Who 2025 update in new tb regime
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WHO 2025 consolidated guidelines tuberculosis module 4 treatment care drug susceptible 2HRZE 4HR update
Here is a comprehensive summary of the WHO 2025 Update on New TB Treatment Regimens (from the WHO Consolidated Guidelines on Tuberculosis, Module 4: Treatment & Care, 2025):
WHO 2025 New TB Regimen Update
1. Drug-Susceptible TB (DS-TB)
New 4-Month Regimen — 2HPZM / 2HPM
This is the major new addition for DS-TB in adults (≥12 years):
| Phase | Old Standard (6 months) | New Option (4 months) |
|---|---|---|
| Intensive (2 months) | 2HRZE | 2HPZM |
| Continuation (2–4 months) | 4HR | 2HPM |
Key drug substitutions:
- Rifampicin (R) → Rifapentine (P) — longer half-life allows once-daily dosing
- Ethambutol (E) → Moxifloxacin (M) — enhanced bactericidal activity
This regimen is conditionally recommended for eligible adults with pulmonary DS-TB. It is not yet recommended in pregnancy.
Children (3 months–16 years) — 4-Month 2HRZ(E)/2HR
- WHO and ATS (2025) now recommend a 4-month regimen of 2HRZ(E)/2HR over the traditional 6-month regimen for children with nonsevere TB (no MDR/RR-TB suspicion).
- The standard 6-month regimen (2HRZE/4HR) remains recommended for severe or CNS TB.
2. Drug-Resistant TB (MDR/RR-TB)
WHO 2025 now structures MDR/RR-TB treatment into three tiers:
Tier 1 — 6-Month All-Oral Regimens (PRIORITY)
| Regimen | Full Name | Indication |
|---|---|---|
| BPaLM | Bedaquiline + Pretomanid + Linezolid + Moxifloxacin | MDR/RR-TB with FQ susceptibility (age ≥14) |
| BPaL | Bedaquiline + Pretomanid + Linezolid | MDR/RR-TB with FQ resistance or intolerance (age ≥14) |
| BDLLfxC (NEW in 2025) | Bedaquiline + Delamanid + Linezolid + Levofloxacin + Clofazimine | MDR/RR-TB with or without FQ resistance — also safe in children |
BDLLfxC was approved/recommended in 2024–2025 and is a significant addition because it excludes pretomanid, making it suitable for children (pretomanid not approved <14 years).
Tier 2 — Modified 9-Month All-Oral Regimens (NEW recommendations)
For MDR/RR-TB without fluoroquinolone resistance:
| Regimen | Components |
|---|---|
| BLMZ | Bedaquiline + Linezolid + Moxifloxacin + Pyrazinamide |
| BLLfxCZ | Bedaquiline + Linezolid + Levofloxacin + Clofazimine + Pyrazinamide |
| BDLLfxZ | Bedaquiline + Delamanid + Linezolid + Levofloxacin + Pyrazinamide |
These modified 9-month regimens are new — recommended for pulmonary MDR/RR-TB including in children, adolescents, PLHIV, pregnant/breastfeeding women, and extensive pulmonary disease (but not CNS TB, osteoarticular TB, or disseminated TB).
Tier 3 — Longer Regimens (18–20 months, Last Resort)
- Individualized regimens, may include amikacin (injectable) in exceptional cases
- Reserved for XDR-TB or when shorter regimens are not feasible
3. Other 2025 Updates
| Area | Update |
|---|---|
| TB & Undernutrition | New WHO guidelines (October 2025) on nutritional care for TB patients — integrating food assistance and nutritional support into TB programs |
| Diagnosis (Module 3) | Updated operational handbook with new IGRAs, targeted next-generation sequencing (tNGS) for DR-TB, updated algorithms for HIV-TB co-infection |
| TB Preventive Treatment (TPT) | Guidance on evidence generation for novel TPT regimens (December 2025) |
| Outcome registration | Updated patient registration and treatment outcome definitions, now aligned across DS- and DR-TB |
4. Global Rollout (as of end-2024)
- 6-month regimens (BPaLM/BPaL): used in 97 countries, up from 41 in 2022
- 34,256 patients started on 6-month regimens in 2024 (vs. 5,653 in 2023)
- 9-month regimens: used in 99 countries
Summary Table
| Category | Old Regimen | New WHO 2025 Recommendation |
|---|---|---|
| DS-TB adult | 2HRZE/4HR (6 months) | 2HPZM/2HPM (4 months) — new option |
| DS-TB children nonsevere | 2HRZE/4HR (6 months) | 2HRZ(E)/2HR (4 months) |
| MDR/RR-TB FQ-susceptible | BPaLM or 9-month | BPaLM (6 months) — prioritized; BDLLfxC added |
| MDR/RR-TB FQ-resistant | BPaL or longer | BPaL or BDLLfxC (6 months) |
| MDR/RR-TB FQ-susceptible (9 mo option) | Single 9-month regimen | BLMZ, BLLfxCZ, or BDLLfxZ |
| Longest regimen | 18–24 months with injectables | 18–20 months, amikacin only as last resort |
Sources: WHO Global TB Report 2025 | The Union, May 2025 | WHO Module 4: Treatment & Care, 2025 | Harrison's Principles of Internal Medicine 22E (2025, McGraw Hill Medical)
Who tb 2025 update in exam way
Here is the WHO TB 2025 Update in exam-focused format — high-yield, MCQ-ready:
WHO TB 2025 Update — Exam Format
DRUG-SUSCEPTIBLE TB (DS-TB)
✦ NEW 4-Month Regimen for Adults
Q: What is the new WHO 2025 recommended short regimen for DS pulmonary TB in adults?
