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pulm.tuberculosis.v1PRODUCTION
pulm.tuberculosis.v1

Tuberculosis (active drug-susceptible, MDR-TB, LTBI)

infectious_diseaseacutechronicadult
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Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Frame as subacute, REPORTABLE infectious disease. Differentiate active pulmonary TB vs latent TB infection vs prior-treated; scope is pulmonary DRUG-SUSCEPTIBLE TB + LTBI + diagnosis — DRUG-RESISTANT TB is owned by id.tb_drug_resistant.v1 (route on rifampin resistance / MDR contact). Place patient in airborne (negative-pressure) isolation the moment active pulmonary TB is suspected (WHO TB Module 4 2022; ATS/CDC/IDSA 2016 PMID 27516382)

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Active vs latent vs prior-treated established AND airborne isolation initiated if active suspected

Patient inputs (24)

Weight-band drug dosing + LTBI risk-benefit; the 4-month rifapentine-moxifloxacin regimen requires age ≥12 yr; pediatric regimens differ (Dorman NEJM 2021 PMID 33951360)

Streptomycin contraindicated (ototoxic); the 4-month rifapentine-moxifloxacin regimen lacks pregnancy safety data → default to 2HRZE/4HR; pyridoxine mandatory (ATS/CDC/IDSA 2016 PMID 27516382)

HIV testing MANDATORY in all TB; HIV alters regimen duration, ART timing (CD4-driven), rifamycin choice, and IRIS risk (ATS/CDC/IDSA 2016 PMID 27516382)

Prior treatment is the strongest acquired-resistance risk factor → drives DST urgency and the DR-TB route (WHO TB Module 4 2022)

Contact with a known MDR/pre-XDR case → route to id.tb_drug_resistant.v1 for empiric DR regimen pending DST (WHO DR-TB 2022)

Baseline hepatic risk for INH/RIF/PZA hepatotoxicity — drives baseline + serial LFT monitoring and a modified regimen if cirrhotic (ATS/CDC/IDSA 2016 PMID 27516382)

INH peripheral neuropathy — pyridoxine 25-50 mg/day mandatory; risk amplified in diabetes, HIV, alcohol, pregnancy, malnutrition, CKD (ATS/CDC/IDSA 2016 PMID 27516382)

RIFAMPIN is a strong CYP3A4/P-gp inducer — collapses levels of PIs/NNRTIs, DOACs, warfarin, hormonal contraceptives, methadone, azoles, corticosteroids; rifabutin substitute for PI-based ART (ATS/CDC/IDSA 2016 PMID 27516382)

Baseline Snellen + Ishihara colour vision before ethambutol (dose-dependent optic neuritis) (ATS/CDC/IDSA 2016 PMID 27516382)

Rapid molecular diagnosis + simultaneous rifampin-resistance call; Xpert Ultra overall sens ~88% / smear-neg-culture-pos ~63% vs culture; RIF+ → route DR-TB sibling (Dorman Lancet ID 2018 PMID 29198911)

AFB smear ×3 (≥1 early-morning) for infectiousness + culture (gold standard) + phenotypic DST; culture is the reference for cure and the month-2 conversion endpoint (ATS/CDC/IDSA 2016 PMID 27516382)

Baseline ALT/AST/bilirubin before INH/RIF/PZA; defines the ALT >3× ULN+symptoms / >5× ULN hold threshold (ATS/CDC/IDSA 2016 PMID 27516382)

eGFR/CrCl for renal interval-extension of ETB and PZA (ATS/CDC/IDSA 2016 PMID 27516382)

Baseline before linezolid (DR-TB sibling) and to track RIF-related cytopenias (WHO TB Module 4 2022)

MANDATORY in every TB case — drives ART timing, regimen, rifamycin choice, IRIS surveillance (ATS/CDC/IDSA 2016 PMID 27516382)

Upper-lobe / cavitary / miliary pattern; cavitation + positive month-2 culture predicts relapse and extends continuation (ATS/CDC/IDSA 2016 PMID 27516382)

