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id.tb-pulmonary.v1PRODUCTION
id.tb-pulmonary.v1

Pulmonary Tuberculosis (Drug-Susceptible)

infectious_diseaseacutesubacutechronicadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Adult drug-SUSCEPTIBLE pulmonary TB + LTBI in the id.* family. Drug-resistant TB is OWNED by id.tb_drug_resistant.v1 — route there on Xpert-RIF+ or MDR contact. Pediatric TB and TB meningitis are out of scope (route to pediatric / neuro siblings). Place patient in airborne (negative-pressure, N95) isolation the moment active pulmonary TB is suspected (ATS/CDC/IDSA 2016 Nahid; WHO 2024)

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Scope confirmed; airborne isolation initiated if active suspected

Patient inputs (14)

HIV co-infection alters ART timing (within 2 wk if CD4<50, 8 wk if CD4≥50 per SAPIT/STRIDE/CAMELIA), rifampin-vs-rifabutin choice with PI/INSTI ART, and IRIS surveillance (ATS/CDC/IDSA 2016 Nahid; WHO 2024)

Prior TB treatment + relapse markedly increases drug-resistance pretest probability — drives DST urgency and may delay SAT vs DOT decision (ATS/CDC/IDSA 2016 Nahid)

Contact with MDR-TB case or origin from high-resistance country shifts empiric coverage and routes to id.tb_drug_resistant.v1 (WHO 2024)

Pregnancy alters drug choice — streptomycin contraindicated; ETB/INH/RIF/PZA acceptable; pyridoxine mandatory (ATS/CDC/IDSA 2016 Nahid)

Baseline hepatic disease, alcohol use, HBV/HCV co-infection increase INH/RIF/PZA hepatotoxicity risk — drives baseline + monthly LFT monitoring threshold (ATS/CDC/IDSA 2016 Nahid)

3 sputum specimens (≥1 early-morning) for AFB smear microscopy — sensitivity ~50–60%, specificity ~98%; airborne-isolation duration anchor (ATS/CDC/IDSA 2016 Nahid)

Xpert MTB/RIF Ultra overall sens ~88%, smear-neg-culture-pos ~63%, HIV+ ~90%; spec ~96% (trace-positive caveat); detects rifampin resistance — routes to id.tb_drug_resistant.v1 on RIF+ (Dorman Lancet ID 2018 PMID 29198911)

Gold standard; quantitative culture + phenotypic DST drives confirmation, 2-mo conversion endpoint, and resistance detection (ATS/CDC/IDSA 2016 Nahid)

INH/RIF/PZA hepatotoxicity baseline — hold drugs if ALT >3× ULN symptomatic or >5× ULN asymptomatic (ATS/CDC/IDSA 2016 Nahid)

ETB and PZA require renal-interval extension (3×/wk) when CrCl<30 mL/min or HD; INH/RIF not renally adjusted (ATS/CDC/IDSA 2016 Nahid)

Mandatory HIV testing on every active-TB diagnosis; CD4 + VL if HIV+ (ATS/CDC/IDSA 2016 Nahid; WHO 2024)

CXR (PA + lateral) for cavitation / upper-lobe distribution / miliary pattern; cavitation + month-2 culture-positivity extends continuation to 7 mo (ATS/CDC/IDSA 2016 Nahid)

Weight-banded dosing for all 4 first-line TB drugs; monthly weight re-dosing during therapy (ATS/CDC/IDSA 2016 Nahid)

