World Health Organization · 4th edition, 2025 · 165 pages
Fourth edition evidence-based recommendations for TB testing: infection, disease and drug resistance detection for clinicians and laboratory personnel
- Issuer
- World Health Organization
- Edition
- 4th edition, 2025
- Audience
- Laboratory managers, clinicians, health care staff, HIV and TB programme managers, policy-makers, technical agencies, donors, implementing partners; individuals responsible for programme planning, budgeting and training
- Evidence
- GRADE-rated recommendations based on systematic reviews of diagnostic accuracy, cost-effectiveness analyses, and qualitative evidence synthesis; certainty of evidence ranges from very low to high by recommendation
- Reviewed
- 15 Oct 2026 · GMJ
What this guideline says
GMJ summary
This fourth edition of WHO’s consolidated TB diagnostic guidelines presents 21 recommendations covering detection of TB infection, active disease and drug resistance. It introduces two new diagnostic test classes: low-complexity automated nucleic acid amplification tests (LC-aNAATs, including Xpert MTB/RIF Ultra and Truenat) and low-complexity manual NAATs (LC-mNAATs, currently TB-LAMP). These class-based recommendations replace previous product-specific guidance.
A major innovation is the strong recommendation for concurrent testing strategies: LC-aNAAT on respiratory samples plus LF-LAM on urine for adults and adolescents living with HIV (those with symptoms, screening positive, seriously ill or with advanced HIV disease), and LC-aNAAT on respiratory and stool samples for children without HIV. For children living with HIV, concurrent testing with both sample types plus LF-LAM may be used. The guidelines also cover follow-on resistance testing using automated NAATs, line probe assays, and targeted next-generation sequencing for comprehensive drug susceptibility profiling.
For TB infection testing, the guidelines affirm that either tuberculin skin tests or interferon-gamma release assays can be used, while Mycobacterium tuberculosis antigen-based skin tests may be considered. Importantly, IGRAs and TSTs should not be used to diagnose active TB disease in low- and middle-income countries. All recommendations are GRADE-rated, with certainty of evidence ranging from very low to high across different tests and populations.
Key points
For clinicians — doses and thresholds as stated in the guideline
- LC-aNAATs (Xpert Ultra, Truenat) should be used on respiratory samples as initial diagnostic tests for pulmonary TB rather than smear microscopy or culture (strong recommendation, high certainty)
- For bacteriologically confirmed TB, LC-aNAATs should be used to detect rifampicin resistance rather than culture-based DST (strong recommendation, high certainty)
- For TB meningitis, LC-aNAATs on cerebrospinal fluid (≥6 mL volume recommended) should be used rather than smear or culture (strong recommendation, moderate-high certainty)
- Adults/adolescents with HIV who have TB symptoms, screen positive, are seriously ill or have advanced disease (CD4 <200 cells/mm³ or WHO stage 3/4) should receive concurrent LC-aNAAT on respiratory samples plus LF-LAM on urine (strong recommendation, low certainty)
- Children without HIV or unknown status with TB symptoms/screening positive should receive concurrent LC-aNAAT testing on respiratory and stool samples (strong recommendation, low certainty)
- LC-mNAATs (TB-LAMP) should be used on respiratory samples as initial tests for TB rather than smear or culture, but require follow-up rifampicin resistance testing (strong recommendation, high certainty)
- Xpert MTB/XDR may be used on sputum from bacteriologically confirmed TB to detect resistance to isoniazid (sensitivity 86.4%) and fluoroquinolones (conditional recommendation, moderate certainty)
- Targeted next-generation sequencing may be used on respiratory samples for comprehensive resistance profiling including rifampicin, isoniazid, fluoroquinolones, pyrazinamide, bedaquiline and linezolid (conditional recommendation, certainty varies by drug)
Classes and products of TB tests for detection of TB, drug-resistant TB and TB infection
Table extracted from the guideline
| Technology class | Included products |
|---|---|
| Low-complexity automated NAATs for TB and rifampicin resistance | Xpert® MTB/RIF and Xpert MTB/RIF Ultra (Cepheid); Truenat MTB Plus and Truenat MTB-RIF Dx (Molbio) |
| Moderate-complexity automated NAATs for TB, rifampicin and isoniazid resistance | Abbott RealTime® MTB and MTB RIF/INH; BD MAX™ MDR-TB; cobas® MTB and MTB-RIF/INH; FluoroType® MTB and MTBDR |
| Low-complexity manual NAATs for TB detection | Loopamp™ MTBC Detection Kit (TB LAMP) (Eiken Chemical) |
| Lateral flow LAM for TB detection | Determine™ TB LAM Ag (Alere/Abbott) |
| Low-complexity automated NAATs for resistance to isoniazid and second-line agents | Xpert® MTB/XDR (Cepheid) |
