From Tuberculosis › Chapter 9: Treatment of drug-susceptible tuberculosis · Médecins Sans Frontières, Current online edition, 2026
MSF clinical guidance on selecting and delivering conventional DS-TB treatment regimens by infection site and patient age.
- Issuer
- Médecins Sans Frontières
- Edition
- Current online edition, 2026
- Audience
- Clinicians and TB programme managers
- Evidence
- Based on WHO guidelines with referenced evidence
- Reviewed
- 22 Oct 2026 · GMJ
What this guideline says
GMJ summary
This MSF guideline section provides conventional treatment regimens for drug-susceptible tuberculosis (DS-TB) stratified by infection site, disease severity and patient age. Five principal regimens are outlined: a 4-month regimen (2HRZE/2HR) for selected children and adolescents under 16 years with non-severe pulmonary or extrapulmonary TB; a standard 6-month regimen (2HRZE/4HR) for most adults and children not eligible for shorter treatment; a 12-month regimen (2HRZE/10HR) for miliary TB and TB meningitis; and a 9–12-month regimen (2HRZE/7–10HR) for bone and joint TB.
Eligibility for the shorter 4-month paediatric regimen requires specific clinical and radiological criteria: smear-negative or low-burden pulmonary TB, or non-severe extrapulmonary TB such as pleural effusion or lymph node disease without complications. When bacteriological testing or chest X-ray is unavailable, symptom-based criteria can guide selection, with treatment potentially extended to 6 months if response is inadequate after 4 months and drug resistance is excluded.
The guideline permits removal of ethambutol from 4- and 6-month regimens in non-HIV-infected children in low HIV/isoniazid resistance settings with smear-negative pulmonary TB or lymph node TB. For spinal TB, rest and back support bracing are recommended alongside drug therapy, with surgery considered for neurological deficit or unstable spine lesions.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Children >3 months and adolescents <16 years with smear-negative or low-burden pulmonary TB (Xpert 'negative', 'trace', 'very low' or 'low') confined to one lobe without cavities are eligible for 4-month treatment: 2(HRZE)/2(HR).
- Adolescents aged ≥16 years and adults with pulmonary or extrapulmonary TB (except miliary TB, TB meningitis and bone/joint TB) receive standard 6-month treatment: 2(HRZE)/4(HR).
- Miliary TB and TB meningitis in all age groups require 12-month treatment: 2(HRZE)/10(HR).
- Bone and joint TB in all age groups requires 9–12 months of treatment: 2(HRZE)/7–10(HR).
- Non-severe extrapulmonary TB eligible for 4-month paediatric regimen includes pleural effusion without complications (no empyema, pneumothorax or fistula) and lymph node TB with no airway obstruction.
- Ethambutol can be omitted from 4- and 6-month regimens in non-HIV-infected children in low HIV/isoniazid resistance areas with smear-negative pulmonary TB or lymph node TB.
- Children without bacteriological testing or chest X-ray may receive 4-month treatment if symptoms do not require hospitalisation (fever <39°C, no severe respiratory distress, no severe acute malnutrition, pallor, restlessness, irritability or lethargy).
- For spinal TB, rest and back support bracing are indicated in addition to drug therapy; surgery can be considered for neurological deficit or unstable spine lesions.
Conventional DS-TB regimens according to the infection site
Table extracted from the guideline
| Regimens | Duration | Eligibility |
|---|---|---|
| 2(HRZE)/2(HR) | 4 months | Children >3 months and adolescents <16 years with: PTB smear-negative or Xpert 'negative', 'trace', 'very low' and 'low' or clinically diagnosed, TB lesions confined to one lobe, no cavities on CXR; EPTB non-severe (pleural effusion without complications, lymph node TB with no airway obstruction) |
| 2(HRZE)/4(HR) | 6 months | PTB and EPTB (except miliary TB, TB meningitis and bone/joint TB): adolescents ≥16 years and adults; children <16 years not eligible for 4-month regimen |
| 2(HRZE)/10(HR) | 12 months | Miliary TB and TB meningitis: all children, adolescents and adults |
| 2(HRZE)/7–10(HR) | 9–12 months | Bone and joint TB: all children, adolescents and adults |
Source: Médecins Sans Frontières, Conventional treatment regimens for drug-susceptible tuberculosis — MSF Tuberculosis. Reproduced in summary form.
From the guideline
Verbatim
“Children > 3 months and adolescents < 16 years with pulmonary TB microscopy smear-negative or Xpert result 'negative', 'trace', 'very low' and 'low' or clinically diagnosed, with TB lesions confined to one lobe and no cavities on chest x-ray are eligible for 2(HRZE)/2(HR) 4-month treatment.”