Snellen + Ishihara before ethambutol; monthly while on ETB to detect optic neuritis (ATS/CDC/IDSA 2016 Nahid)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationallife_threateningmassive_hemoptysis_or_respiratory_failure
    Hemoptysis ≥ 200 mL/24 h with hemodynamic compromise OR respiratory failure / ARDS from extensive cavitary disease (ATS/CDC/IDSA 2016 Nahid)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmiliary_or_disseminated_or_meningeal_tb
    Miliary pattern on CXR/CT, hematogenous dissemination (blood-culture-positive mycobacteria), or TB meningitis features (subacute headache, AMS, CN palsies, basilar enhancement on MRI) (ATS/CDC/IDSA 2016 Nahid)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererifampin_resistance_or_mdr_contact
    Xpert MTB/RIF (Ultra) detects rifampin resistance, OR confirmed contact with MDR-TB case, OR origin from high-resistance country (WHO 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredrug_induced_hepatitis
    INH/RIF/PZA-induced hepatitis — ALT >3× ULN with symptoms (anorexia, nausea, RUQ pain, jaundice) or ALT >5× ULN asymptomatic, or bilirubin >2× ULN attributable to TB drugs (ATS/CDC/IDSA 2016 Nahid)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereethambutol_optic_neuritis
    New decreased visual acuity, color-vision (red-green) impairment, central scotoma, or visual-field defect while on ethambutol (ATS/CDC/IDSA 2016 Nahid)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehiv_coinfection_with_low_cd4
    HIV+ with CD4 < 50 — high IRIS risk and high mortality; ART must start within 2 wk (vs 8 wk for CD4 ≥ 50) per SAPIT/STRIDE/CAMELIA (DHHS 2024 ART)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecavitary_disease_with_month_2_culture_positive
    Cavitary CXR at diagnosis AND sputum culture still positive at month-2 endpoint (ATS/CDC/IDSA 2016 Nahid)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_with_active_tb
    Active drug-susceptible pulmonary TB during pregnancy (ATS/CDC/IDSA 2016 Nahid)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives dose adjustment
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Recommended regimen

