Treatment of tuberculosis
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WHO consolidated guidelines tuberculosis treatment drug-susceptible TB regimen 2025
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tuberculosis treatment
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https://www.who.int/publications/i/item/9789240048126
Treatment of tuberculosis (TB)
TB treatment must be guided by site of disease, drug-susceptibility testing, HIV status, pregnancy, liver disease, and local/national TB-program guidance. Use multiple drugs together and ensure adherence to prevent relapse and resistance.
1. Drug-susceptible active TB
Standard regimen: 6 months
| Phase | Duration | Drugs |
|---|---|---|
| Intensive phase | First 2 months | H isoniazid + R rifampicin/rifampin + Z pyrazinamide + E ethambutol |
| Continuation phase | Next 4 months | H isoniazid + R rifampicin |
Written as: 2HRZE/4HR
This is the usual regimen for newly diagnosed, drug-susceptible pulmonary TB. Combination therapy is required because it kills organisms in different metabolic states and reduces emergence of resistance. Katzung's Basic and Clinical Pharmacology, p. 1313.
Some eligible patients with pulmonary TB may receive a WHO-recommended 4-month regimen using rifapentine + isoniazid + pyrazinamide + moxifloxacin initially, then rifapentine, isoniazid, and moxifloxacin. The standard 6-month regimen remains an accepted option, according to the WHO TB treatment guidance.
2. Important monitoring and adverse effects
- Isoniazid (H): hepatitis, peripheral neuropathy. Give pyridoxine (vitamin B6), particularly in malnutrition, diabetes, HIV, pregnancy, alcohol use, renal failure, or neuropathy risk.
- Rifampicin (R): hepatitis, orange-red discoloration of urine/tears, and major drug interactions, including with some antiretrovirals, anticoagulants, and contraceptives.
- Pyrazinamide (Z): hepatotoxicity, hyperuricemia, arthralgia.
- Ethambutol (E): optic neuritis and reduced red-green color discrimination. Stop and assess promptly if visual symptoms occur.
Check for adverse effects, adherence, weight-based dosing, sputum response, and microbiologic drug susceptibility. Fixed-dose combination tablets and supervised/community-based treatment support can improve adherence.
3. When treatment is longer or modified
Treatment may need extension or modification for:
- Cavitary pulmonary TB with persistently positive sputum culture after 2 months
- TB meningitis, bone/joint TB, or other selected extrapulmonary disease
- HIV infection or significant immunosuppression
- Intolerance, hepatotoxicity, renal impairment, pregnancy, or drug interactions
- Isoniazid resistance, rifampicin resistance, or multidrug-resistant TB
For TB meningitis, corticosteroids are generally used in addition to anti-TB therapy. Do not delay specialist assessment when there are neurologic symptoms.
4. Drug-resistant TB
MDR/RR-TB means rifampicin-resistant TB, often with isoniazid resistance. It requires an all-oral, drug-susceptibility-guided regimen under a TB specialist/program. Current WHO guidance includes shorter regimens for suitable patients, including 6-month bedaquiline-pretomanid-linezolid-moxifloxacin (BPaLM) based on resistance pattern and eligibility. Other patients need a 9-month or individualized longer regimen. See the WHO 2025 treatment and care module.
Do not add a single drug to a failing regimen or treat presumed resistance without molecular/culture drug-susceptibility results where available.
5. Latent TB infection
Latent TB has no symptoms and is not contagious, but treatment prevents future active TB. Common preventive regimens include:
- 3 months once-weekly isoniazid + rifapentine (3HP)
- 3 months daily isoniazid + rifampicin (3HR)
- 4 months daily rifampicin (4R)
- 6 or 9 months daily isoniazid when shorter regimens are unsuitable
Exclude active TB before starting preventive treatment.
Key practical points
- Confirm TB and obtain rapid molecular testing for rifampicin resistance whenever possible.
- Start the appropriate multidrug regimen promptly through a TB program.
- Test and manage HIV, diabetes, undernutrition, hepatitis risk, and drug interactions.
- Ensure adherence support and follow-up.
- Screen close household contacts and offer preventive therapy when indicated.
This is educational information, not an individual prescription. TB medicines and duration should be selected by a clinician or national TB program because incorrect treatment can cause toxicity and drug-resistant TB.
Give doses
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CDC treatment drug-susceptible tuberculosis adults dosing isoniazid rifampin pyrazinamide ethambutol weight band
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tuberculosis treatment dosing
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https://www.cdc.gov/tb/hcp/treatment/tuberculosis-disease.ht…
Standard daily doses for drug-susceptible TB
Regimen: 2HRZE/4HR
| Drug | Adult daily dose | Maximum daily dose | Phase |
|---|---|---|---|
| Isoniazid (H) | 5 mg/kg | 300 mg | 6 months |
| Rifampicin / rifampin (R) | 10 mg/kg | 600 mg | 6 months |
| Pyrazinamide (Z) | 20-25 mg/kg | 2,000 mg | First 2 months |
| Ethambutol (E) | 15-20 mg/kg | 1,600 mg | First 2 months |
- Intensive phase, first 2 months: HRZE once daily
- Continuation phase, next 4 months: HR once daily
Thus: 2HRZE/4HR.
Textbook adult doses list isoniazid 300 mg/day, rifampin 600 mg/day, pyrazinamide 25 mg/kg/day, and ethambutol 15-25 mg/kg/day. Katzung's Basic and Clinical Pharmacology, p. 1313. The CDC regimen guidance supports 2 months of HRZE followed by 4 months of HR for eligible drug-susceptible pulmonary TB.
Pyridoxine with isoniazid
Give pyridoxine (vitamin B6) 25-50 mg orally once daily, especially in diabetes, HIV, alcohol use, malnutrition, pregnancy, renal failure, seizure disorders, or peripheral-neuropathy risk.
Pediatric daily doses
- Isoniazid: 10-15 mg/kg/day, maximum 300 mg/day
- Rifampicin: 10-20 mg/kg/day, maximum 600 mg/day
- Pyrazinamide: 20-40 mg/kg/day, maximum 2 g/day
- Ethambutol: 15-25 mg/kg/day, maximum 2.5 g/day
These are educational doses only. TB treatment must be weight-based and adjusted for drug susceptibility, renal/hepatic dysfunction, pregnancy, HIV antiretroviral interactions, disease site, and national TB-program protocol.
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