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 recognise that this MSF guidance addresses a critical gap in our region: the safe shortening of TB treatment in children. Georgia's National TB Programme, which has achieved notable success in MDR-TB management, must now build capacity for the diagnostics—particularly chest radiography interpretation and Xpert MTB/RIF—required to confidently select children for 4-month regimens. The permission to omit ethambutol in low-resistance settings is particularly relevant for rural areas of Georgia, Armenia and Azerbaijan where paediatric fixed-dose combinations without ethambutol may simplify procurement and adherence. However, implementation requires honest assessment of local isoniazid resistance rates, which vary substantially across the South Caucasus, and programmes must resist the temptation to universally apply shorter regimens without meeting the specified clinical and bacteriological criteria that ensure safety.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 22 Oct 2026
Applicability
Georgia and the South Caucasus
This MSF guidance is directly applicable to Georgia and the South Caucasus, where drug-susceptible TB remains prevalent alongside the region’s well-documented MDR-TB burden. National TB programmes in Georgia, Armenia and Azerbaijan should assess local isoniazid resistance patterns and HIV prevalence to determine eligibility for ethambutol-sparing regimens in children. Implementation of the 4-month paediatric regimen requires capacity for chest radiography and Xpert MTB/RIF testing in district-level facilities, as well as clinical algorithms for settings where these diagnostics are unavailable. Programmes should ensure treatment extension protocols are in place for children who do not respond adequately to the shorter regimen, with clear pathways to exclude drug resistance before extending to 6 months.
Questions this guideline answers
Quick answers
Which children with pulmonary TB can receive 4 months instead of 6 months of treatment?
Children over 3 months and adolescents under 16 years with smear-negative pulmonary TB or Xpert results showing 'negative', 'trace', 'very low' or 'low' bacterial burden, with disease confined to one lobe and no cavities on chest X-ray. Non-severe extrapulmonary TB such as uncomplicated pleural effusion or lymph node TB without airway obstruction also qualifies for 4-month treatment.
Can ethambutol be omitted from the initial phase of treatment in children?
Yes, ethambutol can be removed from 4- and 6-month regimens in non-HIV-infected children living in areas where HIV prevalence and isoniazid resistance are both low, specifically those with smear-negative pulmonary TB or extra-/intra-thoracic lymph node TB.
What should I do if a child on 4-month treatment has not fully recovered after one month?
If symptoms have not completely resolved after one month of treatment, further investigations are needed. If after 4 months symptoms persist or there is no weight gain, investigate further. Treatment can be extended to 6 months only if drug-resistant TB, non-adherence and non-TB disease are ruled out or unlikely.
How long should bone and joint TB be treated?
Bone and joint TB requires 9–12 months of treatment with 2(HRZE)/7–10(HR) in all children, adolescents and adults. For spinal TB specifically, rest and back support bracing are indicated alongside drug therapy, and surgery should be considered for patients with neurological deficit or unstable spine lesions.
Related on GMJ
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Quality & accreditation
Same guideline
- Drugs for drug-resistant tuberculosis — MSF TuberculosisChapter 8: Tuberculosis drugs and treatment regimens
- Tuberculosis drug formulations — MSF TuberculosisChapter 8: Tuberculosis drugs and treatment regimens
- Drugs for drug-susceptible tuberculosis — MSF TuberculosisChapter 8: Tuberculosis drugs and treatment regimens
- Standard code for treatment regimens — MSF TuberculosisChapter 8: Tuberculosis drugs and treatment regimens
- Drug Susceptibility Pattern — Tuberculosis — MSF TuberculosisChapter 7: Case definitions
- Bacteriological status — MSF TuberculosisChapter 7: Case definitions
- Issuer
- Médecins Sans Frontières
- Guideline
- Tuberculosis
- Chapter
- Chapter 9: Treatment of drug-susceptible tuberculosis
- Type
- Clinical guideline (chapter)
- Edition
- Current online edition, 2026
- Status
- Current
- Published
- 2026-10-14
- Scope
- Drug-susceptible tuberculosis treatment regimens
- Audience
- Clinicians and TB programme managers
- Evidence
- Based on WHO guidelines with referenced evidence
- Record history
- Created 22 Oct 2026 · updated 22 Oct 2026 · next check Apr 2027
Médecins Sans Frontières. 9.2 Conventional treatment regimens. In: Tuberculosis [guideline]. Paris: MSF; 2026 Oct 14.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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