Weight-band dosing — INH 5 mg/kg (max 300 mg), RIF 10 mg/kg (max 600 mg), PZA 25 mg/kg (max 2 g), ETB 15-25 mg/kg; re-dose monthly with weight gain (ATS/CDC/IDSA 2016 PMID 27516382)

Sub-radiographic / miliary / mediastinal-adenopathy disease; tree-in-bud; differentiates malignancy and NTM patterns (ATS/CDC/IDSA 2016 PMID 27516382)

ETB and PZA are renally cleared — extend the dosing interval to 3×/week (not dose reduction) if CrCl <30 or on hemodialysis; INH/RIF unchanged (ATS/CDC/IDSA 2016 PMID 27516382)

Diabetes ~2-3× higher treatment failure / relapse / mortality and slower culture conversion → tighter glycemic control + consider extended continuation (WHO TB Module 4 2022)

Latent TB diagnosis — IGRA preferred if BCG-vaccinated (avoids BCG false-positive TST); neither distinguishes LTBI from active disease (CDC LTBI 2020)

HBV/HCV co-infection multiplies drug-induced hepatotoxicity risk → tighter LFT cadence (ATS/CDC/IDSA 2016 PMID 27516382)

Diabetes screen — worse outcomes / slower conversion; affects drug-level monitoring (WHO TB Module 4 2022)

Baseline QTc only if the DR-TB sibling regimen (bedaquiline / moxifloxacin / delamanid) is anticipated (WHO DR-TB 2022)

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

Severity triggers (9)

9 need judgement
  • informationallife_threateningtb_meningitis_or_miliary_disease
    CSF / imaging consistent with TB meningitis OR miliary/disseminated TB
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverexpert_ultra_positive_rif_susceptible_high_prior
    Xpert MTB/RIF Ultra POSITIVE, rifampin-SUSCEPTIBLE, in a patient with a high pretest prior (TB symptoms + endemic origin/exposure ± HIV) — Xpert Ultra overall sens ~88% vs culture (smear-neg-culture-pos ~63%, HIV+ ~90%), specificity ~96%
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererifampin_resistance_route_to_dr_tb_sibling
    Xpert MTB/RIF Ultra reports RIFAMPIN RESISTANCE, OR DST confirms INH+RIF resistance, OR contact with a known MDR/pre-XDR case
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredrug_induced_hepatitis
    ALT >3× ULN with symptoms (nausea, RUQ pain, jaundice) OR ALT >5× ULN asymptomatic on a TB regimen
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereoptic_neuritis_on_ethambutol
    Decreased visual acuity / red-green colour deficit / central scotoma on ethambutol
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepersistent_culture_positivity_at_2_months
    Sputum culture POSITIVE at month 2 on a standard regimen (especially with baseline cavitation)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatefour_month_regimen_eligibility
    DS pulmonary TB in age ≥12 yr, weight ≥40 kg, NOT severe/extensive, NOT pregnant, HIV acceptable only if CD4 ≥100 on efavirenz-based ART
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateiris_in_hiv_coinfection
    Paradoxical worsening of TB symptoms/imaging after starting ART, within ~3 months (immune reconstitution inflammatory syndrome)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildigra_tst_positive_no_active_disease_ltbi
    Positive IGRA (or TST; IGRA preferred if BCG-vaccinated) WITHOUT symptoms, normal CXR, and negative microbiology — latent TB infection
    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

