ATS GUIDELINES Bundle

6 Treatment For the use of the WHO-recommended standardized shorter- course 9–12 month regimen for MDR-TB: ➤ The shorter-course regimen is standardized with the use of kanamycin (which the committee recommends against using), and includes drugs for which there is documented or high likelihood of resistance (e.g., isoniazid, ethionamide, pyrazinamide). Notes: Although the STREAM (Standard Treatment Regimen of Anti-Tuberculosis Drugs for Patients with MDR-TB) Stage 1 randomized trial found the shorter-course regimen to be noninferior to longer injectable containing regimens with respect to the primary efficacy outcome, the guideline committee cannot make a recommendation either for or against this standardized shorter-course regimen, compared with longer individualized all-oral regimens that can be composed in accordance with the recommendations in this practice guideline. The guideline committee makes a research recommendation for the conduct of randomized clinical trials evaluating the efficacy, safety, and tolerability of modified shorter-course regimens that include newer oral agents, exclude injectables, and include drugs for which susceptibility is documented or highly likely. For the role of surgery in the treatment of MDR-TB: ➤ We suggest elective partial lung resection (e.g., lobectomy or wedge resection), rather than medical therapy alone, for adults with MDR-TB receiving antimicrobial-based therapy (conditional recommendation, very low certainty in the evidence). The writing committee believes this option would be beneficial for patients for whom clinical judgement, supported by bacteriological and radiographic data, suggest a strong risk of treatment failure or relapse with medical therapy alone. ➤ We suggest medical therapy alone, rather than including elective total lung resection (pneumonectomy), for adults with MDR-TB receiving antimicrobial therapy (conditional recommendation, very low certainty evidence). For the treatment of isoniazid-resistant TB: ➤ We suggest adding a later-generation fluoroquinolone to a 6-month regimen of daily rifampin, ethambutol, and pyrazinamide for patients with isoniazid-resistant TB (conditional recommendation, very low certainty in the evidence). ➤ In patients with isoniazid-resistant TB treated with a daily regimen of a later-generation fluoroquinolone, rifampin, ethambutol, and pyrazinamide, we suggest that the duration of pyrazinamide can be shortened to 2 months in selected situations (i.e., noncavitary and lower burden disease or toxicity from pyrazinamide) (conditional recommendation, very low certainty in the evidence).

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