| 1. Does adding case management interventions to curative therapy improve outcomes compared with curative therapy alone among patients with tuberculosis? (Case management is defined as patient education/counseling, home visits, integration/coordination of care with specialists and general practitioners, patient reminders, and use of incentives/enablers) |
1. We suggest using case management interventions during treatment of patients with tuberculosis. (Conditional recommendation; very low certainty in the evidence) |
| 2. Does self-administered therapy have similar results compared with directly observed therapy in patients with various forms of tuberculosis? |
2. We suggest using directly observed therapy rather than self-administered therapy for routine treatment of all forms of tuberculosis. (Conditional recommendation; low certainty in the evidence) |
| 3. Does intermittent dosing in the intensive phase have similar outcomes compared with daily dosing in the intensive phase for treatment of drug-susceptible pulmonary tuberculosis? |
3a. We recommend the use of daily rather than intermittent dosing in the intensive phase of therapy for drug susceptible pulmonary tuberculosis. (Strong recommendation; moderate certainty in the evidence))
3b. Use of thrice-weekly directly observed therapy in the intensive phase (with or without an initial 2 weeks of daily therapy) may be considered in patients who are not HIV-infected and are at low risk of relapse (pulmonary tuberculosis caused by drug-susceptible organisms, which at the start of treatment is non-cavitary and/or smear negative). (Conditional recommendation; low certainty in the evidence)
3c. In situations in which daily or thrice-weekly directly observed therapy is difficult to achieve, use of twice-weekly therapy after an initial 2 weeks of daily therapy may be considered for patients who are not HIV-infected and are at low risk of relapse (pulmonary tuberculosis caused by drug-susceptible organisms, which at the start of treatment is non-cavitary and/or smear negative). (Conditional recommendation; very low certainty in the evidence)
Note: If doses are missed in a regimen using twice-weekly dosing, then therapy is equivalent to once weekly, which is inferior (See Question 4). |
| 4. Does intermittent dosing in the maintenance phase have similar outcomes compared with daily dosing in the maintenance phase in patients with drug-susceptible pulmonary tuberculosis? |
4a. We recommend the use of daily or thrice-weekly dosing in the maintenance phase of therapy for drug-susceptible pulmonary tuberculosis. (Strong recommendation; moderate certainty in the evidence)
4b. If intermittent therapy is to be administered in the maintenance phase, we suggest use of thrice-weekly instead of twice-weekly therapy. (Conditional recommendation; low certainty in the evidence)
This recommendation allows for the possibility that if some doses are missed, treatment is still adequate. In contrast, with twice-weekly therapy, if doses are missed, then therapy is equivalent to once weekly, which is inferior.
4c. We recommend against use of once-weekly therapy with isoniazid 900 mg and rifapentine 600 mg in the maintenance phase. (Strong recommendation; high certainty in the evidence)
In uncommon situations in which more than once-weekly directly observed therapy is difficult to achieve, once-weekly maintenance phase therapy with isoniazid 900 mg and rifapentine 600 mg may be considered for use only in HIV-uninfected individuals without cavitation on chest X-ray. |
| 5. Does extending treatment beyond 6 months improve outcomes compared with the standard 6-month treatment regimen among pulmonary tuberculosis patients coinfected with HIV? |
5a. For HIV-infected individuals receiving antiretroviral therapy, we recommend using the standard 6-month daily regimen consisting of an intensive phase of 2 months of isoniazid, rifampin, pyrazinamide, and ethambutol followed by a maintenance phase of 4 months of rifampin and isoniazid for the treatment of drug-susceptible pulmonary tuberculosis. (Conditional recommendation; very low certainty in the evidence)
5b. In uncommon situations in which HIV-infected individuals do not receive antiretroviral therapy during tuberculosis treatment, we recommend extending the maintenance phase with isoniazid and rifampin for an additional 3 months (i.e., a maintenance phase corresponding to a total of 9 months of treatment) for the treatment of drug-susceptible pulmonary tuberculosis. (Conditional recommendation; very low certainty in the evidence) |
| 6. Does initiation of antiretroviral therapy during tuberculosis treatment compared with at the end of tuberculosis treatment improve outcomes among tuberculosis patients coinfected with HIV? |
6. We recommend initiating antiretroviral therapy during tuberculosis treatment. Antiretroviral therapy should ideally be initiated within the first 2 weeks of tuberculosis treatment for individuals with CD4 counts < 50 cells/µL and by 8-12 weeks of tuberculosis treatment initiation for individuals with CD4 counts ≥ 50 cells/µL. (Strong recommendation; high certainty in the evidence)
Note: An exception is individuals with HIV infection and tuberculous meningitis, in whom antiretroviral therapy is not initiated in the first 8 weeks of tuberculosis treatment. |
| 7. Does the use of adjuvant corticosteroids in tuberculous pericarditis provide mortality and morbidity benefits? |
7. We recommend that adjunctive corticosteroid therapy not be routinely used in individuals with tuberculous pericarditis. (Conditional recommendation; very low certainly in the evidence) |
| 8. Does the use of adjuvant corticosteroids in tuberculous meningitis provide mortality and morbidity benefits? |
8. We recommend adjunctive corticosteroid therapy with dexamethasone or prednisolone tapered over 6-8 weeks for individuals with tuberculous meningitis. (Strong recommendation; moderate certainty in the evidence) |
| 9. Does a shorter duration of treatment have similar outcomes compared with the standard 6-month treatment duration among HIV-uninfected individuals with paucibacillary tuberculosis (i.e., sputum smear negative, culture negative)? |
9. We suggest that a 4-month treatment regimen is adequate for treatment of HIV-uninfected adults with sputum smear-negative, culture-negative pulmonary tuberculosis. (Conditional recommendation; very low certainly in the evidence) |