| Line probe assays for drug resistance | GenoType MTBDRplus v1/v2 and MTBDRsl (Hain/Bruker); Genoscholar™ NTM+MDRTB II and PZA-TB II (Nipro) |
| Targeted NGS for drug resistance | Deeplex® Myc-TB (GenoScreen/Illumina); AmPORE®-TB (Oxford Nanopore); TBseq® (Shengting Medical) |
| TB antigen-based skin tests | Diaskintest® (Generium); Siiltibcy™ (Serum Institute); C-TST (Anhui Zhifei Longcom) |
| Interferon-gamma release assays | T-SPOT.TB (Revvity); QuantiFERON-TB Gold Plus (QIAGEN); TB-IGRA (Wantai); STANDARD E TB-Feron; LIAISON QFT-Plus |
Source: World Health Organization, Consolidated guidelines on tuberculosis. Module 3: Diagnosis. Reproduced in summary form.
What changed in this edition
Versus the previous edition
- First edition to combine guidance on TB infection, disease and drug resistance diagnosis into a single consolidated document (previously separate publications)
- Established two new diagnostic test classes (LC-aNAATs and LC-mNAATs) with class-based recommendations replacing previous product-specific recommendations for Xpert MTB/RIF, Xpert Ultra, Truenat and TB-LAMP
- New strong recommendations for concurrent testing strategies in vulnerable populations: LC-aNAAT on respiratory samples plus LF-LAM on urine for adults/adolescents with HIV; LC-aNAAT on respiratory and stool samples for children
- Added description of WHO TB diagnostic class determination and prequalification pathways (Pathway A for first-in-class, Pathway B for within-class products)
- Consolidated four prior web annexes into two: Web Annex A (systematic reviews, GRADE tables, evidence-to-decision tables) and Web Annex B (evidence synthesis and analysis), organized by diagnostic class
From the guideline
Verbatim
“For adults and adolescents with HIV who have signs or symptoms of TB, screen positive for TB, are seriously ill or have advanced HIV disease, concurrent testing using low-complexity automated NAATs on respiratory samples and LF-LAM on urine should be used as the initial diagnostic strategy.”
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 Editor-in-Chief of the Georgian Medical Journal and WHO consultant, I view this consolidated guideline as particularly timely for Georgia and the South Caucasus, where we continue to see significant MDR-TB burdens alongside HIV co-infection. The class-based approach to molecular diagnostics offers our national programmes much-needed procurement flexibility—we are no longer locked into a single manufacturer, which should improve supply chain resilience and potentially reduce costs through competitive procurement. I would stress to Georgian clinicians the concurrent testing recommendation for people living with HIV: our experience shows that many TB-HIV patients present late with advanced immunosuppression, and the combination of respiratory LC-aNAAT plus urine LF-LAM can capture cases we would otherwise miss, reducing the 8-week mortality we still see in this population. The realistic implementation caveat is infrastructure: while the guidelines appropriately recommend these strategies, our peripheral laboratories in rural Kakheti, Samegrelo or mountainous regions may lack consistent electricity, cold chain storage for reagents, or reliable sample transport systems—national TB programmes must conduct honest assessments of laboratory network capacity and potentially phase implementation, starting with regional reference centres before expanding to district level, rather than adopting guidelines uniformly across all sites and risking test wastage or delayed results that undermine the very time-to-treatment benefits these technologies promise.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 15 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia and the South Caucasus region face persistent TB challenges with pockets of high MDR-TB prevalence, making rapid molecular diagnostics particularly relevant. Implementation of class-based LC-aNAAT recommendations offers national programmes flexibility in selecting WHO-prequalified products (Xpert, Truenat) based on local procurement, infrastructure and maintenance capacity. For Eastern European settings with established GeneXpert networks, the concurrent testing strategies for people living with HIV and children can be integrated into existing workflows, though programmes must ensure both LF-LAM availability and robust sample transport systems for stool testing in paediatric cases. National laboratories should prioritize regulatory approval or WHO prequalification verification before implementing new in-class products, establish quality management systems for molecular testing, and develop connectivity solutions to reduce time-to-treatment initiation, particularly critical given the economic barriers to care that drive catastrophic costs for TB patients in the region.
