IDSA - Clinical Strategy to Build an Individualized Treatment Regimen for Multi-Drug Resistant Tuberculosis (MDR-TB)

 • Build a regimen using five or more drugs to which the isolate is susceptible (or has low likelihood of resistance), preferably with drugs that have not been used to treat the patient previously.

 • Choice of drugs is contingent on capacity to appropriately monitor for significant adverse effects, patient comorbidities, and preferences/values (choices therefore subject to program and patient safety limitations).

 • In children with TB disease who are contacts of infectious MDR-TB source cases, the source case’s isolate DST result should be used if an isolate is not obtained from the child. 

 • TB expert medical consultation is recommended (ungraded good practice statement).

Step 1: Choose one later-generation fluoroquinolone: Levofloxacin, Moxifloxacin

Step 2: Choose both of these prioritized drugs: Bedaquiline, Linezolid

Step 3: Choose both of these prioritized drugs: Clofazimine, Cycloserine/terizidone

Step 4: If a regimen cannot be assembled with five effective oral drugs, and the isolate is susceptible, use one of these injectable agents: Amikacin, Streptomycin

Step 5: If needed or if oral agents preferred over injectable agents in Step 4, use the following drugs: Delamanid, Pyrazinamide, Ethambutol

Step 6: If limited options and cannot assemble a regimen of five effective drugs, consider use of the following drugs:  Ethionamide or prothionamidex, Imipenem–cilastatin/clavulanate or meropenem/clavulanate, p-Aminosalicylic acid, High-dose isoniazid

The following drugs are no longer recommended for inclusion in MDR-TB regimens: Capreomycin and kanamycin, Amoxicillin/clavulanate (when used without a carbapenem), Azithromycin and clarithromycin



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