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id.tb_drug_resistant.v1

Drug-resistant tuberculosis (MDR / pre-XDR / XDR)

infectious_diseasechronicsubacuteacuteadultoutpatientacuteinpatienttransition
Start encounter →Print handoutPRODUCTION

Drug-resistant TB dossier — BPaL/BPaLM 6-mo regimens (Nix-TB / ZeNix / TB-PRACTECAL) replacing 18–24 mo regimens. Key monitoring: monthly sputum, q2w CBC for linezolid, monthly ECG QTc, monthly vision/audiometry. HIV co-infection requires ART timing strategy + DDI awareness (bedaquiline + ritonavir / efavirenz). Open: manifest, problem-package, RxCUI verification, DST + QTc-trend calculators absent, tests. Deepened 2026-05-15 (shard-5-obped-id depth-pass-1, solo wave-7): added _briefs/id.tb_drug_resistant.v1.depth.md companion + _research-bundles/id.tb_drug_resistant.v1.md. Added 3 severity triggers: culture_non_conversion_at_2_months (severe — earlier intervention than month-4 failure trigger), xdr_tb_individualized_regimen_required (severe — WHO 2021 redefinition + programmatic management), contact_tracing_and_public_health_notification (moderate — DR-TB public health imperative). Phenotype matrix (resistance × site × host × regimen-eligibility × adverse-event × treatment-response × public-health-status) and Bayesian linkage (Xpert MTB/RIF Ultra + XDR + LPA + MGIT-DST + WGS LRs; T_treat empiric BPaL/BPaLM at high pre-test + epidemiology while awaiting DST; cross-dossier routing to id.hiv-initial.chronic.v1 for ART timing) documented in depth brief + research bundle. First-class TS fields remain schema-blocked.

Entry points (4)

  • symptom
    TB with failed first-line treatment, contact with DR-TB, or DST showing INH + RIF resistance (WHO 2022 Module 4)
    tb_with_failed_first_line_or_resistance
  • lab_abnormality
    Xpert MTB/RIF positive with rifampicin resistance (WHO 2022 rapid-diagnostics recommendation)
    xpert_mtb_rif_resistance
  • history
    Contact with confirmed MDR-TB case (WHO 2022 contact-investigation guidance)
    mdr_contact
  • symptom
    TB meningitis, miliary TB, severe pulmonary TB (ATS/IDSA/CDC 2022)
    severe_tb_disease

Required inputs (19)

  • agerequired
    demographic • used at CONTEXT
    Drug doses; pregnancy considerations (WHO 2022)
  • pregnancy_statusrequired
    demographic • used at CONTEXT
    Bedaquiline / pretomanid limited pregnancy data (WHO 2022 Module 4)
  • sputum_AFB_smear_culturerequired
    lab • used at INITIAL_WORKUP
    Diagnostic + monitoring conversion (WHO 2022)
  • xpert_mtb_rif_xdrrequired
    lab • used at INITIAL_WORKUP
    Rapid resistance screen (WHO 2022 Xpert MTB/RIF Ultra + XDR recommendation)
  • mgit_culture_dstrequired
    lab • used at INITIAL_WORKUP
    Phenotypic DST gold standard (WHO 2022)
  • line_probe_or_wgs
    lab • used at BRANCHING_WORKUP
    Genotypic resistance (WHO 2022 LPA / WGS recommendation)
  • hiv_testrequired
    lab • used at INITIAL_WORKUP
    HIV co-infection alters regimen + ART interactions (WHO 2022)
  • cd4_count_if_HIV
    lab • used at INITIAL_WORKUP
    OI prophylaxis + ART timing (WHO 2022)
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Linezolid myelosuppression baseline (ZeNix NEJM 2022)
  • lftrequired
    lab • used at INITIAL_WORKUP
    Bedaquiline / pretomanid hepatotox (Nix-TB NEJM 2020)
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    Drug dosing (WHO 2022)
  • k_mgrequired
    lab • used at INITIAL_WORKUP
    QT correction — bedaquiline QT monitoring (WHO 2022)
  • cxrrequired
    imaging • used at INITIAL_WORKUP
    Disease extent (WHO 2022)
  • ct_chest
    imaging • used at BRANCHING_WORKUP
    Cavitary, miliary, pleural (ATS/IDSA/CDC 2022)
  • brain_mri
    imaging • used at BRANCHING_WORKUP
    TB meningitis / tuberculoma (ATS/IDSA/CDC 2022)
  • ecg_qtcrequired
    imaging • used at INITIAL_WORKUP
    Bedaquiline + moxifloxacin QT monitoring (WHO 2022 aDSM)
  • vision_audiometryrequired
    imaging • used at INITIAL_WORKUP
    Linezolid optic neuropathy + ototoxicity baseline (ZeNix NEJM 2022; WHO 2022 aDSM)
  • prior_TB_treatmentrequired
    history • used at CONTEXT
    Resistance risk (WHO 2022)
  • current_medsrequired
    medication • used at CONTEXT
    DDI esp ART, QT-prolongers, MAOI for linezolid serotonergic (WHO 2022)

