Special situations in multidrug-resistant and rifampicin-resistant tuberculosis treatment — MSF Tuberculosis

What this guideline says

GMJ summary

This section of the MSF tuberculosis guideline addresses treatment of multidrug-resistant and rifampicin-resistant tuberculosis (MDR/RR-TB) in six special patient populations. It emphasises that pregnant and breastfeeding women and children should be treated without delay, with specific modifications to standard treatment regimens.

For pregnant and breastfeeding women, shorter treatment regimens (STRs) are recommended except BPaLM/BPaL regimens due to limited safety data on pretomanid. Among longer treatment regimens (LTRs), endTB1 is preferred as it contains only 4 drugs. Infant formula is recommended for breastfeeding women when it can be used safely, with mothers receiving necessary supplies and training. For children under 14 years, BPaLM/BPaL regimens are not recommended due to limited dosing data for pretomanid, but children generally tolerate DR-TB drugs well and those with non-severe TB may be treated for less than 18 months.

The guideline provides specific considerations for extrapulmonary TB, particularly TB of the central nervous system where drug penetration is critical. For patients with diabetes, increased blood glucose monitoring is necessary and certain drugs (ethambutol, linezolid) should be avoided in those with pre-existing diabetic retinopathy. In renal insufficiency with creatinine clearance less than 30 ml/minute, dose adjustments are required for certain TB drugs.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. Pregnant and breastfeeding women should be treated without delay; STRs are recommended except BPaLM/BPaL regimens due to limited pretomanid safety data
2. Among endTB regimens, endTB1 is preferred for pregnant women as it includes only 4 drugs (versus 5 for endTB2 and endTB3)
3. Infant formula is recommended for breastfeeding women on second-line TB drugs; mothers must receive formula, clean water, fuel for boiling, heating device and training on preparation
4. Children and adolescents under 14 years should not receive BPaLM/BPaL regimens due to limited pretomanid dosing evidence; they generally tolerate DR-TB drugs well
5. Children with non-severe TB receiving an LTR can usually be treated for less than 18 months
6. For TB of the central nervous system, fluoroquinolones and linezolid have good CNS penetration; meropenem is preferred over imipenem/cilastatin due to lower seizure risk
7. In patients with diabetes and pre-existing diabetic retinopathy, avoid prescribing ethambutol or linezolid
8. In renal insufficiency with creatinine clearance less than 30 ml/minute, doses of certain TB drugs should be adjusted

Choice of TB drugs for TB of the central nervous system

Table extracted from the guideline

Source: Médecins Sans Frontières, Special situations in multidrug-resistant and rifampicin-resistant tuberculosis treatment — MSF Tuberculosis. Reproduced in summary form.

From the guideline

Verbatim

“Pregnant and breastfeeding women should be treated without delay.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

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