Patient Monitoring — Multidrug-Resistant and Rifampicin-Resistant Tuberculosis — MSF Tuberculosis — Médecins Sans Frontières 2026

Q: How often should patients on linezolid have blood tests?

Full blood count (haemoglobin, red and white blood cells, and platelets) should be performed every 2 weeks for the first 2 months, then once a month throughout linezolid treatment. Additionally, monthly brief peripheral neuropathy screening is required to detect peripheral neuropathy.

Q: When is weekly ECG monitoring required instead of monthly?

Weekly ECG for one month (then monthly thereafter) is required for patients taking ≥2 moderate or strong QT-prolonging TB drugs, taking ≥3 QT-prolonging drugs (TB and non-TB combined), or those with other risk factors including history of syncopal episodes, torsade de pointes, congenital long QT syndrome, uncompensated heart failure, severe coronary disease, bradycardia, or untreated hypothyroidism.

Q: What bacteriological tests are needed if a patient has positive culture at Month 4?

If culture is positive at Month 4 or later, full phenotypic DST (or genome sequencing) should be performed. Additionally, if microscopy is positive at Month 4 or later, Xpert MTB/XDR (or GenoType MTBDRsl if Xpert MTB/XDR is not available) should be performed to detect resistance-conferring mutations not present at baseline.

Q: Do patients need monitoring after completing MDR-TB treatment?

Yes, for patients on BPaLM/BPaL regimens: culture and microscopy are required at 6 and 12 months post-treatment completion (or at any time if symptoms reappear) to detect relapse. For patients on longer treatment regimens, post-treatment tests are performed for operational research purposes only.

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 monitoring protocol for MDR/RR-TB patients throughout treatment, with schedules for clinical visits, bacteriology, ECG, and laboratory tests.

In one sentenceMDR/RR-TB patients require weekly then monthly clinical visits, monthly bacteriology and liver function tests, ECG monitoring (weekly then monthly if on ≥2 QT-prolonging TB drugs), and drug-specific monitoring including peripheral neuropathy screening for linezolid.

Issuer: Médecins Sans Frontières
Edition: Current online edition, 2026
Audience: Clinicians managing MDR/RR-TB patients
Evidence: Expert consensus based on WHO recommendations and MSF field experience
Reviewed: 23 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 23 Oct 2026•Next check Apr 2027

What this guideline says

GMJ summary

This MSF clinical guideline section provides a comprehensive monitoring framework for patients undergoing treatment for multidrug-resistant and rifampicin-resistant tuberculosis (MDR/RR-TB). It establishes baseline assessment requirements and follow-up schedules for clinical visits, bacteriological testing, and investigations needed to detect treatment response, adverse effects, and adherence issues throughout the course of therapy.

Monitoring includes weekly clinical visits in the first month, fortnightly in the second month, then monthly if stable. Bacteriological tests (microscopy and culture) are performed monthly until treatment completion. Specific investigations are required based on the drugs prescribed: ECG monitoring for QT-prolonging medications (weekly for one month if ≥2 moderate/strong QT-prolonging TB drugs, then monthly), monthly brief peripheral neuropathy screening for linezolid recipients, monthly visual function tests for drugs with ocular toxicity, and tailored laboratory monitoring including full blood count every 2 weeks for the first 2 months on linezolid, and monthly liver function tests for all patients.

Post-treatment surveillance differs by regimen: patients on BPaLM/BPaL require culture and microscopy at 6 and 12 months post-treatment to detect relapse, while for patients on longer treatment regimens, post-treatment tests are performed for operational research purposes only.

Key points

For clinicians — doses and thresholds as stated in the guideline

Clinical visits: weekly for the first month, every other week for the second month, then monthly if stable; additional visits required for comorbidities, severe adverse effects, or pregnancy
Bacteriological monitoring: monthly sputum smear microscopy and culture until treatment completion; full phenotypic DST or genome sequencing if positive culture at Month 4 or later
ECG monitoring: baseline for all patients on QT-prolonging drugs; weekly for one month then monthly if taking ≥2 moderate/strong QT-prolonging TB drugs or ≥3 total QT-prolonging drugs (TB and non-TB)
Linezolid recipients: brief peripheral neuropathy screen monthly; full blood count every 2 weeks for the first 2 months, then monthly
Liver function tests: baseline AST and ALT for all patients, then monthly; monitor more frequently if AST/ALT elevated or hepatitis B/C present
Post-treatment surveillance for BPaLM/BPaL regimens: culture and microscopy at 6 and 12 months post-treatment completion to detect relapse
Aminoglycoside recipients: monthly audiometry and monthly serum creatinine and potassium monitoring
Patients on drugs with ocular toxicity: monthly visual acuity and colour vision tests (Ishihara test) to detect optic neuritis

ECG Monitoring Schedule by Risk Category

Table extracted from the guideline

Patient category	Baseline	Follow-up frequency
Taking <2 moderate/strong QT-prolonging TB drugs AND <3 total QT-prolonging drugs (TB and non-TB)	Yes	Once a month
Taking ≥2 moderate/strong QT-prolonging TB drugs OR ≥3 total QT-prolonging drugs (TB and non-TB)	Yes	Once a week for one month, then once a month
With other risk factors for QT prolongation or TdP (history of syncopal episodes, TdP, congenital long QT syndrome, uncompensated heart failure, severe coronary disease, bradycardia, untreated hypothyroidism)	Yes	Once a week for one month, then once a month

Source: Médecins Sans Frontières, Patient Monitoring — Multidrug-Resistant and Rifampicin-Resistant Tuberculosis — MSF Tuberculosis. Reproduced in summary form.

