treatment regimen. In general ATS/CDC/ERS/IDSA recommend shorter treatment regimens that include fluoroquinolones. Below you will find a brief review of the differences in these key categories. For more information we encourage you to review the full guidelines, linked in the previous table.
Age of patient:
- ATS/CDC/ERS/IDSA makes different recommendations based on the age of the patient.
- The recommendations from NICE are for all age groups.
Drug susceptible TB, treatment duration:
- ATS/CDC/ERS/IDSA recommends a shorter duration of treatment with 4 month regimens.
- NICE recommends 6 month treatment regimens.
Drug susceptible TB, drug choice:
- ATS/CDC/ERS/IDSA recommends treatment regimens of isoniazid, rifapentine, moxifloxacin, and pyrazinamide.
- NICE recommends ethambutol instead of moxifloxacin during the first 2 months of treatment and then just isoniazid (with pyridoxine) and rifampicin.
Drug resistant TB regimens, based on specific drug resistance:
- ATS/CDC/ERS/IDSA recommends 2 treatment regimens for rifampin resistant TB. One for patients who can take fluoroquinolones and another for patients who cannot take fluoroquinolones.
- NICE recommends separate treatment regimens for TB that is resistant to either isoniazid, pyrazinamide, or ethambutol and makes a recommendation for multidrug resistance/rifampin resistant TB.
Drug resistant TB, treatment duration:
- ATS/CDC/ERS/IDSA recommends shorter duration of treatment with 6 month regimens.
- NICE recommends treatment regimens be continued for a total of 6 to 12 months depending on drug resistance.
Drug resistant TB, drug choice:
- ATS/CDC/ERS/IDSA recommendations are all for rifampin resistant TB and include using a fluoroquinolone in patients who can be treated with fluoroquinolones. Regimens use a combination of four medications.
- NICE recommends a combination of three drugs for single drug resistant TB (does not include a fluoroquinolone). For rifampin resistant and multidrug resistant TB NICE recommends a combination of at least 6 drugs.
| Recommendation Category | NICE | ATS/CDC/ERS/IDSA |
|---|---|---|
| Dosing Schedule | Do not offer anti‑TB treatment dosing regimens of fewer than 3 times per week. Offer a daily dosing schedule to people with active pulmonary TB. Consider 3-times weekly dosing for people with active TB only if a risk assessment identifies a need for directly observed therapy and enhanced case management and daily directly observed therapy is not possible. | Not Addressed |
| Treatment of Drug Susceptible TB | For people with active TB without central nervous system involvement, offer isoniazid (with pyridoxine), rifampicin, pyrazinamide and ethambutol for 2 months then isoniazid (with pyridoxine) and rifampicin for a further 4 months. Modify the treatment regimen according to drug susceptibility testing. | In people aged 12 years or older with drug-susceptible pulmonary tuberculosis, we conditionally recommend the use of a 4-month regimen of isoniazid, rifapentine, moxifloxacin, and pyrazinamide In children and adolescents between 3 months and 16 years of age with nonsevere TB (without suspicion or evidence of multidrug-resistant [MDR]/rifampin-resistant [RR]-TB), we recommend the use of a 4-month treatment regimen of 2HRZ(E)/2HR rather than the 6-month drug-susceptible TB regimen of 2HRZ(E)/4HR. |
| Treatment of Drug Resistant TB | For people with TB, without central nervous system involvement, that is resistant to just one drug consider the treatments as below: Isoniazid resistant TB: First 2 months - Rifampicin, pyrazinamide and ethambutol followed by Rifampicin and ethambutol for 7 months (up to 10 months for extensive disease). Pyrazinamide resistant TB: First 2 months - Rifampicin, isoniazid (with pyridoxine) and ethambutol followed by Rifampicin and isoniazid (with pyridoxine) for 7 months. Ethambutol resistant TB: First 2 months - Rifampicin, isoniazid (with pyridoxine) and pyrazinamide followed by Rifampicin and isoniazid (with pyridoxine) for 4 months. Rifampicin resistant TB: offer a treatment regimen involving at least 6 drugs to which the mycobacterium is likely to be sensitive and test for resistance to second-line drugs. | In adolescents aged 14 and older and adults with rifampin-resistant, fluoroquinolone-susceptible pulmonary TB, we recommend the use of a 6-month BPaLM treatment regimen, rather than the 15-month or longer regimens in patients with MDR/RR-TB. In adolescents aged 14 and older and adults with rifampin-resistant pulmonary TB with resistance or patient intolerance to fluoroquinolones, who either have had no previous exposure to bedaquiline and linezolid or have been exposed for less than 1 month, we recommend the use of the 6-month treatment BPaL regimen, rather than more than 15-month regimens. |
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