TB treatment by phenotype — DS-TB 6-month (2HRZE/4HR) vs 4-month rifapentine-moxifloxacin (Study 31) vs LTBI (3HP/4R/3HR/9H); DR-TB routed to id.tb_drug_resistant.v1
axis: tb_treatment_ladderstep active_drug_susceptible_6mo - Active drug-susceptible TB — standard 6-month 2HRZE/4HR (2-mo RIPE intensive → 4-mo INH+RIF continuation)
Selected step "Active drug-susceptible TB — standard 6-month 2HRZE/4HR (2-mo RIPE intensive → 4-mo INH+RIF continuation)" — Confirmed/probable drug-susceptible pulmonary or extrapulmonary TB; pregnant patients, severe/extensive disease, or anyone ineligible for the 4-month regimen — the universal default
  • isoniazid
    first line
    antimycobacterial_isonicotinic
    5 mg/kg PO daily (max 300 mg) • PO • daily × 6 months (intensive + continuation) (max: 300 mg/day)
    triggers: intensive_phase, continuation_phase
    Early-bactericidal backbone. Hepatotoxicity + dose-dependent peripheral neuropathy (pyridoxine MANDATORY). RxCUI corrected 1011→6038 RxNav-verified IN 2026-05-16 (1011 was anti-thymocyte globulin — SAFETY-CRITICAL) (ATS/CDC/IDSA 2016 PMID 27516382)
    rxcui 6038
  • rifampin
    first line
    antimycobacterial_rifamycin
    10 mg/kg PO daily (max 600 mg) • PO • daily on empty stomach × 6 months (max: 600 mg/day)
    triggers: intensive_phase, continuation_phase
    Sterilising backbone enabling the 6-month course. STRONG CYP3A4/P-gp inducer — collapses PI/NNRTI, DOAC, warfarin, hormonal-contraceptive, methadone, azole, steroid levels; substitute rifabutin (RxCUI 55672) for PI-based ART. Orange body fluids — counsel. RxCUI 9384 RxNav-verified IN 2026-05-16
    rxcui 9384
  • pyrazinamide
    first line
    antimycobacterial_pyrazine
    25 mg/kg PO daily (max 2000 mg) • PO • daily × 2 months (intensive phase only) (max: 2000 mg/day)
    triggers: intensive_phase
    Sterilising in the acidic intracellular milieu — its 2-month use is what permits a 6-month total. Hepatotoxic; hyperuricemia/arthralgia; renal interval-extension to 3×/week if CrCl <30. RxCUI 8987 RxNav-verified IN 2026-05-16
    rxcui 8987
  • ethambutol
    first line
    antimycobacterial_ethylenediamine
    15-25 mg/kg PO daily • PO • daily × 2 months (until pan-susceptibility confirmed) (max: per weight band)
    triggers: intensive_phase
    Companion drug preventing resistance amplification until INH/RIF susceptibility confirmed — DROP once DST shows full susceptibility. Dose-dependent optic neuritis — baseline + monthly Snellen/Ishihara; renal interval-extension if CrCl <30. RxCUI 4110 RxNav-verified IN 2026-05-16
    rxcui 4110
  • pyridoxine
    add on
    vitamin_b6
    25-50 mg PO daily • PO • daily for the entire INH-containing course
    triggers: any_isoniazid_use
    MANDATORY with INH to prevent peripheral neuropathy — risk amplified in diabetes, HIV, alcohol, pregnancy, malnutrition, CKD. RxCUI 684879 RxNav-verified IN 2026-05-16
    rxcui 684879

outpatient playbook — drug actions (6)

