Evidence-based recommendations for treating drug-susceptible and drug-resistant tuberculosis in adults, children, and adolescents worldwide
What this guideline saysGMJ summary
This second edition consolidates all current WHO recommendations on tuberculosis treatment and care. It covers drug-susceptible TB (DS-TB) treatment, drug-resistant TB (DR-TB) treatment, and patient support interventions across all age groups. The guidelines maintain the standard 6-month rifampicin-based regimen (2HRZE/4HR) for DS-TB as the backbone of treatment, while introducing important updates for DR-TB management.
Key updates in this edition include stratified 6-month regimens for multidrug-resistant/rifampicin-resistant TB (MDR/RR-TB) based on disease severity, with BPaLM remaining the preferred regimen for most patients. For pulmonary pre-extensively drug-resistant TB (pre-XDR-TB), the guidelines now suggest BPaL for non-severe disease and BPaLC (with clofazimine) for severe disease. A new recommendation introduces palliative care interventions alongside effective MDR/RR-TB treatment, the first WHO guidance addressing palliative needs during TB treatment.
The guidelines also consolidate shorter treatment options for children and adolescents with non-severe TB (4-month regimen) and TB meningitis (6-month intensive regimen as alternative to 12 months). All recommendations follow GRADE methodology, with explicit strength ratings and certainty-of-evidence assessments to support national programme decision-making.
Key pointsfor clinicians
- Standard DS-TB treatment: 2HRZE/4HR (2 months isoniazid, rifampicin, pyrazinamide, ethambutol; 4 months isoniazid, rifampicin) administered daily throughout therapy, preferably as fixed-dose combinations
- Four-month DS-TB regimen for adults/adolescents ≥12 years: 2HPMZ/2HPM (isoniazid, rifapentine 1200 mg, moxifloxacin, pyrazinamide for 2 months; then isoniazid, rifapentine, moxifloxacin for 2 months) – conditional recommendation
- Children 3 months–16 years with non-severe TB: 4-month regimen 2HRZ(E)/2HR should be used (strong recommendation); non-severe TB defined as peripheral lymph node TB, intrathoracic lymph nodes without obstruction, uncomplicated pleural effusion, or paucibacillary non-cavitary disease in one lobe
- MDR/RR-TB treatment: 6-month BPaLM (bedaquiline, pretomanid, linezolid, moxifloxacin) suggested for most patients; for pulmonary pre-XDR-TB, use BPaL (without moxifloxacin) for non-severe disease or BPaLC (with clofazimine) for severe disease
- TB meningitis in children/adolescents: 6-month intensive regimen 6HRZEto (isoniazid 20 mg/kg max 400 mg, rifampicin 20 mg/kg max 600 mg, pyrazinamide 40 mg/kg max 2000 mg, ethionamide 20 mg/kg max 750 mg daily) may be used as alternative to 12-month regimen; adjuvant corticosteroids (dexamethasone or prednisolone tapered over 6–8 weeks) strongly recommended
- HIV-coinfected TB patients: start ART within 2 weeks of TB treatment regardless of CD4 count (strong recommendation), except delay 4–8 weeks if TB meningitis suspected; TB treatment duration same as HIV-negative patients
- Thrice-weekly or twice-weekly dosing not recommended in any phase of DS-TB treatment; daily dosing throughout therapy is the recommended frequency (conditional recommendation, very low certainty evidence)
- Palliative care for MDR/RR-TB patients: integrate palliative care assessment and interventions by trained providers alongside effective treatment (conditional recommendation, moderate certainty evidence) – addresses physical, psychological, social and spiritual suffering
Summary of updated and new recommendations (2026 edition)extracted from the guideline
| ID | Recommendation | Strength/Certainty | Status |
|---|---|---|---|
| B1.1 | 6-month BPaLM regimen for MDR/RR-TB patients rather than 9-month or 18-month regimens | Conditional/very low | UPDATED (2026) |
| B1.1a | 6-month BPaL (without moxifloxacin) for non-severe pulmonary pre-XDR-TB rather than BPaLC | Conditional/very low | NEW (2026) |
| B1.1b | 6-month BPaLC (with clofazimine) for severe pulmonary pre-XDR-TB rather than BPaL | Conditional/very low | NEW (2026) |
| B1.2 | 6-month BDLLfx/C regimen (bedaquiline, delamanid, linezolid 600 mg, levofloxacin, clofazimine) for MDR/RR-TB with or without fluoroquinolone resistance | Conditional/very low | UPDATED (2026) |
| B1.2a | 6-month BDLC regimen for non-severe pulmonary pre-XDR-TB over 18-month regimens | Conditional/very low | NEW (2026) |
| B1.2b | Suggest against 6-month BDLC for severe pulmonary pre-XDR-TB (use longer regimens) | Conditional/very low | NEW (2026) |
| C4.1 | Integrate palliative care assessment and interventions for pulmonary MDR/RR-TB patients | Conditional/moderate | NEW (2026) |
What changed in this edition
- Updated B1.1 recommendation on 6-month BPaL/M/C regimens now includes two new sub-recommendations (B1.1a, B1.1b) for pulmonary pre-XDR-TB based on disease severity, using pooled evidence from BEAT Tuberculosis and endTB-Q trials with extended TB-PRACTECAL follow-up