From the guideline

Verbatim

“Culture conversion and reversion are useful markers of whether the treatment is effective or not.”

— Médecins Sans Frontières, Patient Monitoring — Multidrug-Resistant and Rifampicin-Resistant Tuberculosis — MSF Tuberculosis, Section 10.6.2, Follow-up tests (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 Chair of the Public Health Institute of Georgia and a WHO consultant, I recognise this MSF monitoring protocol addresses critical gaps in our regional MDR-TB programmes. Georgia has made substantial progress in TB control, but the intensive monitoring requirements outlined here—particularly weekly ECG monitoring in the first month for patients on multiple QT-prolonging drugs and biweekly blood counts for linezolid recipients—demand significant health system capacity. The distinction between BPaLM/BPaL post-treatment surveillance (mandatory at 6 and 12 months) versus longer regimens is essential as our national programme transitions to all-oral shorter regimens. Georgian clinicians should particularly note the threshold of ≥2 moderate or strong QT-prolonging TB drugs triggering weekly ECG, as bedaquiline-containing regimens often meet this criterion. The realistic implementation challenge for Georgia and neighbouring countries will be decentralising this intensive monitoring to regional centres whilst maintaining quality, especially for specialised assessments like brief peripheral neuropathy screening and Ishihara colour vision testing, which may require additional training of TB nurses and investment in point-of-care equipment.

ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026

Applicability

Georgia and the South Caucasus

This MSF protocol is directly applicable to Georgia’s National TB Programme, which manages a significant MDR-TB burden in the South Caucasus region. Georgian programmes would need to ensure laboratory capacity for monthly culture and DST, access to ECG monitoring (particularly for patients on newer regimens containing bedaquiline and delamanid), and integration of peripheral neuropathy and visual function screening into routine TB care. The post-treatment surveillance requirements for BPaLM/BPaL regimens align with WHO recommendations and should be incorporated as Georgia adopts shorter all-oral regimens. Programmes must assess their capacity to deliver the intensive monitoring schedule, particularly weekly ECG monitoring in the first month for high-risk patients, and consider task-shifting strategies for brief peripheral neuropathy screening and visual acuity testing to TB nurses with appropriate training.

Questions this guideline answers

Quick answers

How often should patients on linezolid have blood tests?

Full blood count (haemoglobin, red and white blood cells, and platelets) should be performed every 2 weeks for the first 2 months, then once a month throughout linezolid treatment. Additionally, monthly brief peripheral neuropathy screening is required to detect peripheral neuropathy.

When is weekly ECG monitoring required instead of monthly?

Weekly ECG for one month (then monthly thereafter) is required for patients taking ≥2 moderate or strong QT-prolonging TB drugs, taking ≥3 QT-prolonging drugs (TB and non-TB combined), or those with other risk factors including history of syncopal episodes, torsade de pointes, congenital long QT syndrome, uncompensated heart failure, severe coronary disease, bradycardia, or untreated hypothyroidism.

What bacteriological tests are needed if a patient has positive culture at Month 4?

If culture is positive at Month 4 or later, full phenotypic DST (or genome sequencing) should be performed. Additionally, if microscopy is positive at Month 4 or later, Xpert MTB/XDR (or GenoType MTBDRsl if Xpert MTB/XDR is not available) should be performed to detect resistance-conferring mutations not present at baseline.

Do patients need monitoring after completing MDR-TB treatment?

Yes, for patients on BPaLM/BPaL regimens: culture and microscopy are required at 6 and 12 months post-treatment completion (or at any time if symptoms reappear) to detect relapse. For patients on longer treatment regimens, post-treatment tests are performed for operational research purposes only.

Related on GMJ

Interconnected resources

Drugs A–Z

Quality & accreditation

Same guideline

Special situations in multidrug-resistant and rifampicin-resistant tuberculosis treatment — MSF TuberculosisChapter 10: Treatment of multidrug-resistant and rifampicin-resistant tuberculosis
Treatment regimens in operational research conditions — MSF TuberculosisChapter 10: Treatment of multidrug-resistant and rifampicin-resistant tuberculosis
Treatment Regimens in Programmatic Conditions for Multidrug-Resistant and Rifampicin-Resistant Tuberculosis — MSF TuberculosisChapter 10: Treatment of multidrug-resistant and rifampicin-resistant tuberculosis
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

Patient Monitoring — Multidrug-Resistant and Rifampicin-Resistant Tuberculosis — MSF Tuberculosis

What this guideline says

Key points

ECG Monitoring Schedule by Risk Category

From the guideline