  1. 1. RIPE intensive phase (2HRZE)
    INH 5 mg/kg (max 300) + RIF 10 mg/kg (max 600) + PZA 25 mg/kg (max 2 g) + ETB 15-25 mg/kg • PO • daily × 2 months DOT
    trigger: Drug-susceptible (or pending DST) active TB
    Standard intensive phase (ATS/CDC/IDSA 2016 PMID 27516382)
  2. 2. INH+RIF continuation (4HR)
    INH 5 mg/kg + RIF 10 mg/kg • PO • daily × 4 months DOT
    trigger: Completion of intensive phase, DS confirmed
    2HRZE/4HR — total 6 months
  3. 3. 4-month rifapentine-moxifloxacin alternative
    INH 300 + rifapentine 1200 + moxifloxacin 400 + PZA 25 mg/kg × 8 wk → INH + rifapentine + moxifloxacin × 9 wk • PO • daily
    trigger: Eligible: age ≥12 yr, ≥40 kg, DS pulmonary TB, not severe, not pregnant
    Study 31 / A5349 (Dorman NEJM 2021 PMID 33951360) — non-inferior to 6-month regimen
  4. 4. pyridoxine 25-50 mg daily
    25-50 mg PO daily • PO • daily for the entire INH course
    trigger: Any INH use
    MANDATORY neuropathy prophylaxis
  5. 5. LTBI short regimen
    3HP (INH 15 mg/kg + rifapentine 750-900 mg weekly × 12) OR 4R OR 3HR • PO • per regimen
    trigger: IGRA/TST+ but no active disease
    3HP preferred — completion 82.1% vs 9H 69.0% (Sterling NEJM 2011 PMID 22150035)
  6. 6. ART coordination
    DTG- or efavirenz-based ART with rifampin (substitute rifabutin if PI-based) • PO • daily
    trigger: HIV co-infection
    ART within 2 wk if CD4 <50; within 8 wk otherwise (ATS/CDC/IDSA 2016 PMID 27516382)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Cough ≥2 weeks + weight loss + drenching night sweats + fever ± hemoptysis — WHO 4-symptom screen (sens ~70-90% for active pulmonary TB; lower in HIV) (WHO TB Module 4 2022); Upper-lobe / apical / cavitary / miliary infiltrate on CXR or CT — cavitation raises pretest probability and predicts relapse (ATS/CDC/IDSA 2016 PMID 27516382); Positive Xpert MTB/RIF Ultra or AFB smear / mycobacterial culture from sputum — Xpert Ultra overall sens ~88% vs culture (Dorman Lancet ID 2018 PMID 29198911).

Objective

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

Assessment

**Tuberculosis (active drug-susceptible, MDR-TB, LTBI)** (pulm.tuberculosis.v1).
Phenotype framing: §5.5.2 — active pulmonary TB vs LTBI (IGRA/TST+ but asymptomatic, normal CXR, micro-negative) vs NTM (non-cavitary bronchiectasis, Xpert-negative repeated AFB+) vs bacterial CAP (acute, lobar, responds to β-lactam → pulm.cap.core.v1) vs lung cancer (mass, smoker, no micro → onc.lung-cancer.core.v1) vs endemic fungal histo/cocci/blasto (travel/endemic, urine antigen → id.invasive-aspergillosis.core.v1 for invasive-mould overlap) vs sarcoidosis (bilateral hilar adenopathy, non-caseating granulomas, micro-negative → pulm.sarcoidosis.v1) vs lymphoma. Pivots: Xpert Ultra sens/spec, AFB-smear sens, IGRA vs TST in BCG-vaccinated, CXR cavitation/upper-lobe distribution, urine fungal antigen (ATS/CDC/IDSA 2016 PMID 27516382; Dorman Lancet ID 2018 PMID 29198911)
Scope: Frame as subacute, REPORTABLE infectious disease. Differentiate active pulmonary TB vs latent TB infection vs prior-treated; scope is pulmonary DRUG-SUSCEPTIBLE TB + LTBI + diagnosis — DRUG-RESISTANT TB is owned by id.tb_drug_resistant.v1 (route on rifampin resistance / MDR contact). Place patient in airborne (negative-pressure) isolation the moment active pulmonary TB is suspected (WHO TB Module 4 2022; ATS/CDC/IDSA 2016 PMID 27516382)

No severity triggers fired against current inputs.