Drug-susceptible active TB + LTBI regimen ladder (ATS/CDC/IDSA 2016 Nahid; Study 31 Dorman NEJM 2021; PREVENT-TB Sterling NEJM 2011; CDC LTBI 2020; WHO 2024)
axis: tb_drug_susceptible_active_and_ltbi_ladder
Selected axis "Drug-susceptible active TB + LTBI regimen ladder (ATS/CDC/IDSA 2016 Nahid; Study 31 Dorman NEJM 2021; PREVENT-TB Sterling NEJM 2011; CDC LTBI 2020; WHO 2024)" by default fallback (first axis)
  • isoniazid
    first line
    tb_first_line_inh
    Adult: 5 mg/kg/day PO (max 300 mg) daily for 6-mo standard regimen; 15 mg/kg twice/thrice weekly DOT; 4-mo regimen: standard daily INH × 4 mo; 3HP-LTBI: weight-banded 15 mg/kg weekly × 12 doses (max 900 mg) • PO • daily (intensive + continuation) or weekly (3HP)
    triggers: active_ds_tb_intensive_2mo, active_ds_tb_continuation_4mo, ltbi_3hp_weekly, ltbi_4r_alternative_includes_inh_no, pregnancy_acceptable
    ATS/CDC/IDSA 2016 Nahid PMID 27516382 — backbone of every drug-susceptible regimen. Bactericidal + sterilising. Pyridoxine 25–50 mg/d MANDATORY co-administration to prevent peripheral neuropathy. Hepatotoxicity baseline + symptom-driven LFT monitoring; hold for ALT >3× ULN symptomatic or >5× ULN asymptomatic.
    rxcui 6038
  • rifampin
    first line
    tb_first_line_rifamycin
    Adult: 10 mg/kg/day PO (max 600 mg) daily for both intensive and continuation phases of 6-mo regimen; 4R-LTBI alternative: 10 mg/kg/d × 4 mo. Substitute rifabutin if PI-based or some INSTI-based ART • PO • daily
    triggers: active_ds_tb_standard_6mo_regimen, ltbi_4r_alternative, ltbi_3hr_alternative
    ATS/CDC/IDSA 2016 Nahid — sterilising backbone of all rifamycin-containing regimens. Major CYP3A4 inducer — DDI with HIV ART (PI, some INSTI), anticoagulants, oral contraceptives, calcineurin inhibitors, statins, anticonvulsants. Orange-discolours secretions (counsel). Hepatotoxic; flu-like syndrome on intermittent dosing.
    rxcui 9384
  • pyrazinamide
    first line
    tb_first_line_pza
    Adult weight-banded: 40–55 kg → 1000 mg/d; 56–75 kg → 1500 mg/d; 76–90 kg → 2000 mg/d (max 2 g daily). 2-mo intensive phase only of 6-mo regimen; full 4 mo of the Dorman 2021 4-mo rifapentine+moxi regimen • PO • daily
    triggers: active_ds_tb_intensive_phase_2mo, active_ds_tb_4mo_dorman_regimen
    ATS/CDC/IDSA 2016 Nahid — accelerates 2-mo culture conversion; sterilising. Hepatotoxic; hyperuricaemia (usually asymptomatic — do not treat unless gout flare). Renal-adjust: CrCl<30 → 25–35 mg/kg 3×/wk post-dialysis. AVOID in pregnancy in some guidelines (acceptable per WHO 2024 / ATS 2016 — limited teratogenicity data; benefits > risks).
    rxcui 8987
  • ethambutol
    first line
    tb_first_line_etb
    Adult weight-banded: 40–55 kg → 800 mg/d; 56–75 kg → 1200 mg/d; 76–90 kg → 1600 mg/d (max 1.6 g daily). 2-mo intensive only; DROP once DST confirms pan-susceptibility • PO • daily
    triggers: active_ds_tb_intensive_2mo_until_pan_susceptible_confirmed
    ATS/CDC/IDSA 2016 Nahid — added pending DST to cover unsuspected INH resistance; bacteriostatic. Optic neuritis (dose- and duration-dependent) — baseline Snellen + Ishihara, monthly while on therapy; hold immediately for any visual change. Renal-adjust: CrCl<30 → 15–25 mg/kg 3×/wk post-dialysis. (SAFETY-CRITICAL: prompt-seed RxCUI 4083 was ESTRADIOL — corrected to 4110 via RxNav reverse lookup 2026-05-26.)
    rxcui 4110
  • rifapentine
    first line
    tb_first_line_rifamycin_long_half_life
    4-mo Dorman 2021 regimen: 1200 mg PO daily × 2 mo intensive + × 2 mo continuation (long half-life rifamycin component). 3HP-LTBI: weight-banded once-weekly (32.1–49.9 kg → 750 mg; ≥ 50 kg → 900 mg) × 12 doses • PO • daily (Dorman 4-mo) or weekly (3HP)
    triggers: active_ds_tb_4mo_dorman_regimen_age_ge_12_weight_ge_40_not_pregnant_not_severe, ltbi_3hp_12_weekly_doses_preferred
    Dorman NEJM 2021 PMID 33951360 — INH+rifapentine+moxi+PZA × 2 mo → INH+rifapentine+moxi × 2 mo NON-INFERIOR (TB cure 84.6% vs 85.4% for 6-mo regimen). Sterling NEJM 2011 PMID 22150035 — 3HP LTBI completion 82.1% vs 9H 69.0%, TB development 0.19% vs 0.43%, hepatotoxicity 0.4% vs 2.7%. CYP3A4 inducer (caution with ART).
    rxcui 35617
  • rifabutin
    first line
    tb_first_line_rifamycin_alt
    Adult: 300 mg PO daily as substitute for rifampin when PI-based or some INSTI-based ART; dose adjust per concurrent ART per DHHS table • PO • daily
    triggers: hiv_coinfection_with_protease_inhibitor_or_certain_integrase_ART, rifampin_intolerance
    ATS/CDC/IDSA 2016 Nahid — weaker CYP3A4 induction than rifampin; preferred rifamycin with PI ART. Uveitis (dose-related), leukopenia, polyarthralgia. (SAFETY-CRITICAL: prompt-seed 9383 was empty {} — corrected to 55672 via RxNav reverse lookup 2026-05-26.)
    rxcui 55672
  • moxifloxacin
    first line
    fluoroquinolone
    400 mg PO daily — component of Dorman 2021 4-mo regimen × 4 mo total • PO • daily
    triggers: active_ds_tb_4mo_dorman_regimen
    Dorman NEJM 2021 PMID 33951360 — non-inferior 4-mo regimen anchor. QTc prolongation (avoid with class IA/III antiarrhythmics, methadone, ondansetron); tendinopathy / tendon rupture (age, steroids, transplant); CNS effects. Avoid in pregnancy + age <18 yr unless no alternative.
    rxcui 139462
  • pyridoxine
    first line
    vitamin_b6
    25–50 mg PO daily — MANDATORY co-administration with every INH-containing regimen • PO • daily
    triggers: any_inh_containing_regimen, pregnancy_breastfeeding, hiv_alcohol_dm_uremia_seizure_history
    ATS/CDC/IDSA 2016 Nahid — prevents INH-induced peripheral neuropathy (B6 antagonism); strongly recommended for pregnancy, breastfeeding, HIV, alcohol-use disorder, DM, uraemia, malnutrition, seizure history. (SAFETY-CRITICAL: prompt-seed 8696 was empty {} — corrected to 684879 via RxNav reverse lookup 2026-05-26.)
    rxcui 684879
  • dexamethasone
    rescue
    corticosteroid
    TB meningitis only: dexamethasone 0.4 mg/kg/day IV taper over 6–8 wk (NOT for routine pulmonary disease) • IV/PO • tapered
    triggers: tb_meningitis_adjunct_route_to_neuro_sibling, severe_tb_iris_post_art
    ATS/CDC/IDSA 2016 Nahid; Thwaites NEJM 2004 (TB meningitis adjunct) — survival benefit in TB meningitis only. NOT used for routine pulmonary TB. Severe paradoxical TB-IRIS post-ART start may warrant short-course steroids per DHHS OI 2024.
    rxcui 3264
  • prednisolone
    rescue
    corticosteroid
    TB pericarditis: prednisolone 120 mg/d taper over 6 wk per IMPI 2014 (not for pulmonary disease) • PO • tapered
    triggers: tb_pericarditis_adjunct
    IMPI Mayosi NEJM 2014 — prednisolone in TB pericarditis reduced constrictive pericarditis + hospitalisation; effect modest, did not lower mortality. HIV+: increased Kaposi sarcoma signal observed. NOT for routine pulmonary TB. (Verified RxCUI 8638 = prednisolone IN; distinguished from prednisone 8635.)
    rxcui 8638

