Tuberculosis Treatment Complete DRUGS – ATT (ANTITUBERCULAR TREATMENT)with MDR

Tuberculosis  Complete DRUGS –


Case definitions:

  • 1. Tuberculosis suspect : Any person with symp­toms or signsHepatitis Types Causes Symptoms Diagnosis and Treatment. Read more ... » suggestive of tuberculosis like cough more than 2 weeks.
  • 2. Case of tuberculosis: A patient in whom tuber­culosis is confirmed bacteriologically
  • 3. Definite case of tuberculosis : A patient with positive culture for M. tuberculosis complex or patient with 2 sputum smears showing AFB

History of treatment – Definitions for diagnosis:

  • 1. New -A patient who has never taken antituber­cular treatment or taken for less than a month.
  • 2. Relapse -A patient treated for TB and declared cured, or full treatment taken but smear or cul­ture for tuberculosis is positive.
  • 3. Treatment after failure – A patient given An again, after failed previous treatment
  • 4. Treatment after default – If a patient, bacterio­logically positive, interrupts treatment for 2 moths or more and starts An again.
  • 5. Transfer in – A patient transferred from another TB centre for continuation of treatment.
  • 6. Other – Any other case like chronicChronic Hepatitis Classification viral hepatitis Clinical features and Treatment. Read more ... » case, spu­tum positive at the end of repeat treatment.
  • Sometimes pulmonary and extra pulmonary relapse cases may be smear-negative.

ATT Abbreviations Tuberculosis :

Recommended Antituberculosis Treatment Regimens

  Initial Phase Continuation Phase
Indication Duration, Months Drugs Duration, Months Drugs
New smear- or culture-positive cases 2 HRZEa,b 4 HRa,c,d
New culture-negative cases 2 HRZEa 2 HRa
Pregnancy 2 HREe 7 HR
Failure and relapsef
Resistance (or intolerance) to H Throughout (6) RZEg
Resistance to H + R Throughout (12–18) ZEQ + S (or another injectable agenth)
Resistance to all first-line drugs Throughout (24) 1 injectable agenth + 3 of these 4: ethionamide, cycloserine, Q, PAS
Standardized re-treatment (susceptibility testing unavailable) 3 HRZESi 5 HRE
Drug intolerance to R Throughout (12)j HZE
Drug intolerance to Z 2 HRE 7 HR


  • cThe continuation phase should be extended to 7 months for patients with cavitary pulmonary tuberculosis who remain sputum culture–positive after the initial phase of treatment.
  • dHIV-negative patients with noncavitary pulmonary tuberculosis who have negative sputum AFB smears after the initial phase of treatment can be given once-weekly rifapentine/isoniazid in the continuation phase.

RUGS – ATT (ANTITUBERCULAR TREATMENT) There are 3 main properties of antituberculous drugs:

  • 1. Bactericidal action
  • 2 Sterilizing activity
  • 3-To prevent resistance.

The first line agents consist of Isoniazid, Rifampin, Pyrazinamide, Ethambutol.

  • These drugs are given orally, once a day.
  • Peak level is at 4 hours and effect lasts for 24 hours. Second line drugs have lower efficacy and more toxicity. These are streptomycin, kanamycin, amikacin, capreomycin, ethionamide, cycloserine, and PAS(Paraamino salicylic acid).
  • Other drugs are Ofloxacin, Levofloxacin, Gatifloxacin, Moxifloxacin, Clofazimine, thiacetazone, amoxycillin and linezolid.
  • Isoniazid and RifampicinRifampicin. Read more ... » are strong bactericidal drugs. Pyrazinamide and streptomycin are also bactericidal Streptomycin is bactericidal against rapidly multiply­ing tubercle bacilli.
  • Rifampicin is the most potent sterilizing drug. Ethambutol and thiocetazone prevent resistance to drugs.

Standard Treatment Regimens: Treatment is started with:

  • 1 st–  intensive phase for 2 months and
  • 2 nd– continuation phase for 4 – 6 months.

Intensive phase consists of Isoniazid, Rifampicin, Pyrazinamide, and EthambutoL.

This intensive phase results in rapid killing of tubercle bacilli.

Continuation phase consists of lesser drugs for longer time.

