MDR tuberculosis: When mycobacterium tuberculosis is resistant to both isoniazid and rifampicin

Treatment options: There are 3 regimes that can be individualized. Shorter (further divided into 2 regimes) and longer regimes. 

Shorter Regime:

• 1st shorter regime: 9-12 month regime: A total of 7 drugs are used for the intensive phase for a period of 4-6 months: Initially these 7 drugs are given for 4 months, then sputum studies are done, in case of a positive result, continue these drugs for 2 more months (Total of 6 months). These 7 drugs are as follows
  1. Bidaqualine: For initial 6 months irrespective of Sputum studies
  2. Levofloxacin/moxifloxacin
  3. Clofazimine
  4. Ethionamide
  5. Ethambutol
  6. Isoniazid (high dose)
  7. Pyrazinamide

4 drugs are given for the period of 5 months: these drugs are

1. Levofloxacin
2. Clofizamine
3. Pyrazinamide
4. Ethambutol

•  2nd shorter regime: 6-9 months:  BPal regime: It should be used when strict supervision can be done for adverse effects
  • Badequiline
  • Pretoaminid
  • Linezolid

Longer Regime: 18 months or more. Drugs are divided into 3 groups for the longer regime:

1. Group A: Levofloxacin/ moxifloxacin, Bidaquiline or linezolid
2. Group B: Clofazimine, Cycloserine or terizinidone
3. Group C: Ethambutol, Delamanid, pyrazinamide, imipenem-cilastatin or meropenem, Amikacin or streptomycin, Ethionamide, P-aminosalicylic acid

How to give a longer regime: 

1. For the initial 6 months: ​​​​​​​ Total 4 drugs: All 3 group A drugs plus 1of the group B drug
2. For the next 12 months:  Except bedaquiline, continue the rest of 3 drugs which were being given the initial 6 months
3. When medicine from group A or Group B can not be used, then drug from group C can be added to complete the regime

Indications of the longer regime: 

1. Pregnancy: regimes containing ethionamide/ aminoglycosides are contraindicated
2. Resistance to flouroquinolones
3. 2nd line drug has been used for more than 1 month and then discontinued
4. Extensive Tb: Bilateral cavitation or extensive parenchymal disease
5. If age is less than 6 years
6. Severe extrapulmonary tuberculosis:
   1. Tubercular meningitis
   2. Miliary tuberculosis
   3. If age is less than 15 years except lymph node TB