outpatient playbook — drug actions (3)

  1. 1. continuation INH + rifampin × 4 mo (or × 7 mo if cavitary + month-2 culture+)
    INH 5 mg/kg + rifampin 10 mg/kg PO daily DOT (or 2–3×/wk DOT in low-risk) • PO • daily (or 2–3×/wk DOT)
    trigger: Completion of 2-mo intensive phase + sputum conversion
    ATS/CDC/IDSA 2016 Nahid
  2. 2. 3HP for LTBI in contacts (preferred)
    rxcui 35617
    Rifapentine weight-banded once-weekly (32.1–49.9 kg → 750 mg; ≥ 50 kg → 900 mg) + INH 15 mg/kg (max 900 mg) × 12 doses • PO • weekly × 12
    trigger: Contact screened with positive IGRA/TST + active disease excluded
    Sterling NEJM 2011 PMID 22150035 (PREVENT-TB) — 3HP non-inferior to 9H with better completion + less hepatotoxicity; CDC LTBI 2020 preferred regimen
  3. 3. continued pyridoxine 25–50 mg/d
    rxcui 684879
    25–50 mg PO daily • PO • daily
    trigger: Any INH-containing regimen
    ATS/CDC/IDSA 2016 Nahid

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Cough ≥ 2–3 wk with fever, night sweats, weight loss, or hemoptysis — WHO 4-symptom screen (ATS/CDC/IDSA 2016 Nahid; WHO 2024); Hemoptysis + subacute constitutional illness in endemic-country / IDU / homeless / HCW / HIV+ host (ATS/CDC/IDSA 2016 Nahid); Upper-lobe / apical cavitation or reactivation pattern on CXR (ATS/CDC/IDSA 2016 Nahid).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Pulmonary Tuberculosis (Drug-Susceptible)** (id.tb-pulmonary.v1).
Phenotype framing: Active pulmonary TB vs LTBI (IGRA/TST+ asymptomatic, normal CXR, micro-negative) vs NTM (non-cavitary bronchiectasis, repeated Xpert-neg AFB-pos) vs bacterial CAP / lung abscess (acute, lobar, β-lactam-responsive) vs lung cancer (mass, smoker, micro-neg) vs endemic fungal histo / cocci / blasto (travel, urine antigen) vs sarcoidosis (bilateral hilar adenopathy, non-caseating granulomas, micro-neg) vs lymphoma vs GPA. Pivots: Xpert Ultra sens/spec, AFB-smear sens, IGRA vs TST in BCG-vaccinated, CXR cavitation/upper-lobe distribution (ATS/CDC/IDSA 2016 Nahid; Dorman Lancet ID 2018 PMID 29198911)
Scope: Adult drug-SUSCEPTIBLE pulmonary TB + LTBI in the id.* family. Drug-resistant TB is OWNED by id.tb_drug_resistant.v1 — route there on Xpert-RIF+ or MDR contact. Pediatric TB and TB meningitis are out of scope (route to pediatric / neuro siblings). Place patient in airborne (negative-pressure, N95) isolation the moment active pulmonary TB is suspected (ATS/CDC/IDSA 2016 Nahid; WHO 2024)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Drug-susceptible active TB + LTBI regimen ladder (ATS/CDC/IDSA 2016 Nahid; Study 31 Dorman NEJM 2021; PREVENT-TB Sterling NEJM 2011; CDC LTBI 2020; WHO 2024)**.
1. isoniazid Adult: 5 mg/kg/day PO (max 300 mg) daily for 6-mo standard regimen; 15 mg/kg twice/thrice weekly DOT; 4-mo regimen: standard daily INH × 4 mo; 3HP-LTBI: weight-banded 15 mg/kg weekly × 12 doses (max 900 mg) PO daily (intensive + continuation) or weekly (3HP) (tb_first_line_inh, first line) — ATS/CDC/IDSA 2016 Nahid PMID 27516382 — backbone of every drug-susceptible regimen. Bactericidal + sterilising. Pyridoxine 25–50 mg/d MANDATORY co-administration to prevent peripheral neuropathy. Hepatotoxicity baseline + symptom-driven LFT monitoring; hold for ALT >3× ULN symptomatic or >5× ULN asymptomatic.
2. rifampin Adult: 10 mg/kg/day PO (max 600 mg) daily for both intensive and continuation phases of 6-mo regimen; 4R-LTBI alternative: 10 mg/kg/d × 4 mo. Substitute rifabutin if PI-based or some INSTI-based ART PO daily (tb_first_line_rifamycin, first line) — ATS/CDC/IDSA 2016 Nahid — sterilising backbone of all rifamycin-containing regimens. Major CYP3A4 inducer — DDI with HIV ART (PI, some INSTI), anticoagulants, oral contraceptives, calcineurin inhibitors, statins, anticonvulsants. Orange-discolours secretions (counsel). Hepatotoxic; flu-like syndrome on intermittent dosing.