Plan

Regimen axis: **TB treatment by phenotype — DS-TB 6-month (2HRZE/4HR) vs 4-month rifapentine-moxifloxacin (Study 31) vs LTBI (3HP/4R/3HR/9H); DR-TB routed to id.tb_drug_resistant.v1** — step "Active drug-susceptible TB — standard 6-month 2HRZE/4HR (2-mo RIPE intensive → 4-mo INH+RIF continuation)".
1. isoniazid 5 mg/kg PO daily (max 300 mg) PO daily × 6 months (intensive + continuation) (antimycobacterial_isonicotinic, first line) — Early-bactericidal backbone. Hepatotoxicity + dose-dependent peripheral neuropathy (pyridoxine MANDATORY). RxCUI corrected 1011→6038 RxNav-verified IN 2026-05-16 (1011 was anti-thymocyte globulin — SAFETY-CRITICAL) (ATS/CDC/IDSA 2016 PMID 27516382)
2. rifampin 10 mg/kg PO daily (max 600 mg) PO daily on empty stomach × 6 months (antimycobacterial_rifamycin, first line) — Sterilising backbone enabling the 6-month course. STRONG CYP3A4/P-gp inducer — collapses PI/NNRTI, DOAC, warfarin, hormonal-contraceptive, methadone, azole, steroid levels; substitute rifabutin (RxCUI 55672) for PI-based ART. Orange body fluids — counsel. RxCUI 9384 RxNav-verified IN 2026-05-16
3. pyrazinamide 25 mg/kg PO daily (max 2000 mg) PO daily × 2 months (intensive phase only) (antimycobacterial_pyrazine, first line) — Sterilising in the acidic intracellular milieu — its 2-month use is what permits a 6-month total. Hepatotoxic; hyperuricemia/arthralgia; renal interval-extension to 3×/week if CrCl <30. RxCUI 8987 RxNav-verified IN 2026-05-16
4. ethambutol 15-25 mg/kg PO daily PO daily × 2 months (until pan-susceptibility confirmed) (antimycobacterial_ethylenediamine, first line) — Companion drug preventing resistance amplification until INH/RIF susceptibility confirmed — DROP once DST shows full susceptibility. Dose-dependent optic neuritis — baseline + monthly Snellen/Ishihara; renal interval-extension if CrCl <30. RxCUI 4110 RxNav-verified IN 2026-05-16
5. pyridoxine 25-50 mg PO daily PO daily for the entire INH-containing course (vitamin_b6, add on) — MANDATORY with INH to prevent peripheral neuropathy — risk amplified in diabetes, HIV, alcohol, pregnancy, malnutrition, CKD. RxCUI 684879 RxNav-verified IN 2026-05-16

Setting playbook (outpatient) — Public-health-coordinated DOT delivery of the standard 6-month or 4-month DS-TB regimen (or an LTBI short regimen), toxicity surveillance, adherence support, HIV co-treatment, and complete contact tracing — the default care setting for stable DS-TB
6. RIPE intensive phase (2HRZE) INH 5 mg/kg (max 300) + RIF 10 mg/kg (max 600) + PZA 25 mg/kg (max 2 g) + ETB 15-25 mg/kg PO daily × 2 months DOT — Drug-susceptible (or pending DST) active TB (Standard intensive phase (ATS/CDC/IDSA 2016 PMID 27516382))
7. INH+RIF continuation (4HR) INH 5 mg/kg + RIF 10 mg/kg PO daily × 4 months DOT — Completion of intensive phase, DS confirmed (2HRZE/4HR — total 6 months)
8. 4-month rifapentine-moxifloxacin alternative INH 300 + rifapentine 1200 + moxifloxacin 400 + PZA 25 mg/kg × 8 wk → INH + rifapentine + moxifloxacin × 9 wk PO daily — Eligible: age ≥12 yr, ≥40 kg, DS pulmonary TB, not severe, not pregnant (Study 31 / A5349 (Dorman NEJM 2021 PMID 33951360) — non-inferior to 6-month regimen)
9. pyridoxine 25-50 mg daily 25-50 mg PO daily PO daily for the entire INH course — Any INH use (MANDATORY neuropathy prophylaxis)
10. LTBI short regimen 3HP (INH 15 mg/kg + rifapentine 750-900 mg weekly × 12) OR 4R OR 3HR PO per regimen — IGRA/TST+ but no active disease (3HP preferred — completion 82.1% vs 9H 69.0% (Sterling NEJM 2011 PMID 22150035))
11. ART coordination DTG- or efavirenz-based ART with rifampin (substitute rifabutin if PI-based) PO daily — HIV co-infection (ART within 2 wk if CD4 <50; within 8 wk otherwise (ATS/CDC/IDSA 2016 PMID 27516382))