12-phase flow (12)

  1. 1FRAME
    Confirm MDR / pre-XDR / XDR via Xpert + DST + WGS; classify resistance pattern per WHO 2021 redefinition
    inputs: xpert_mtb_rif_xdr, mgit_culture_dst
    advance: Resistance pattern documented
  2. 2ENTRY
    TB with risk for resistance, treatment failure, contact with DR-TB (WHO 2022 Module 4)
    inputs: age
    advance: Engine entered
  3. 3CONTEXT
    HIV status, hepatic / renal function, QTc, neuropathy, pregnancy, prior TB Rx (WHO 2022 pre-treatment assessment)
    inputs: pregnancy_status, prior_TB_treatment, hiv_test, current_meds
    advance: Context complete
  4. 4RED_FLAGS
    Severe disease (meningitis, miliary, sepsis, respiratory failure), hemoptysis, vision loss on linezolid (ZeNix NEJM 2022), drug-induced hepatitis (Nix-TB NEJM 2020)
    actions: hemoptysis
    advance: Stabilised
  5. 5INITIAL_WORKUP
    Sputum smear + MGIT culture + DST, Xpert MTB/RIF + XDR, line probe, WGS, HIV/CD4, CBC, LFT, BMP, K/Mg, ECG, vision + audiometry, CXR (IDSA 2024)
    inputs: sputum_AFB_smear_culture, xpert_mtb_rif_xdr, mgit_culture_dst, hiv_test, cbc, lft, creatinine_egfr, k_mg, cxr, ecg_qtc, vision_audiometry
    actions: panel.cbc, panel.lft, panel.renal
    advance: Stage-1 returned
  6. 6BRANCHING_WORKUP
    CT chest, brain MRI for neuro, bronchoscopy if culture-neg, HIV ART start, contact tracing (IDSA 2024)
    inputs: ct_chest, brain_mri
    actions: hiv_initial
    advance: Branch resolved
  7. 7DIFFERENTIAL
    MDR vs pre-XDR vs XDR; mixed infection vs reinfection vs relapse (IDSA 2024)
    advance: Diagnosis confirmed
  8. 8RISK_STRATIFICATION
    Disease severity; resistance pattern; drug tolerability; HIV; pregnancy (IDSA 2024)
    advance: Tier documented
  9. 9TREATMENT
    BPaL (6 mo) for MDR / pre-XDR / XDR per ZeNix (NEJM 2022); BPaLM for MDR per TB-PRACTECAL (NEJM 2022); longer 9–18 mo individualized regimens for ineligible (WHO 2022). Pyridoxine for linezolid neuropathy. Manage HIV ART concurrently — avoid bedaquiline + ritonavir/efavirenz interactions (WHO 2022).
    inputs: lft, cbc, k_mg, ecg_qtc
    advance: Plan documented
  10. 10DISPOSITION
    DOT clinic outpatient if stable; admit for severe disease / drug AE / smear-positive requiring isolation (WHO 2022)
    advance: Disposition documented
  11. 11MONITORING
    Monthly sputum culture until conversion then q3 mo; CBC q2 wks x 8 then q1 mo on linezolid; LFT q1 mo; ECG q2 wks x 4 then q1 mo; vision + audiometry q1 mo on linezolid (WHO 2022 aDSM; ZeNix NEJM 2022)
    inputs: cbc, lft, ecg_qtc, vision_audiometry
    advance: Schedule documented
  12. 12FOLLOWUP
    TB clinic monthly; contact tracing; HIV care; nutrition (WHO 2022)
    advance: Follow-up booked