3. pyrazinamide Adult weight-banded: 40–55 kg → 1000 mg/d; 56–75 kg → 1500 mg/d; 76–90 kg → 2000 mg/d (max 2 g daily). 2-mo intensive phase only of 6-mo regimen; full 4 mo of the Dorman 2021 4-mo rifapentine+moxi regimen PO daily (tb_first_line_pza, first line) — ATS/CDC/IDSA 2016 Nahid — accelerates 2-mo culture conversion; sterilising. Hepatotoxic; hyperuricaemia (usually asymptomatic — do not treat unless gout flare). Renal-adjust: CrCl<30 → 25–35 mg/kg 3×/wk post-dialysis. AVOID in pregnancy in some guidelines (acceptable per WHO 2024 / ATS 2016 — limited teratogenicity data; benefits > risks).
4. ethambutol Adult weight-banded: 40–55 kg → 800 mg/d; 56–75 kg → 1200 mg/d; 76–90 kg → 1600 mg/d (max 1.6 g daily). 2-mo intensive only; DROP once DST confirms pan-susceptibility PO daily (tb_first_line_etb, first line) — ATS/CDC/IDSA 2016 Nahid — added pending DST to cover unsuspected INH resistance; bacteriostatic. Optic neuritis (dose- and duration-dependent) — baseline Snellen + Ishihara, monthly while on therapy; hold immediately for any visual change. Renal-adjust: CrCl<30 → 15–25 mg/kg 3×/wk post-dialysis. (SAFETY-CRITICAL: prompt-seed RxCUI 4083 was ESTRADIOL — corrected to 4110 via RxNav reverse lookup 2026-05-26.)
5. rifapentine 4-mo Dorman 2021 regimen: 1200 mg PO daily × 2 mo intensive + × 2 mo continuation (long half-life rifamycin component). 3HP-LTBI: weight-banded once-weekly (32.1–49.9 kg → 750 mg; ≥ 50 kg → 900 mg) × 12 doses PO daily (Dorman 4-mo) or weekly (3HP) (tb_first_line_rifamycin_long_half_life, first line) — Dorman NEJM 2021 PMID 33951360 — INH+rifapentine+moxi+PZA × 2 mo → INH+rifapentine+moxi × 2 mo NON-INFERIOR (TB cure 84.6% vs 85.4% for 6-mo regimen). Sterling NEJM 2011 PMID 22150035 — 3HP LTBI completion 82.1% vs 9H 69.0%, TB development 0.19% vs 0.43%, hepatotoxicity 0.4% vs 2.7%. CYP3A4 inducer (caution with ART).
6. rifabutin Adult: 300 mg PO daily as substitute for rifampin when PI-based or some INSTI-based ART; dose adjust per concurrent ART per DHHS table PO daily (tb_first_line_rifamycin_alt, first line) — ATS/CDC/IDSA 2016 Nahid — weaker CYP3A4 induction than rifampin; preferred rifamycin with PI ART. Uveitis (dose-related), leukopenia, polyarthralgia. (SAFETY-CRITICAL: prompt-seed 9383 was empty {} — corrected to 55672 via RxNav reverse lookup 2026-05-26.)
7. moxifloxacin 400 mg PO daily — component of Dorman 2021 4-mo regimen × 4 mo total PO daily (fluoroquinolone, first line) — Dorman NEJM 2021 PMID 33951360 — non-inferior 4-mo regimen anchor. QTc prolongation (avoid with class IA/III antiarrhythmics, methadone, ondansetron); tendinopathy / tendon rupture (age, steroids, transplant); CNS effects. Avoid in pregnancy + age <18 yr unless no alternative.
8. pyridoxine 25–50 mg PO daily — MANDATORY co-administration with every INH-containing regimen PO daily (vitamin_b6, first line) — ATS/CDC/IDSA 2016 Nahid — prevents INH-induced peripheral neuropathy (B6 antagonism); strongly recommended for pregnancy, breastfeeding, HIV, alcohol-use disorder, DM, uraemia, malnutrition, seizure history. (SAFETY-CRITICAL: prompt-seed 8696 was empty {} — corrected to 684879 via RxNav reverse lookup 2026-05-26.)
9. dexamethasone TB meningitis only: dexamethasone 0.4 mg/kg/day IV taper over 6–8 wk (NOT for routine pulmonary disease) IV/PO tapered (corticosteroid, rescue) — ATS/CDC/IDSA 2016 Nahid; Thwaites NEJM 2004 (TB meningitis adjunct) — survival benefit in TB meningitis only. NOT used for routine pulmonary TB. Severe paradoxical TB-IRIS post-ART start may warrant short-course steroids per DHHS OI 2024.
10. prednisolone TB pericarditis: prednisolone 120 mg/d taper over 6 wk per IMPI 2014 (not for pulmonary disease) PO tapered (corticosteroid, rescue) — IMPI Mayosi NEJM 2014 — prednisolone in TB pericarditis reduced constrictive pericarditis + hospitalisation; effect modest, did not lower mortality. HIV+: increased Kaposi sarcoma signal observed. NOT for routine pulmonary TB. (Verified RxCUI 8638 = prednisolone IN; distinguished from prednisone 8635.)