Non-pharmacologic actions:
- DOT (health-department or video DOT) for all active disease
- Adherence / housing / nutrition / transportation support
- Smoking cessation; alcohol-use-disorder treatment
- Contact tracing — close contacts → IGRA/TST + symptom screen + LTBI evaluation
- Mandatory public-health reporting
- Respiratory hygiene + masking education until smear-negative

AVOID / contraindication checks:
-  rifampin/rifapentine are STRONG CYP3A4/P gp inducers — review & adjust ART (substitute rifabutin for PI based), DOACs/warfarin, hormonal contraceptives, methadone, azoles, corticosteroids (ATS/CDC/IDSA 2016 PMID 27516382)
-  isoniazid hepatotoxicity — baseline LFT; hold INH/RIF/PZA if ALT >3× ULN with symptoms or >5× ULN asymptomatic; sequential rechallenge after normalisation (ATS/CDC/IDSA 2016 PMID 27516382)
-  pyrazinamide hepatotoxic + hyperuricemic — avoid/substitute in decompensated cirrhosis; renal interval extension if CrCl <30 (ATS/CDC/IDSA 2016 PMID 27516382)
-  ethambutol dose dependent optic neuritis — baseline + monthly Snellen/Ishihara; discontinue on any visual change; renal interval extension if CrCl <30 (ATS/CDC/IDSA 2016 PMID 27516382)
-  moxifloxacin/fluoroquinolone QTc prolongation + tendon/aortic/neuropathy/dysglycemia warnings — baseline ECG if other QT prolonging drugs (FDA; WHO TB Module 4 2022)
-  streptomycin CONTRAINDICATED in pregnancy (irreversible fetal ototoxicity); aminoglycoside renal + auditory monitoring (ATS/CDC/IDSA 2016 PMID 27516382)
-  pyridoxine 25 50 mg/day MANDATORY with any isoniazid containing regimen (ATS/CDC/IDSA 2016 PMID 27516382)
-  the 4 month rifapentine moxifloxacin regimen — NOT for pregnancy/breastfeeding, age <12 yr, weight <40 kg, severe/extensive disease, or HIV with CD4 <100 / non efavirenz ART (Dorman NEJM 2021 PMID 33951360)
-  rifampin causes harmless orange discolouration of body fluids — counsel to prevent non adherence; permanent staining of soft contact lenses (ATS/CDC/IDSA 2016 PMID 27516382)
- Renal: extend the dosing INTERVAL (3×/week) for ethambutol & pyrazinamide if CrCl <30 mL/min or hemodialysis — do NOT simply reduce the dose; INH/RIF unchanged (ATS/CDC/IDSA 2016 PMID 27516382)
- Hepatic: in established cirrhosis use a hepatotoxicity sparing regimen (e.g., RIF + ETB + a fluoroquinolone, ± reduced/omitted PZA) with intensive LFT monitoring (ATS/CDC/IDSA 2016 PMID 27516382)
-  rifampin resistance on Xpert / confirmed MDR — do NOT escalate here; ROUTE to id.tb_drug_resistant.v1 (BPaL/BPaLM owned there) (WHO DR TB 2022)

