Treatment Regimens in Programmatic Conditions for Multidrug-Resistant and Rifampicin-Resistant Tuberculosis — MSF Tuberculosis — Médecins Sans Frontières 2026

MSFClinical guideline (chapter)Current edition

From Tuberculosis › Chapter 10: Treatment of multidrug-resistant and rifampicin-resistant tuberculosis · Médecins Sans Frontières, Current online edition, 2026

MSF guidance on short and long treatment regimens for MDR/RR-TB in programmatic settings for clinicians and TB programme staff.

In one sentenceMSF recommends 6–9 month short regimens for fluoroquinolone-susceptible MDR/RR-TB (including 6BPaLM and endTB options) and ≥18 month individualised long regimens with ≥4–5 likely effective drugs for resistant forms.

Issuer: Médecins Sans Frontières
Edition: Current online edition, 2026
Audience: Clinicians, TB programme staff, infectious disease specialists
Evidence: Based on WHO recommendations and clinical trial evidence including endTB and BEAT Tuberculosis trials
Reviewed: 22 Oct 2026 · GMJ

Read the original on MSF Whole guideline (PDF)

Summary by GMJ Guidelines Desk•Reviewed by Prof. Giorgi Pkhakadze, MD, MPH, PhD•Record updated 22 Oct 2026•Next check Apr 2027

What this guideline says

GMJ summary

This section of the MSF Tuberculosis guideline provides detailed treatment regimens for multidrug-resistant and rifampicin-resistant tuberculosis (MDR/RR-TB) in programmatic conditions. It distinguishes between short treatment regimens (STRs) lasting 6–9 months for fluoroquinolone-susceptible disease and longer treatment regimens (LTRs) lasting at least 18 months for more resistant forms or when STRs are unsuitable.

For fluoroquinolone-susceptible MDR/RR-TB, five STR options are presented: 6BPaLM (for patients ≥14 years, not pregnant/breastfeeding, without miliary/osteoarticular/CNS TB); three 9-month endTB regimens with different drug combinations; and the 6–9 month BEAT Tuberculosis regimen. For pre-XDR-TB, options include BPaL (6–9 months with bedaquiline-pretomanid-linezolid), BEAT Tuberculosis, or an LTR. XDR-TB requires LTRs.

Long treatment regimens are built using a stepwise approach prioritising Group A drugs (fluoroquinolones, bedaquiline, linezolid), adding Group B drugs (clofazimine, cycloserine/terizidone), and Group C drugs as needed to achieve at least 4–5 likely effective drugs. Treatment duration is at least 18 months with at least 15 months after culture conversion. The guidance emphasises individualising regimens based on drug susceptibility testing and notes that bedaquiline can be used beyond 6 months without safety concerns, addressing high culture reversion rates when stopped early.

Key points

For clinicians — doses and thresholds as stated in the guideline

6BPaLM regimen (6 months of bedaquiline-pretomanid-linezolid-moxifloxacin) for patients ≥14 years with fluoroquinolone-susceptible MDR/RR-TB, excluding pregnant/breastfeeding women and those with miliary, osteoarticular or CNS TB
Three endTB regimens (9 months): endTB1 with bedaquiline-linezolid-moxifloxacin-pyrazinamide; endTB2 with bedaquiline-clofazimine-linezolid-levofloxacin-pyrazinamide; endTB3 with bedaquiline-delamanid-linezolid-levofloxacin-pyrazinamide
BEAT Tuberculosis regimen (6–9 months of bedaquiline-delamanid-linezolid-levofloxacin), extended to 9 months if no culture conversion at month 4
For 6BPaLM and endTB regimens, linezolid dose is reduced after 16 weeks; for BPaL regimen, linezolid 600 mg daily for 6 months without dose reduction
Long treatment regimens require at least 4 likely effective drugs including 3 from Group A (fluoroquinolone, bedaquiline, linezolid) and 1 from Group B (clofazimine, cycloserine/terizidone); if not feasible, at least 5 drugs prioritising Groups A and B
Long treatment regimen duration: at least 18 months total, with at least 15 months after culture conversion
All drugs in long regimens should continue for full treatment duration if well tolerated; bedaquiline can be used beyond 6 months as stopping at 6 months is associated with high culture reversion rates
Carbapenems (imipenem/cilastatin or meropenem with amoxicillin/clavulanic acid) used for minimum 2 months after culture conversion, or entire treatment duration if limited likely effective drugs available

Steps to Build an Individualised Long Treatment Regimen

Table extracted from the guideline

Step	Action	Drug Details
Step 1	Use all 3 Group A drugs unless confirmed resistance or contra-indication	1.1 Levofloxacin or moxifloxacin (use Lfx with other QT-prolonging drugs); 1.2 Bedaquiline; 1.3 Linezolid
Step 2	Add 1 or 2 Group B drugs unless confirmed/suspected resistance or contra-indication	2.1 Clofazimine (preferred over Cs/Trd for better safety); 2.2 Cycloserine or terizidone (interchangeable, same dose)
Step 3	Add Group C drugs when 3 Group A + 1 Group B not feasible, to reach 5 likely effective drugs	3.1 Delamanid (first choice); 3.2 Ethambutol, pyrazinamide; 3.3 Imipenem/cilastatin or meropenem (with amoxicillin/clavulanic acid); 3.4 Amikacin or streptomycin; 3.5 Ethionamide or prothionamide; 3.6 PAS; 3.7 High-dose isoniazid

Source: Médecins Sans Frontières, Treatment Regimens in Programmatic Conditions for Multidrug-Resistant and Rifampicin-Resistant Tuberculosis — MSF Tuberculosis. Reproduced in summary form.