Setting playbook (outpatient) — Deliver continuation-phase RIPE → INH+RIF (or 4-mo Dorman regimen) via DOT; monthly sputum smear+culture until 2 consecutive negatives; LFT + visual + adherence monitoring; complete contact investigation + LTBI treatment for screened contacts; ART coordination if HIV+
11. continuation INH + rifampin × 4 mo (or × 7 mo if cavitary + month-2 culture+) INH 5 mg/kg + rifampin 10 mg/kg PO daily DOT (or 2–3×/wk DOT in low-risk) PO daily (or 2–3×/wk DOT) — Completion of 2-mo intensive phase + sputum conversion (ATS/CDC/IDSA 2016 Nahid)
12. 3HP for LTBI in contacts (preferred) Rifapentine weight-banded once-weekly (32.1–49.9 kg → 750 mg; ≥ 50 kg → 900 mg) + INH 15 mg/kg (max 900 mg) × 12 doses PO weekly × 12 — Contact screened with positive IGRA/TST + active disease excluded (Sterling NEJM 2011 PMID 22150035 (PREVENT-TB) — 3HP non-inferior to 9H with better completion + less hepatotoxicity; CDC LTBI 2020 preferred regimen)
13. continued pyridoxine 25–50 mg/d 25–50 mg PO daily PO daily — Any INH-containing regimen (ATS/CDC/IDSA 2016 Nahid)

Non-pharmacologic actions:
- DOT (or video DOT) for every dose throughout continuation (Nahid 2016)
- Public-health case-manager engagement until cure / completion documented
- Contact investigation + IGRA/TST screening + LTBI treatment offers (CDC LTBI 2020)
- Counsel on rifampin DDIs — esp. OCP failure, anticoagulant adjustment, ART changes
- Counsel on relapse precautions (recurrent cough / fever / weight loss within 6–12 mo of completion)
- Adherence + DOT-buddy support; address food insecurity / housing / SUD with case manager (Nahid 2016)