Monitoring

Regimen monitoring:
- sputum smear + culture monthly until two consecutive negatives; the MONTH-2 culture is the key conversion endpoint (positive + cavitation → extend continuation to 7 mo) (ATS/CDC/IDSA 2016 PMID 27516382)
- LFT baseline, then symptom-driven; monthly if hepatic risk / HBV / HCV / HIV / alcohol / pregnancy (ATS/CDC/IDSA 2016 PMID 27516382)
- Snellen + Ishihara colour vision monthly while on ethambutol (ATS/CDC/IDSA 2016 PMID 27516382)
- weight monthly for weight-band re-dosing (ATS/CDC/IDSA 2016 PMID 27516382)
- HIV test in ALL patients; if HIV+ — CD4 + viral load; ART within 2 wk if CD4 <50, within 8 wk otherwise (ATS/CDC/IDSA 2016 PMID 27516382)
- IRIS surveillance during the first 3 months of ART — continue both TB and ART; corticosteroid for severe IRIS (ATS/CDC/IDSA 2016 PMID 27516382)
- DOT (or video DOT) visits documented every dose for active disease; adherence review each LTBI visit (CDC LTBI 2020)
- QTc baseline + monthly ONLY if a DR-TB regimen (bedaquiline/moxifloxacin/delamanid) is anticipated — defer to id.tb drug resistant.v1 (WHO DR-TB 2022)
- glycemic control + A1c if diabetic — worse outcomes / slower conversion; consider extended continuation (WHO TB Module 4 2022)

Setting (outpatient) monitoring:
- Sputum smear + culture monthly until conversion (month-2 culture is the key endpoint) (ATS/CDC/IDSA 2016 PMID 27516382)
- LFT baseline then symptom-driven (monthly if hepatic risk) (ATS/CDC/IDSA 2016 PMID 27516382)
- Snellen + Ishihara monthly on ETB (ATS/CDC/IDSA 2016 PMID 27516382)
- Monthly weight for re-dosing (ATS/CDC/IDSA 2016 PMID 27516382)
- HIV CD4 + viral load; IRIS surveillance first 3 months of ART (ATS/CDC/IDSA 2016 PMID 27516382)

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

Monitoring phase: Sputum smear + culture monthly until two consecutive negative cultures (the month-2 culture is the key conversion endpoint; positive at 2 mo with cavitation → extend continuation). LFT at baseline then symptom-driven (monthly if hepatic risk/HBV/HCV/HIV/alcohol/pregnancy) — hold INH/RIF/PZA if ALT >3× ULN with symptoms or >5× ULN asymptomatic. Snellen + Ishihara monthly on ETB. Pyridoxine adherence. ART + IRIS surveillance during the first 3 months of ART. Monthly weight for re-dosing. DOT adherence each visit (ATS/CDC/IDSA 2016 PMID 27516382)

Disposition

Current setting: outpatient — Public-health-coordinated DOT delivery of the standard 6-month or 4-month DS-TB regimen (or an LTBI short regimen), toxicity surveillance, adherence support, HIV co-treatment, and complete contact tracing — the default care setting for stable DS-TB

Disposition criteria:
- Continue outpatient DOT if smear-negative trajectory, adherent, no severe toxicity, workable home plan (ATS/CDC/IDSA 2016 PMID 27516382)
- Admit if hemoptysis, miliary/meningeal/disseminated, severe immunocompromise, rifampin-resistance with infection-control risk, or unworkable DOT (ATS/CDC/IDSA 2016 PMID 27516382)

Escalation triggers (move to higher acuity):
- Positive culture at month 2 → re-DST + consider extended continuation + ID consult (ATS/CDC/IDSA 2016 PMID 27516382)
- Drug-induced hepatitis (ALT >3× ULN + symptoms or >5× ULN) → hold hepatotoxic agents + ID (ATS/CDC/IDSA 2016 PMID 27516382)
- New visual change on ETB → discontinue ETB + ophthalmology (ATS/CDC/IDSA 2016 PMID 27516382)
- Rifampin resistance on Xpert / confirmed MDR by DST → route id.tb_drug_resistant.v1 + admit if infection-control risk (WHO DR-TB 2022)
- Massive hemoptysis / miliary / meningeal disease → admit (ATS/CDC/IDSA 2016 PMID 27516382)

Patient Action Plan

**Tuberculosis adherence + toxicity monitoring action plan**
Personalised values: regimen_chosen, DOT_provider, public_health_contact, pharmacy_refill_dates, monitoring_lab_schedule.

