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id.tb_drug_resistant.v1PRODUCTION
id.tb_drug_resistant.v1

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

infectious_diseasechronicsubacuteacuteadult
Hard-required inputs
0 / 15
Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Confirm MDR / pre-XDR / XDR via Xpert + DST + WGS; classify resistance pattern per WHO 2021 redefinition

Inputs
2
Actions
0
Advance rule
Set
Advance when

Resistance pattern documented

Patient inputs (19)

Drug doses; pregnancy considerations (WHO 2022)

Bedaquiline / pretomanid limited pregnancy data (WHO 2022 Module 4)

Resistance risk (WHO 2022)

DDI esp ART, QT-prolongers, MAOI for linezolid serotonergic (WHO 2022)

Diagnostic + monitoring conversion (WHO 2022)

Rapid resistance screen (WHO 2022 Xpert MTB/RIF Ultra + XDR recommendation)

Phenotypic DST gold standard (WHO 2022)

HIV co-infection alters regimen + ART interactions (WHO 2022)

Linezolid myelosuppression baseline (ZeNix NEJM 2022)

Bedaquiline / pretomanid hepatotox (Nix-TB NEJM 2020)

Drug dosing (WHO 2022)

QT correction — bedaquiline QT monitoring (WHO 2022)

Disease extent (WHO 2022)

Bedaquiline + moxifloxacin QT monitoring (WHO 2022 aDSM)

Linezolid optic neuropathy + ototoxicity baseline (ZeNix NEJM 2022; WHO 2022 aDSM)

Genotypic resistance (WHO 2022 LPA / WGS recommendation)

Cavitary, miliary, pleural (ATS/IDSA/CDC 2022)

TB meningitis / tuberculoma (ATS/IDSA/CDC 2022)

OI prophylaxis + ART timing (WHO 2022)

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

Severity triggers (10)

10 need judgement
  • informationallife_threateningtb_meningitis_or_miliary
    TB meningitis or miliary disease with confirmed MDR (IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelinezolid_optic_neuropathy
    Vision change, colour vision loss, or visual field change on linezolid (IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebedaquiline_qtc_prolongation
    QTc >500 ms or rising 60 ms on bedaquiline (IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelinezolid_myelosuppression
    Hgb drop ≥2 g/dL, ANC <500, plt <50K on linezolid (IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_with_drtb
    Pregnancy in MDR / pre-XDR / XDR-TB (IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehiv_coinfection_drtb
    HIV-positive patient with DR-TB (IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretreatment_failure_or_relapse
    Sputum culture not converting at 4 mo or relapse (IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereculture_non_conversion_at_2_months
    Sputum culture still positive at month 2 of BPaL/BPaLM (WHO 2022 — early marker of poor outcome)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverexdr_tb_individualized_regimen_required
    XDR-TB confirmed (MDR + FQ + LZD/BDQ resistance per WHO 2021 redefinition)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecontact_tracing_and_public_health_notification
    Every confirmed DR-TB case (active or latent in close contact) — public health notification and contact tracing required
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENTrequiredDrives dose adjustment
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Recommended regimen

BPaL / BPaLM 6-month short-course MDR/pre-XDR/XDR-TB (IDSA 2024)
axis: bpal_bpalm_short_course
Selected axis "BPaL / BPaLM 6-month short-course MDR/pre-XDR/XDR-TB (IDSA 2024)" by default fallback (first axis)
  • bedaquiline
    first line
    diarylquinoline
    400 mg daily × 2 wks then 200 mg three times weekly • PO • daily then 3×/wk
    triggers: MDR_TB, pre_XDR, XDR_TB
    Backbone of BPaL/BPaLM; QT prolonging (WHO 2022; Nix-TB NEJM 2020)
    rxcui 1364504
  • pretomanid
    first line
    nitroimidazole
    200 mg • PO • daily for 26 wks
    triggers: MDR_TB, pre_XDR, XDR_TB
    Nix-TB (NEJM 2020) / ZeNix (NEJM 2022); pretomanid + bedaquiline + linezolid 6 mo
    rxcui 2198359
  • linezolid
    first line
    oxazolidinone
    600 mg daily (or 1200 in severe per WHO 2022) • PO • daily
    triggers: MDR_TB, pre_XDR, XDR_TB
    ZeNix (NEJM 2022) — 600 mg × 26 wks balances efficacy + toxicity
    rxcui 190376
  • moxifloxacin
    add on
    fluoroquinolone
    400 mg • PO • daily
    triggers: MDR_TB_BPaLM_eligible_no_FQ_resistance
    TB-PRACTECAL (NEJM 2022) — added to BPaL as BPaLM for MDR-TB
    rxcui 139462
  • pyridoxine_b6
    add on
    vitamin
    50–100 mg • PO • daily
    triggers: linezolid_or_INH
    Reduces neuropathy (WHO 2022)
    rxcui 684879

outpatient playbook — drug actions (1)

  1. 1. BPaL or BPaLM
    per regimen • PO • per regimen
    trigger: MDR / pre-XDR / XDR (WHO 2022)
    WHO 2022; ZeNix NEJM 2022; TB-PRACTECAL NEJM 2022

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: TB with failed first-line treatment, contact with DR-TB, or DST showing INH + RIF resistance (WHO 2022 Module 4); Xpert MTB/RIF positive with rifampicin resistance (WHO 2022 rapid-diagnostics recommendation); Contact with confirmed MDR-TB case (WHO 2022 contact-investigation guidance).

