PICO question | Recommendation(s) | Comments | |
1 | Does adding case management# interventions to curative therapy improve outcomes compared with curative therapy alone among patients with TB? | We suggest using case management interventions during treatment of patients with TB | Conditional recommendation/very low confidence in the effects |
2 | Does SAT have similar outcomes compared with DOT in patients with various forms of TB? | We suggest using DOT rather than SAT for routine treatment of patients with all forms of TB | Conditional recommendation/low confidence in the effects |
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 TB? | We recommend the use of daily rather than intermittent dosing in the intensive phase of therapy for drug-susceptible pulmonary TB | Strong recommendation/moderate confidence in the effects |
Use of three times weekly 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 also at low risk of relapse (pulmonary TB caused by drug-susceptible organisms, which at the start of treatment is non-cavitary and/or smear negative) | Conditional recommendation/low confidence in the effects | ||
In situations where daily or three times weekly DOT 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 also at low risk of relapse (pulmonary TB caused by drug-susceptible organisms, which at the start of treatment is non-cavitary and/or smear negative) | Conditional recommendation/very low confidence in the effects Note: if doses are missed in a regimen using twice weekly dosing then therapy is equivalent to once weekly, which is inferior (see PICO question 4) | ||
4 | Does intermittent dosing in the continuation phase have similar outcomes compared with daily dosing in the continuation phase in patients with drug-susceptible pulmonary TB? | We recommend the use of daily or three times weekly dosing in the continuation phase of therapy for drug-susceptible pulmonary TB | Strong recommendation/moderate confidence in the effects |
If intermittent therapy is to be administered in the continuation phase, then we suggest use of three times weekly instead of twice weekly therapy | Conditional recommendation/low confidence in the effects This recommendation allows for the possibility of some doses being missed; with twice weekly therapy, if doses are missed then therapy is equivalent to once weekly, which is inferior | ||
We recommend against use of once weekly therapy with INH 900 mg and RPT 600 mg in the continuation phase | Strong recommendation/high confidence in the effects In uncommon situations where more than once-weekly DOT is difficult to achieve, once weekly continuation phase therapy with INH 900 mg plus RPT 600 mg may be considered for use only in HIV-negative persons without cavitation on chest radiography | ||
5 | Does extending treatment beyond 6 months improve outcomes compared with the standard 6-month treatment regimen among pulmonary TB patients co-infected with HIV? | For HIV-infected patients receiving antiretroviral therapy, we suggest using the standard 6-month daily regimen consisting of an intensive phase of 2 months of INH, RIF, PZA and EMB followed by a continuation phase of 4 months of INH and RIF for the treatment of drug-susceptible pulmonary TB | Conditional recommendation/very low confidence in the effects |
In uncommon situations in which HIV-infected patients do not receive antiretroviral therapy during TB treatment, we suggest extending the continuation phase with INH and RIF for an additional 3 months (i.e. a continuation phase of 7 months in duration, corresponding to a total of 9 months of therapy) for treatment of drug-susceptible pulmonary TB | Conditional recommendation/very low confidence in the effects | ||
6 | Does initiation of antiretroviral therapy during TB treatment compared with at the end of TB treatment improve outcomes among TB patients co-infected with HIV? | We recommend initiating antiretroviral therapy during TB treatment Antiretroviral therapy should ideally be initiated within the first 2 weeks of TB treatment for patients with CD4 cell counts <50 per mm3 and within 8–12 weeks of TB treatment initiation for patients with CD4 cell counts ≥50 per mm3 | Strong recommendation/high confidence in the effects Note: an exception is patients with HIV infection and tuberculous meningitis |
7 | Does the use of adjuvant corticosteroids in tuberculous pericarditis provide mortality and morbidity benefits? | We suggest initial adjunctive corticosteroid therapy not be routinely used in patients with tuberculous pericarditis | Conditional recommendation/very low confidence in the effects |
8 | Does the use of adjuvant corticosteroids in tuberculous meningitis provide mortality and morbidity benefits? | We recommend initial adjunctive corticosteroid therapy with dexamethasone given for 6 weeks for patients with tuberculous meningitis | Strong recommendation/moderate confidence in the effects |
9 | Does a shorter duration of treatment have similar outcomes compared with the standard 6-month treatment duration among HIV-negative patients with paucibacillary TB (i.e. smear negative, culture negative)? | We suggest that a 4-month treatment regimen is adequate for treatment of HIV-negative adult patients with AFB smear- and culture-negative pulmonary TB | Conditional recommendation/very low confidence in the effects |
SAT: self-administered therapy; DOT: directly observed therapy; INH: isoniazid; RPT: rifapentin; RIF: rifampicin; PZA: pyrazinamide; EMB: ethambutol; AFB: acid-fast bacilli. #: case management: patient education/counselling, field/home visits, integration/coordination of care with specialists and medical home, patient reminders, incentives/enablers.