Questions this guideline answers
Quick answers
What is the difference between LC-aNAATs and LC-mNAATs, and when should each be used?
LC-aNAATs (like Xpert Ultra and Truenat) are largely automated after sample loading, provide results including rifampicin resistance detection, and are suitable for decentralized laboratories with basic infrastructure. LC-mNAATs (currently TB-LAMP) require more manual steps (up to 10 pipetting steps), detect only TB without resistance information, are cheaper, and can operate with very basic equipment (heat block). LC-aNAATs are preferred when resistance detection is needed immediately; LC-mNAATs are suitable for peripheral sites where infrastructure is limited, but all positive results require follow-up rifampicin resistance testing.
How should concurrent testing be implemented for adults with HIV—must both samples always be collected?
For adults and adolescents with HIV who have TB symptoms, screen positive, are seriously ill (respiratory rate ≥30/min, temperature ≥39°C, heart rate ≥120/min, unable to walk unaided) or have advanced disease (CD4 <200 cells/mm³ or WHO stage 3/4), concurrent LC-aNAAT on respiratory samples and LF-LAM on urine should be used. However, inability to collect one specimen or lack of one test type should not delay testing of available specimens—test what is available and collect/test the other as soon as possible. A positive result on either test is positive for the combination.
What does a 'trace' result on Xpert Ultra mean and how should it be interpreted?
Trace results may represent false-positive results for TB disease (M. tuberculosis DNA detected but organism non-viable) in people who are HIV-negative or not at risk for HIV, and those with prior TB treatment ending within the past 5 years. Trace results are more common in paucibacillary samples like cerebrospinal fluid, where they formed 16–63% of positive results in TB meningitis studies. In cerebrospinal fluid for TB meningitis diagnosis, trace results are considered positive. Clinical context, patient history and culture confirmation (where possible) should guide interpretation.
Can targeted next-generation sequencing replace all other drug susceptibility testing?
Targeted NGS (Deeplex Myc-TB, AmPORE-TB, TBseq) may be used for comprehensive resistance profiling on respiratory samples from bacteriologically confirmed TB, detecting resistance to rifampicin, isoniazid, fluoroquinolones, pyrazinamide, ethambutol, bedaquiline, linezolid, clofazimine, amikacin and streptomycin. However, these are conditional recommendations with varying certainty of evidence (very low to high by drug), require high-complexity laboratory infrastructure, and are most applicable to reference laboratories in high-burden settings. They complement rather than immediately replace existing rapid molecular tests, which remain essential for initial diagnosis and rifampicin resistance detection at decentralized levels.
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- Issuer
- World Health Organization
- Type
- Guideline
- Edition
- 4th edition, 2025
- Replaces
- WHO consolidated guidelines on tuberculosis. Module 3: diagnosis – rapid diagnostics for tuberculosis detection, third edition, 2021; WHO consolidated guidelines on tuberculosis. Module 1: prevention – tuberculosis preventive treatment, 2020
- Status
- Current
- Published
- 2025-04-16
- Languages
- English
- Scope
- Detection of Mycobacterium tuberculosis complex, mutations associated with drug resistance, and TB infection in adults, adolescents and children; includes pulmonary, extrapulmonary and disseminated TB
- Audience
- Laboratory managers, clinicians, health care staff, HIV and TB programme managers, policy-makers, technical agencies, donors, implementing partners; individuals responsible for programme planning, budgeting and training
- Pages
- 165
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-4-010798-4
- Evidence
- GRADE-rated recommendations based on systematic reviews of diagnostic accuracy, cost-effectiveness analyses, and qualitative evidence synthesis; certainty of evidence ranges from very low to high by recommendation
- Record history
- Created 15 Oct 2026 · updated 15 Oct 2026 · next check Apr 2027
World Health Organization. WHO consolidated guidelines on tuberculosis. Module 3: diagnosis. Geneva: World Health Organization; 2025. 165 p. Licence: CC BY-NC-SA 3.0 IGO.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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