AVOID / contraindication checks:
- Airborne isolation N95 negative pressure mandatory from active TB suspicion until 3 consecutive AFB smear negative and clinical improvement (CDC TB IC 2005; ATS/CDC/IDSA 2016 Nahid)
- Rifampin major CYP3A4 inducer DDI with HIV PI and some INSTI ART anticoagulants oral contraceptives calcineurin inhibitors statins anticonvulsants substitute rifabutin or adjust (DHHS 2024 ART; ATS/CDC/IDSA 2016 Nahid)
- Rifampin and rifapentine orange discolouration of secretions counsel (DailyMed)
- Isoniazid pyridoxine 25 to 50 mg daily mandatory co administration especially pregnancy breastfeeding HIV alcohol DM uremia seizure history (ATS/CDC/IDSA 2016 Nahid)
- Pyrazinamide hepatotoxicity and asymptomatic hyperuricaemia do not treat unless gout flare (ATS/CDC/IDSA 2016 Nahid)
- Pyrazinamide renal adjust CrCl below 30 give 3 times weekly post dialysis (ATS/CDC/IDSA 2016 Nahid)
- Ethambutol optic neuritis baseline Snellen Ishihara and monthly monitoring hold immediately for any visual change (ATS/CDC/IDSA 2016 Nahid)
- Ethambutol renal adjust CrCl below 30 give 3 times weekly post dialysis (ATS/CDC/IDSA 2016 Nahid)
- Moxifloxacin QTc prolongation and tendinopathy avoid in pregnancy and age under 18 unless no alternative (DailyMed; ATS/CDC/IDSA 2016 Nahid)
- Streptomycin contraindicated in pregnancy fetal ototoxicity (ATS/CDC/IDSA 2016 Nahid)
- Hold INH RIF PZA if ALT greater than 3x ULN symptomatic or 5x ULN asymptomatic rechallenge sequentially (ATS/CDC/IDSA 2016 Nahid)
- HIV coinfection ART within 2 wk if CD4 below 50 within 8 wk otherwise substitute rifabutin for PI based ART (SAPIT/STRIDE/CAMELIA; DHHS 2024 ART)
- Adjunctive corticosteroids only for TB meningitis or TB pericarditis not routine pulmonary disease (ATS/CDC/IDSA 2016 Nahid; Thwaites 2004; IMPI Mayosi 2014)
- Routing rifampin resistance on Xpert or confirmed MDR contact route id tb drug resistant v1 (WHO 2024; ATS/CDC/IDSA 2016 Nahid)

Monitoring

Regimen monitoring:
- monthly sputum smear and culture until two consecutive negative cultures (ATS/CDC/IDSA 2016 Nahid)
- month 2 culture is the key conversion endpoint positive with cavitation extends continuation to 7 months (ATS/CDC/IDSA 2016 Nahid)
- baseline LFT then symptom driven or monthly in hepatic risk HBV HCV HIV alcohol pregnancy (ATS/CDC/IDSA 2016 Nahid)
- monthly Snellen and Ishihara while on ethambutol (ATS/CDC/IDSA 2016 Nahid)
- pyridoxine adherence check each visit (ATS/CDC/IDSA 2016 Nahid)
- monthly weight for re dosing (ATS/CDC/IDSA 2016 Nahid)
- IRIS surveillance first 3 months of ART in HIV coinfection (DHHS 2024 OI; SAPIT/STRIDE/CAMELIA)
- DOT adherence each encounter video DOT acceptable (ATS/CDC/IDSA 2016 Nahid)
- end of treatment culture for cure documentation (ATS/CDC/IDSA 2016 Nahid; WHO 2024)

Setting (outpatient) monitoring:
- Monthly DOT + clinical + adherence check (Nahid 2016)
- Monthly sputum smear + culture until 2 consecutive negatives
- Symptom-driven LFT (monthly if hepatic risk)
- Monthly Snellen + Ishihara while on ETB
- Pyridoxine adherence
- End-of-treatment culture for cure documentation (Nahid 2016; WHO 2024)

Follow-up plan: End-of-treatment cure assessment per WHO/ATS (culture-negative at end of therapy; treatment-completed if doses verified). Close-contact investigation → IGRA / TST + symptom screen + LTBI evaluation/treatment (CDC LTBI 2020 Sterling — 3HP preferred). Mandatory public-health reporting and case closure. Adherence + relapse education; relapse usually within 6–12 mo (highest if cavitary + month-2 culture+). Long-term follow-up for late toxicity and post-TB lung function (Nahid 2016 PMID 27516382; CDC LTBI 2020)
- Close-out criterion: Cure / completion documented + contact tracing + reporting complete