Objective

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

Assessment

**Drug-resistant tuberculosis (MDR / pre-XDR / XDR)** (id.tb_drug_resistant.v1).
Phenotype framing: MDR vs pre-XDR vs XDR; mixed infection vs reinfection vs relapse (IDSA 2024)
Scope: Confirm MDR / pre-XDR / XDR via Xpert + DST + WGS; classify resistance pattern per WHO 2021 redefinition

No severity triggers fired against current inputs.

Plan

Regimen axis: **BPaL / BPaLM 6-month short-course MDR/pre-XDR/XDR-TB (IDSA 2024)**.
1. bedaquiline 400 mg daily × 2 wks then 200 mg three times weekly PO daily then 3×/wk (diarylquinoline, first line) — Backbone of BPaL/BPaLM; QT prolonging (WHO 2022; Nix-TB NEJM 2020)
2. pretomanid 200 mg PO daily for 26 wks (nitroimidazole, first line) — Nix-TB (NEJM 2020) / ZeNix (NEJM 2022); pretomanid + bedaquiline + linezolid 6 mo
3. linezolid 600 mg daily (or 1200 in severe per WHO 2022) PO daily (oxazolidinone, first line) — ZeNix (NEJM 2022) — 600 mg × 26 wks balances efficacy + toxicity
4. moxifloxacin 400 mg PO daily (fluoroquinolone, add on) — TB-PRACTECAL (NEJM 2022) — added to BPaL as BPaLM for MDR-TB
5. pyridoxine_b6 50–100 mg PO daily (vitamin, add on) — Reduces neuropathy (WHO 2022)

Setting playbook (outpatient) — DOT regimen, monitoring, contact tracing, HIV co-management (IDSA 2024)
6. BPaL or BPaLM per regimen PO per regimen — MDR / pre-XDR / XDR (WHO 2022) (WHO 2022; ZeNix NEJM 2022; TB-PRACTECAL NEJM 2022)

Non-pharmacologic actions:
- DOT (directly observed therapy) (IDSA 2024)
- Contact tracing (IDSA 2024)
- Infection control (mask, ventilation) (IDSA 2024)
- Vaccinations (avoid live in HIV/cd4) (IDSA 2024)

AVOID / contraindication checks:
- Bedaquiline QTc monitoring baseline and monthly (IDSA 2024)
- Pretomanid hepatotoxicity LFT q1m (IDSA 2024)
- Linezolid CBC q2w x8_then_q1m (IDSA 2024)
- Linezolid vision audiometry q1m (IDSA 2024)
- Linezolid MAOI serotonergic DDI (IDSA 2024)
- Moxifloxacin tendinopathy QTc (IDSA 2024)

Monitoring

Regimen monitoring:
- sputum culture monthly to conversion (IDSA 2024)
- CBC q2w x8 then q1m (IDSA 2024)
- LFT q1m (IDSA 2024)
- BMP K Mg q2w (IDSA 2024)
- ECG QTc baseline 2w 4w 8w then q1m (IDSA 2024)
- vision audiometry q1m on linezolid (IDSA 2024)

Setting (outpatient) monitoring:
- Per regimen schedule (IDSA 2024)

Follow-up plan: TB clinic monthly; contact tracing; HIV care; nutrition (WHO 2022)
- Close-out criterion: Follow-up booked

Monitoring phase: 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)

Disposition

Current setting: outpatient — DOT regimen, monitoring, contact tracing, HIV co-management (IDSA 2024)

Disposition criteria:
- Continue DOT (IDSA 2024)

Escalation triggers (move to higher acuity):
- Severe AE (vision loss, neuropathy, hepatitis, QTc) → adjust regimen (IDSA 2024)
- Treatment failure → DST + repeat workup (IDSA 2024)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] TB meningitis or miliary disease with confirmed MDR (IDSA 2024)
- [SEVERE] Vision change, colour vision loss, or visual field change on linezolid (IDSA 2024)
- [SEVERE] QTc >500 ms or rising 60 ms on bedaquiline (IDSA 2024)

Citations

- WHO 2022 consolidated guidelines on TB treatment (Module 4 drug-resistant) [PMID:32130813](https://pubmed.ncbi.nlm.nih.gov/32130813/)
- Cited evidence (PMID 36053506) [PMID:36053506](https://pubmed.ncbi.nlm.nih.gov/36053506/)
- Cited evidence (PMID 36546625) [PMID:36546625](https://pubmed.ncbi.nlm.nih.gov/36546625/)

Last reconciled with current guidelines: 2026-05-22.
References