**On track — taking every dose, no toxicity, sputum converting** (green):
Triggers:
- Taking medication every dose with DOT
- No new symptoms (jaundice, vision change, foot numbness, severe nausea)
- Sputum becoming smear-negative on schedule
Actions:
- Continue all medications as prescribed — even a few missed doses can drive resistance
- Attend all DOT visits and lab appointments
- Take pyridoxine (B6) every day if on isoniazid
- Wear a mask in public until your provider clears you

**Caution — early side effects or missed doses** (yellow):
Triggers:
- New mild nausea, appetite loss, joint pain (PZA), pins-and-needles in the feet (neuropathy)
- Reddish/orange tears, urine, sweat (rifampin — expected; confirm with provider)
- Mild rash; missed 1-2 doses
Actions:
- Call your provider or DOT nurse the same day
- Do not stop medication on your own — your provider will adjust
- Increase pyridoxine to 50 mg daily if foot numbness
- Bring a current medication + supplement list to the next visit
Contact provider when:
- Missed >2 doses
- New symptoms persisting >24 h
- Rash spreading or with fever

**Medical alert — drug toxicity or worsening TB** (red):
Triggers:
- Yellow eyes/skin (jaundice), dark urine, severe nausea/vomiting/abdominal pain
- Vision change — blurring, decreased acuity, red-green colour change (possible ethambutol toxicity)
- Worsening cough/breathlessness/fevers despite weeks of therapy
- Coughing up blood (hemoptysis)
- New seizures / confusion / severe headache
Actions:
- STOP medication and call your provider / DOT nurse immediately
- Go to the emergency department for jaundice, hemoptysis, vision change, severe abdominal pain, or new neurologic symptoms
- Bring all medication bottles with you
- Do not restart until cleared by your provider
Contact provider when:
- Any red-zone symptom — emergency department now, do not wait

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] CSF / imaging consistent with TB meningitis OR miliary/disseminated TB
- [SEVERE] Xpert MTB/RIF Ultra POSITIVE, rifampin-SUSCEPTIBLE, in a patient with a high pretest prior (TB symptoms + endemic origin/exposure ± HIV) — Xpert Ultra overall sens ~88% vs culture (smear-neg-culture-pos ~63%, HIV+ ~90%), specificity ~96%
- [SEVERE] Xpert MTB/RIF Ultra reports RIFAMPIN RESISTANCE, OR DST confirms INH+RIF resistance, OR contact with a known MDR/pre-XDR case

Citations

- WHO Consolidated Guidelines on TB Module 4: Treatment — drug-susceptible TB & patient care (2022) + ATS/CDC/IDSA Treatment of Drug-Susceptible Tuberculosis (Nahid CID 2016; PMID 27516382) + CDC 2022 4-month rifapentine-moxifloxacin update (Study 31/A5349) + CDC/NTCA LTBI Treatment Guidelines 2020 + WHO LTBI consolidated guidelines 2024 [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/)
- Cited evidence (PMID 36546625) [PMID:36546625](https://pubmed.ncbi.nlm.nih.gov/36546625/)

Last reconciled with current guidelines: 2026-05-16.
References
  • WHO Consolidated Guidelines on TB Module 4: Treatment — drug-susceptible TB & patient care (2022) + ATS/CDC/IDSA Treatment of Drug-Susceptible Tuberculosis (Nahid CID 2016; PMID 27516382) + CDC 2022 4-month rifapentine-moxifloxacin update (Study 31/A5349) + CDC/NTCA LTBI Treatment Guidelines 2020 + WHO LTBI consolidated guidelines 2024 — PMID:27516382
  • Cited evidence (PMID 33951360) — PMID:33951360
  • Cited evidence (PMID 22150035) — PMID:22150035
  • Cited evidence (PMID 29198911) — PMID:29198911
  • Cited evidence (PMID 36546625) — PMID:36546625