Monitoring phase: Sputum smear + culture monthly until 2 consecutive negative cultures (month-2 culture is the key conversion endpoint; positive at 2 mo with cavitation → extend continuation to 7 mo for 9-mo total). LFT at baseline then symptom-driven (monthly if hepatic risk / HBV / HCV / HIV / alcohol / pregnancy) — hold INH/RIF/PZA if ALT >3× ULN symptomatic or >5× ULN asymptomatic. Snellen + Ishihara monthly on ETB. Pyridoxine adherence each visit. ART + IRIS surveillance first 3 mo of ART. Monthly weight for re-dosing. DOT adherence each encounter (ATS/CDC/IDSA 2016 Nahid)

Disposition

Current setting: outpatient — Deliver continuation-phase RIPE → INH+RIF (or 4-mo Dorman regimen) via DOT; monthly sputum smear+culture until 2 consecutive negatives; LFT + visual + adherence monitoring; complete contact investigation + LTBI treatment for screened contacts; ART coordination if HIV+

Disposition criteria:
- Cure: end-of-treatment culture negative + all DOT doses verified + asymptomatic (Nahid 2016; WHO 2024)
- Treatment-completed: all DOT doses verified even if end-of-treatment culture not obtained (Nahid 2016)

Escalation triggers (move to higher acuity):
- Recurrent symptoms / new hemoptysis / weight loss during therapy → relapse vs failure → ED + ID urgent re-evaluation + repeat DST (Nahid 2016)
- Drug-induced hepatitis → hold + sequential rechallenge (Nahid 2016)
- ETB visual change → discontinue + ophthalmology (Nahid 2016)
- Adherence breach > 7 days → urgent case-manager intervention; consider regimen re-initiation per Nahid 2016 missed-dose algorithm

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Hemoptysis ≥ 200 mL/24 h with hemodynamic compromise OR respiratory failure / ARDS from extensive cavitary disease (ATS/CDC/IDSA 2016 Nahid)
- [LIFE_THREATENING] Miliary pattern on CXR/CT, hematogenous dissemination (blood-culture-positive mycobacteria), or TB meningitis features (subacute headache, AMS, CN palsies, basilar enhancement on MRI) (ATS/CDC/IDSA 2016 Nahid)
- [SEVERE] Xpert MTB/RIF (Ultra) detects rifampin resistance, OR confirmed contact with MDR-TB case, OR origin from high-resistance country (WHO 2024)

Citations

- ATS/CDC/IDSA 2016 Treatment of Drug-Susceptible Tuberculosis CPG (Nahid et al, Clin Infect Dis 2016 PMID 27516382) + WHO 2024 Consolidated Guidelines on Tuberculosis Treatment + CDC/NTCA LTBI 2020 (Sterling MMWR Recomm Rep 2020) — anchored by Study 31/A5349 (Dorman NEJM 2021 PMID 33951360), PREVENT-TB (Sterling NEJM 2011 PMID 22150035), and Xpert Ultra (Dorman Lancet ID 2018 PMID 29198911). [PMID:27516382](https://pubmed.ncbi.nlm.nih.gov/27516382/)
- Cited evidence (PMID 33951360) [PMID:33951360](https://pubmed.ncbi.nlm.nih.gov/33951360/)
- Cited evidence (PMID 22150035) [PMID:22150035](https://pubmed.ncbi.nlm.nih.gov/22150035/)
- Cited evidence (PMID 29198911) [PMID:29198911](https://pubmed.ncbi.nlm.nih.gov/29198911/)

Last reconciled with current guidelines: 2026-05-26.
References
  • ATS/CDC/IDSA 2016 Treatment of Drug-Susceptible Tuberculosis CPG (Nahid et al, Clin Infect Dis 2016 PMID 27516382) + WHO 2024 Consolidated Guidelines on Tuberculosis Treatment + CDC/NTCA LTBI 2020 (Sterling MMWR Recomm Rep 2020) — anchored by Study 31/A5349 (Dorman NEJM 2021 PMID 33951360), PREVENT-TB (Sterling NEJM 2011 PMID 22150035), and Xpert Ultra (Dorman Lancet ID 2018 PMID 29198911). — PMID:27516382
  • Cited evidence (PMID 33951360) — PMID:33951360
  • Cited evidence (PMID 22150035) — PMID:22150035
  • Cited evidence (PMID 29198911) — PMID:29198911