Tuberculosis (pulmonary and extrapulmonary)
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Tuberculosis is a broad topic with two major forms:
-
Pulmonary TB
- Primary and post-primary TB
- Symptoms, transmission, diagnosis
- Sputum tests, chest radiography, NAAT, culture
- Drug-sensitive and drug-resistant TB treatment
- Prevention and infection control
-
Extrapulmonary TB
- TB lymphadenitis
- Pleural TB
- TB meningitis
- Abdominal/peritoneal TB
- Bone and joint TB, including Pott disease
- Genitourinary TB
- Pericardial and disseminated/miliary TB
- Diagnosis and treatment differences by site
High-level overview: TB is caused by Mycobacterium tuberculosis and is transmitted mainly through airborne particles from people with infectious pulmonary or laryngeal disease. It can remain latent or progress to active disease. Pulmonary TB most often causes persistent cough, fever, night sweats, weight loss, and sometimes hemoptysis. Extrapulmonary TB can affect almost any organ and may present without respiratory symptoms.
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Find the latest guidelines for drug-sensitive and drug-resistant TB
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Searching the Web
site:who.int tuberculosis consolidated guidelines module 4 treatment care drug susceptible drug resistant 2025 WHO
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2025 2026 drug susceptible drug resistant tuberculosis treatment guidelines CDC ATS IDSA WHO
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tuberculosis AND treatment
Reading Web Page
https://www.who.int/publications/i/item/9789240107243
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tuberculosis AND guideline
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Latest major TB treatment guidelines
The most current global reference is the WHO Consolidated Guidelines on Tuberculosis, Module 4: Treatment and Care (2025), which unifies recommendations for drug-susceptible TB (DS-TB), drug-resistant TB (DR-TB), and patient support. For low-incidence, well-resourced settings, the current joint ATS/CDC/ERS/IDSA 2025 clinical practice guideline is also highly relevant. The latter adapts much of the newer WHO evidence. See the WHO Module 4 guideline page and the 2025 ATS/CDC/ERS/IDSA guideline.
1. Drug-susceptible TB
| Population / situation | Current recommended option | Important point |
|---|---|---|
| Most people with pulmonary DS-TB | Standard 6-month regimen: 2 months HRZE followed by 4 months HR | Still the dependable standard and remains appropriate when a shorter regimen is unsuitable or unavailable. |
| Pulmonary DS-TB, age ≥12 years, eligible | 4-month rifapentine-moxifloxacin regimen: 2 months HPZM followed by 2 months HPM | H = isoniazid, P = rifapentine, Z = pyrazinamide, M = moxifloxacin. ATS/CDC/ERS/IDSA conditionally recommends it, with moderate-certainty evidence. |
| Children and adolescents, age 3 months to 16 years, non-severe DS-TB | 4 months: 2HRZ(E)/2HR | Recommended instead of the conventional 6-month course for carefully defined non-severe disease. |
| Severe, disseminated, CNS, bone/joint, or other complex extrapulmonary TB | Regimen and duration should be individualized | Do not automatically apply a shortened pulmonary-TB regimen. TB meningitis especially needs specialist-directed treatment. |
Abbreviations: H is isoniazid, R is rifampicin/rifampin, Z is pyrazinamide, E is ethambutol, P is rifapentine, and M is moxifloxacin.
The 2025 ATS/CDC/ERS/IDSA recommendation for people aged 12 years or older with drug-susceptible pulmonary TB is the 4-month H-P-Z-M regimen. Its pediatric recommendation supports 2HRZ(E)/2HR for non-severe TB in children aged 3 months to 16 years. These are not universal substitutions for all forms of TB. ATS/CDC/ERS/IDSA recommendations
2. Drug-resistant TB
Drug-resistant TB treatment should be selected only after rapid molecular testing and full drug-susceptibility testing, including rifampicin, fluoroquinolone, and where locally appropriate, other drug resistance. Management should be through a TB program or an experienced TB specialist.
WHO 2025 direction: prioritize shorter, all-oral regimens where eligible
| Regimen | Core drugs | Typical duration | Main setting |
|---|---|---|---|
| BPaLM | Bedaquiline + pretomanid + linezolid + moxifloxacin | 6 months | MDR/RR-TB where fluoroquinolone susceptibility supports moxifloxacin use |
| BPaL | Bedaquiline + pretomanid + linezolid | 6 months | MDR/RR-TB with fluoroquinolone resistance or inability to use moxifloxacin, subject to eligibility |
| BDLLfxC | Bedaquiline + delamanid + linezolid + levofloxacin + clofazimine | 6 months | New WHO 2025 all-oral option for MDR/RR-TB, including pre-XDR-TB |
| Modified 9-month all-oral regimens | Regimen composition depends on fluoroquinolone susceptibility, prior exposure, and availability | 9 months | MDR/RR-TB when fluoroquinolone resistance has been excluded and 6-month options cannot be used |
| Longer individualized all-oral regimen | Built using effective drugs based on DST and prior treatment | Usually 18-20 months | Extensive resistance, intolerance, ineligibility for shorter regimens, or complex disease |
Definitions
- RR-TB: rifampicin-resistant TB, with or without resistance to other drugs.
- MDR-TB: TB resistant to at least isoniazid and rifampicin.
- Pre-XDR-TB: MDR/RR-TB with additional resistance to a fluoroquinolone.
WHO's major 2025 change is addition of BDLLfxC, a 6-month all-oral regimen that may be used for MDR/RR-TB with or without fluoroquinolone resistance. WHO also recommends modified 9-month regimens when fluoroquinolone resistance is excluded. WHO's April 2025 announcement
Practical safety points
- Obtain bacteriologic confirmation and resistance testing before finalizing a regimen. Do not delay effective treatment in a seriously ill person while arranging specialist input.
- Bedaquiline, delamanid, clofazimine, and fluoroquinolones can prolong QT interval. ECG and electrolyte monitoring are important when indicated.
- Linezolid can cause peripheral/optic neuropathy and myelosuppression. Monitor symptoms and blood counts, with dose adjustment when required.
- Check for major rifamycin-antiretroviral interactions in people living with HIV. The appropriateness of rifapentine-based DS-TB regimens also depends on the ART regimen.
- Use adherence support, toxicity monitoring, microbiological follow-up, nutritional and psychosocial care, and public-health measures as part of treatment.
Evidence and currency note
The main updated international guideline is Saukkonen et al. (2025), Updates on the Treatment of Drug-Susceptible and Drug-Resistant Tuberculosis: An Official ATS/CDC/ERS/IDSA Clinical Practice Guideline, PMID: 40693952. The guideline is broadly aligned with WHO evidence reviews but targets lower-incidence, resource-rich contexts.
A recent systematic review/meta-analysis of DR-TB treatment regimens is Geng et al. (2026), BMC Infectious Diseases, PMID: 41566231. It does not replace guideline-based, DST-directed regimen selection.
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