Inclusion criteria (who can receive BPaLM)

1. Age 14 years or above with confirmed/probable MDR/RR-TB needing a new course
   • Means the person is an adolescent/adult and has rifampicin-resistant or multidrug-resistant TB, and treatment needs to be started/restarted.
   • “Failed H mono/poly DR-TB treatment” means prior treatment for isoniazid-resistant patterns did not work, so they may need this stronger regimen.
2. Drug exposure history compatible with BPaLM use The regimen may be used if:
   • Previous exposure to Bdq/Lzd/Pa was <1 month, or
   • Exposure was >1 month but susceptibility is documented, or
   • Prior Bdq/Lzd regimen was used but no treatment failure, and drug susceptibility is documented.
   In plain words: these key drugs can be used if the bacteria are still expected to respond, and there is no clear evidence they already failed due to resistance.
3. QTc (ECG) safety criteria
   • Baseline QTc should be within safe limits:
     • ≤450 ms (men)
     • ≤470 ms (women)
   • If electrolytes are abnormal and initial QTc is prolonged, correct electrolytes and repeat ECG; QTc must come down to acceptable range.
   Why: Bedaquiline can prolong QT interval, so arrhythmia risk must be minimized.
4. Pregnancy/lactation-related eligibility
   • Includes non-lactating women, lactating but not breastfeeding women, non-pregnant women.
   • Also includes women in early pregnancy (<20 or as per guideline threshold) who are willing/eligible for MTP as per legal norms.
   Why: Pretomanid/linezolid safety concerns in pregnancy and breastfeeding require careful selection.

Exclusion criteria / contraindications (who should NOT receive BPaLM)

1. Age below 14 years
   • Regimen not recommended in younger children per this protocol.
2. Documented resistance to Bdq, Lzd, and/or Pa
   • If TB bacilli are resistant to regimen drugs, BPaLM is unlikely to work.
3. Significant liver dysfunction
   • Typically marked LFT elevation (e.g., AST/ALT >3× ULN with symptoms or severe bilirubin rise).
   • Because these drugs can worsen hepatotoxicity risk.
4. Severe extrapulmonary/disseminated TB forms
   • Examples: CNS TB, spinal/skeletal TB, miliary/disseminated disease.
   • These forms often need individualized/longer regimens and drugs with better site penetration evidence.
5. Major cardiac conduction or rhythm risk Includes:
   • Structural heart disease, long QT syndrome, AV block, significant arrhythmias.
   • Uncontrolled arrhythmia needing medication.
   • Additional torsades risk factors (heart failure, hypokalemia, family history of long QT, etc.).
   • Baseline QTc too high:
     • >450 ms men / >470 ms women with normal electrolytes, or
     • Remains above limit even after correcting electrolytes on repeat ECG.
   Why: high risk of dangerous ventricular arrhythmias with QT-prolonging therapy.

Quick practical summary

• ≥14 years
• Have MDR/RR-TB needing treatment
• Have no confirmed resistance to BPaLM drugs
• Have acceptable ECG/QTc and corrected electrolytes
• Have no major liver/cardiac contraindications
• Meet pregnancy/lactation safety conditions

1. maximize cure chance, and 2) avoid serious toxicity/death.

Why each inclusion criterion exists

1. Age ≥14 years

• Evidence, dosing, and safety data for BPaLM are strongest in adolescents/adults.
• Younger children have different pharmacokinetics and need pediatric-specific regimens.

1. Confirmed/probable MDR/RR-TB needing new treatment

• BPaLM is a targeted regimen for drug-resistant TB, not routine drug-sensitive TB.
• Using it only where indicated preserves efficacy and prevents unnecessary resistance pressure.

1. Limited/prior exposure rules for Bdq, Lzd, Pa + documented susceptibility

• If patient had long prior exposure or failure on these drugs, resistance risk is higher.
• Confirming susceptibility increases probability that regimen will actually work.

1. QTc threshold and electrolyte correction requirement

• Bedaquiline can prolong QT interval.
• Prolonged QT + low K/Mg/Ca can trigger torsades de pointes (potentially fatal arrhythmia).
• So baseline QT must be safe, and reversible causes corrected before starting.

1. Pregnancy/lactation restrictions

• Safety data for some components (especially pretomanid) in pregnancy/breastfeeding are limited or concerning.
• Criteria reduce fetal/neonatal risk and medicolegal risk.

Why each exclusion criterion exists

1. Age <14 years

• Insufficient robust safety/efficacy evidence in this age group under this protocol.

1. Documented resistance to Bdq/Lzd/Pa

• Core drugs would be ineffective.
• Continuing ineffective drugs drives further resistance and treatment failure.

1. Significant liver dysfunction

• TB drugs can cause hepatotoxicity.
• Pre-existing liver injury raises risk of liver failure or severe adverse events.

1. Severe extrapulmonary/disseminated TB (CNS, spinal, miliary, multiorgan)

• These forms often need individualized regimens with stronger site-specific evidence, longer duration, and closer specialist monitoring.
• Standard short all-oral regimens may be insufficient in some of these cases.

1. Major cardiac disease/arrhythmia/high QT risk

• BPaLM (mainly bedaquiline) can worsen conduction instability.
• In patients with baseline rhythm vulnerability, risk of sudden cardiac events is much higher.

Core logic in one line