- Updated B1.2 recommendation on 6-month BDLLfx/C regimen adds two new sub-recommendations (B1.2a, B1.2b) for pulmonary pre-XDR-TB: BDLC variant suggested for non-severe disease but suggested against for severe disease due to amplification risk
- New recommendation C4.1 introduces palliative care interventions for MDR/RR-TB patients – the first WHO recommendation addressing palliative care needs during TB treatment, drawing on randomized trial of nurse-led palliative care in Uganda
- Consolidated recommendations from 2022 WHO guidelines on TB management in children and adolescents (A1.6a–c, A5.1, A5.2) into this module
- All other recommendations from 2025 first edition remain valid without modification, including DS-TB treatment (Chapter 1), 9-month all-oral regimens, longer regimens, Hr-TB regimen, monitoring, ART, surgery, HCV co-administration, and existing care and support recommendations C1–C3
ApplicabilityGeorgia and the region
These guidelines are directly applicable to Georgia and the South Caucasus region, where tuberculosis remains a significant public health challenge with notable rates of drug-resistant TB. Georgia’s National TB Programme should assess local drug-resistance patterns to determine eligibility for shorter regimens versus longer treatment. Implementation will require strengthening rapid molecular diagnostics (Xpert MTB/RIF Ultra, line probe assays) to detect fluoroquinolone and other resistance patterns that guide regimen selection. National programmes should ensure procurement systems can provide child-friendly formulations (dispersible FDCs), rifapentine for 4-month regimens, and newer medicines (bedaquiline, pretomanid, linezolid, delamanid) through mechanisms like the Global Drug Facility. Training clinicians to assess disease severity in children and to integrate palliative care for MDR-TB patients will be essential. The region’s established TB services and laboratory networks provide a foundation for adopting these evidence-based recommendations, though financing shorter regimens and monitoring outcomes will require sustained investment.
Questions this guideline answers
Can children under 12 years receive the 4-month rifapentine-moxifloxacin regimen (2HPMZ/2HPM)?
No. The 4-month rifapentine-moxifloxacin regimen (A2.1) is conditionally recommended only for people aged 12 years or older. The trial enrolled patients from age 12, with the youngest participant being 13 years. Children aged 3 months to 16 years with non-severe TB should receive the 4-month regimen 2HRZ(E)/2HR instead (recommendation A2.2, strong recommendation).
How do I decide between BPaL and BPaLC for a patient with pre-XDR-TB?
The choice depends on disease severity. For non-severe pulmonary pre-XDR-TB, use the 6-month BPaL regimen (bedaquiline, pretomanid, linezolid without clofazimine) – recommendation B1.1a. For severe pulmonary pre-XDR-TB (bilateral cavitary disease or extensive parenchymal damage on chest X-ray), use the 6-month BPaLC regimen (adding clofazimine) – recommendation B1.1b. Severe disease has higher risk of resistance amplification with the three-drug regimen alone.
Should I still use the 12-month regimen for TB meningitis in children or can I use 6 months?
Both options exist. The longstanding recommendation (A5.1) of 2HRZE/10HR (12 months total, strong recommendation) remains valid. The new conditional recommendation (A5.2) offers a 6-month intensive regimen (6HRZEto: isoniazid 20 mg/kg, rifampicin 20 mg/kg, pyrazinamide 40 mg/kg, ethionamide 20 mg/kg daily) as an alternative for children/adolescents with confirmed drug-susceptible TB meningitis and no suspicion of drug resistance. The 6-month option should not be used in HIV-positive children with TB meningitis due to lack of data. Both regimens require adjuvant corticosteroids tapered over 6–8 weeks.
Related on GMJinterconnected resources
Drugs A–Z
Dictionary of Public Health
GMJ News coverage
Other guidelines on this topic
- Issuer
- World Health Organization
- Type
- Guideline
- Edition
- 2nd edition, 2026
- Replaces
- WHO consolidated guidelines on tuberculosis. Module 4: treatment and care, 1st edition, 2025
- Status
- Current
- Published
- 2026-09-30
- Languages
- English (other UN languages expected)
- Scope
- Treatment and care of drug-susceptible and drug-resistant tuberculosis in all age groups; includes pulmonary and extrapulmonary TB, HIV coinfection, patient support models, and palliative care
- Audience
- National TB programme managers, policy-makers in ministries of health, clinicians (doctors, nurses, pharmacists), technical agencies, researchers, civil society organizations, TB-affected communities
- Pages
- 512
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-4-012512-4
- Evidence
- GRADE-rated recommendations from systematic reviews, randomized controlled trials, and observational data; strength rated as strong or conditional with certainty of evidence (high, moderate, low, very low)
- Next review
- Not specified; guidelines updated as new evidence emerges through WHO Guideline Development Group meetings
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