From the guideline

Verbatim

“Treatment should last at least for 18 months, with at least 15 months after culture conversion.”

— Médecins Sans Frontières, Treatment Regimens in Programmatic Conditions for Multidrug-Resistant and Rifampicin-Resistant Tuberculosis — MSF Tuberculosis, Section 10.2.2, Duration of treatment (2026)

Editor’s perspective

Why this matters for Georgia and the region

Prof. Giorgi Pkhakadze, MD, MPH, PhD

Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration

As someone who has worked extensively on tuberculosis control in Georgia and the region, I recognise that this MSF guidance addresses a critical gap in MDR-TB management by clearly delineating when shorter regimens can replace the traditional 18–24 month treatments. For Georgian clinicians, the most important recommendation is the stepwise approach to building long regimens prioritising Group A drugs—bedaquiline, a fluoroquinolone and linezolid—which requires ensuring these medicines are consistently available in our national programme. The guidance on continuing bedaquiline beyond 6 months when tolerated is particularly valuable given Georgia's experience with high culture reversion rates. However, implementation will require significant investment in drug susceptibility testing infrastructure, especially for rapid fluoroquinolone resistance detection, and in training clinicians to manage linezolid toxicity, which remains a major challenge in our ambulatory care settings where most MDR-TB patients are now treated.

ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 22 Oct 2026

Applicability

Georgia and the South Caucasus

Georgia and neighbouring South Caucasus countries have substantial MDR-TB burdens requiring access to newer regimens. National TB programmes in the region will need to ensure availability of all drugs listed for short treatment regimens (bedaquiline, pretomanid, linezolid, delamanid, moxifloxacin, levofloxacin, clofazimine) to provide individualised care. The shorter 6–9 month regimens offer important advantages over 18-month treatments in terms of adherence, cost and patient burden. Implementation requires robust drug susceptibility testing capacity, particularly for fluoroquinolone resistance detection, and systems for monitoring linezolid toxicity and managing adverse events. Georgia’s existing partnerships with international organisations and experience with ambulatory MDR-TB care provide a foundation for adopting these recommendations, though procurement systems, clinical training and laboratory infrastructure will need strengthening to deliver the full range of regimen options.

Questions this guideline answers

Quick answers

Which patients with MDR/RR-TB are eligible for the 6-month BPaLM regimen?

Patients aged 14 years or older with fluoroquinolone-susceptible MDR/RR-TB who are not pregnant or breastfeeding, have all drugs in the regimen likely effective, and do not have miliary TB, osteoarticular TB or TB of the central nervous system (brain, spinal cord or meninges).

How long should bedaquiline be continued in long treatment regimens?

Bedaquiline should generally be continued for the full treatment duration if well tolerated, rather than stopping at 6 months. Evidence shows that stopping bedaquiline at 6 months is associated with high rates of culture reversion in patients with resistance to several drugs or extensive lung damage, and no safety issues have been reported with treatment longer than 6 months.

What is the minimum number of effective drugs needed in a long treatment regimen?

At least 4 likely effective TB drugs are required, including 3 from Group A (fluoroquinolone, bedaquiline, linezolid) and 1 from Group B (clofazimine or cycloserine/terizidone). If this optimal combination is not feasible, at least 5 likely effective drugs are needed, prioritising Groups A and B and adding Group C drugs to reach the total of 5.

How is linezolid dosing managed in different regimens?

For BPaLM and endTB regimens, the linezolid dose is reduced after 16 weeks. For the BPaL regimen (pre-XDR-TB), linezolid is given at 600 mg per day for 6 months with no dose reduction at 16 weeks. The guidance notes that linezolid causes frequent and often severe adverse effects requiring monitoring and potential interruption.

Related on GMJ

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Treatment of Multidrug-Resistant and Rifampicin-Resistant Tuberculosis: Introduction — MSF TuberculosisChapter 10: Treatment of multidrug-resistant and rifampicin-resistant tuberculosis
Patient monitoring — MSF TuberculosisChapter 9: Treatment of drug-susceptible tuberculosis
Adjunctive Therapy in Drug-Susceptible Tuberculosis — MSF TuberculosisChapter 9: Treatment of drug-susceptible tuberculosis
Special situations in drug-susceptible tuberculosis treatment — MSF TuberculosisChapter 9: Treatment of drug-susceptible tuberculosis
Alternative treatment regimens for drug-susceptible tuberculosis — MSF TuberculosisChapter 9: Treatment of drug-susceptible tuberculosis
Conventional treatment regimens for drug-susceptible tuberculosis — MSF TuberculosisChapter 9: Treatment of drug-susceptible tuberculosis

Treatment Regimens in Programmatic Conditions for Multidrug-Resistant and Rifampicin-Resistant Tuberculosis — MSF Tuberculosis

What this guideline says

Key points

Steps to Build an Individualised Long Treatment Regimen

From the guideline