Answer: 2HPZM → 2HPM (4 months total)
| Phase | Drugs | Duration |
|---|---|---|
| Intensive | H + P (rifaPentine) + Z + M (Moxifloxacin) | 2 months |
| Continuation | H + P + M | 2 months |
Key changes from old 6-month regimen:
- Rifampicin (R) replaced by Rifapentine (P)
- Ethambutol (E) replaced by Moxifloxacin (M)
Mnemonic: "Pentine and Moxi CUT it to 4 months"
⚠️ Not recommended in pregnancy | Requires fluoroquinolone DST before use
✦ 4-Month Regimen for Children (Nonsevere TB)
Q: WHO 2025 recommends which regimen for children (3 months–16 years) with nonsevere DS-TB?
Answer: 2HRZ(E) / 2HR — replacing old 2HRZ(E)/4HR
- Reduces duration from 6 → 4 months
- Not for CNS TB or severe TB (still need 6–12 months)
DRUG-RESISTANT TB (MDR/RR-TB)
✦ TIER 1 — 6-Month All-Oral Regimens (PRIORITY)
| Regimen | Drugs | Use When |
|---|---|---|
| BPaLM | Bedaquiline + Pretomanid + Linezolid + Moxifloxacin | FQ-susceptible MDR/RR-TB, age ≥14 |
| BPaL | Bedaquiline + Pretomanid + Linezolid | FQ-resistant (pre-XDR/XDR-TB), age ≥14 |
| BDLLfxC ⭐NEW | Bedaquiline + Delamanid + Linezolid + Levofloxacin + Clofazimine | FQ-susceptible OR resistant; safe in children |
Q: Which new 6-month regimen was added in 2025 that is safe in children? Answer: BDLLfxC (no pretomanid — pretomanid not approved <14 yrs)
Q: BPaLM is preferred over BPaL when? Answer: When fluoroquinolone susceptibility is confirmed or unknown
✦ TIER 2 — Modified 9-Month All-Oral Regimens (NEW)
For MDR/RR-TB without FQ resistance
| Regimen | Drugs |
|---|---|
| BLMZ | Bedaquiline + Linezolid + Moxifloxacin + Pyrazinamide |
| BLLfxCZ | Bedaquiline + Linezolid + Levofloxacin + Clofazimine + Pyrazinamide |
| BDLLfxZ | Bedaquiline + Delamanid + Linezolid + Levofloxacin + Pyrazinamide |
- Safe in: children, PLHIV, pregnant/breastfeeding women, extensive PTB
- NOT for: CNS TB, osteoarticular TB, disseminated TB
✦ TIER 3 — Longer Regimens (Last Resort)
- 18–20 months, individualized
- Amikacin (injectable) may be included — only as last resort
- Used for XDR-TB when shorter regimens fail/not feasible
HIGH-YIELD COMPARISON TABLE
| Feature | Old | New (WHO 2025) |
|---|---|---|
| DS-TB adult standard | 2HRZE/4HR (6 mo) | 2HPZM/2HPM (4 mo) — new option |
| DS-TB child nonsevere | 2HRZ(E)/4HR (6 mo) | 2HRZ(E)/2HR (4 mo) |
| MDR-TB FQ-susceptible | BPaLM or 9-mo | BPaLM preferred (6 mo) |
| MDR-TB FQ-resistant | Longer regimen | BPaL or BDLLfxC (6 mo) |
| MDR-TB children | Limited short options | BDLLfxC or 9-mo modified |
| 9-month regimen options | Single regimen | BLMZ / BLLfxCZ / BDLLfxZ (new) |
CLASSIC MCQ TRAPS
| Question | Answer |
|---|---|
| New drug added in DS-TB 4-month regimen replacing ethambutol? | Moxifloxacin |
| New drug replacing rifampicin in 4-month DS-TB? | Rifapentine |
| 6-month MDR regimen without pretomanid (safe for children)? | BDLLfxC |
| MDR-TB regimen for FQ-resistant pre-XDR/XDR? | BPaL |
| MDR-TB 9-month regimens are for which patients? | MDR/RR-TB without FQ resistance |
| Injectable drug still allowed in which tier? | Tier 3 (longer regimen) as last resort |
| WHO 2025 new module covering DS + DR-TB together? | Module 4: Treatment & Care |
| Duration of DS-TB treatment in CNS/TBM? | Still 12 months (2HRZE/10HR) |
DRUG ABBREVIATIONS (Exam Must-Know)
| Letter | Drug |
|---|---|
| H | Isoniazid |
| R | Rifampicin |
| P | Rifapentine |
| Z | Pyrazinamide |
| E | Ethambutol |
| M / Mfx | Moxifloxacin |
| Lfx | Levofloxacin |
| B / Bdq | Bedaquiline |
| Pa | Pretomanid |
| L / Lzd | Linezolid |
| D / Dlm | Delamanid |
| C / Cfz | Clofazimine |
BONUS — OTHER 2025 UPDATES TO KNOW
| Topic | Key Point |
|---|---|
| TB + Undernutrition | New WHO guidelines (Oct 2025) — nutritional support integrated into TB care |
| TB Diagnosis (Module 3) | New IGRAs approved; tNGS for DR-TB; updated HIV-TB co-infection algorithms |
| TB Preventive Treatment | Guidance on novel TPT regimen evidence generation (Dec 2025) |
| Global rollout | BPaLM/BPaL now used in 97 countries; 34,256 patients treated in 2024 |
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