Retreatment Regimen:

  • For patients with smear or culture positive tuberculo­sis, 5 drugs in initial phase and 3 drugs in continua­tion phase should be given.
  • Rifampicin, Isonex, Ethambutol are given throughout the treatment.

Standard code for Anti- TB regimens  :

  • Each antitubercular drug has an abbreviation as fol­lows:
  • Rifampicin – R
  • Isoniazid – H
  • Pyrazinamide – Z
  • Streptomycin – S
  • Ethambutol – E
  • Thioacetazone – T.

Any regimen consists of :

  1. Initial phase
  2. Continuation phase
  • The number before a phase is duration of that phase in months.
  • Letters in brackets indicate the names of drugs.
  • A subscript after the letters in brackets indicates num­ber of doses per week. Eg. 2 (HRZE) / 4 (HR)3
  • This means that initial phase of 2 months consists of Isoniazid, Rifampicin, Pyrazinamide, Ethambutol. The

TB Diagnostic TB Patients Category

  • New smear positive patients; New smear negative PTB with extensive parenchymal involvement;
  • Severe concomitant HIV disease or severe forms of EPTB
  • Previously treated sputum smear-positive PTB :
  • – relapse;

treatment after interruption; treatment failure

  • New smear negative PTB (other than in Category I); Less severe forms of EPTB
  • Chronic and MDR – TB cases (still sputum positive after supervised re-treatment)

Treatment Regimen in Special Conditions  Pregnancy:


  • Streptomycin is unsafe. It is hepatotoxic to fetus and so should not be used in pregnancy.

Breastfeeding :

  • All drugs are safe. Baby can be given Isoniazid during infectious stage of mother and for 3 months after that.

Oral contraception:

  • Rifampicin interacts with oral contraceptives and de­creases their efficacy.

Liver disease:

  • Isoniazid, Rifampicin and Pyrazinamide can cause hepatitis.
  • Rifampicin is least toxic, but can cause cholestatic jaundice.
  • Pyrazinamide is most hepatotoxic.
  • Patients with chronic liver disease should not take Pyrazinamide.
  • In chronic liver disease patient can take isoniazid and rifampicin with streptomycin and etham­butol for 8 months.
  • In acuteGrave's disease Causes and Treatment. Read more ... » he(?atitis, treatment should be delayed till hepatitis resolves otherwise streptomycin and etham-
  • continuation phase is of 4 months consisting of Iso­niazid and Rifampicin given 3 times / week.

TB treatment regimens

  1. Initial phase (Daily Continuation phase
  2. or 3 times weekly) (Daily or 3 times weekly)a
  • Specially designed standardized or individualized regimens are suggested for this category
  • ethambutol can be given for 3 months and when hepatitis is resolved, isoniazid and rifampicin may be given.
  • If acute hepatitis does not resolve for many months then only Streptomycin and Ethambutol should be continued for 12 months.

Renal Failure:

  • In renal failure, Isoniazid, Rifampicin and Pyrazina­mide can be given in normal doses.
  • Pyridoxin should be given with Isoniazid to prevent peripheral neuropathy if renal failure patients.
  • Streptomycin and Ethambutol are avoided or given in low doses.
  • Thiocetazone should not be used.
  • Patients with renal failure should be on 2 HRZ / 4 HR.

HIV infected patients:

  • Thiocetazone is not given. Rest of the drugs can be given.

Chronic and MDR (Mutli-Drug Resistant) TB :

  • Chronic tuberculosis is a patient with tuberculosis who. is sputum-positive after standard treatment with es­sential drugs given for complete duration.
  • MDR TB is a patient who is Multi-Drug Resistant, i.e. who has active tuberculosis with bacilli resistant to at least Rifampicin and Isoniazid.


  • Anorexia, nausea, abdominal pain Joint pains.
  • Burning sensation in the feet
  • Orange j red urine
  • Pyrazinamide Isoniazid


  • Itching, skin rash Deafness (no wax on auroscopy) Dizziness (vertigo and nystagmus) Jaundice (other causesGrave's disease Causes and Treatment. Read more ... » excluded) hepatitis
  • Confusion (suspect drug induced acute liver failure if jaundice present)
  • Visual impairment (other causes excluded)
  • Shock, purpura, acute renal failure
  • Thioacetazone (SHRZ) Streptomycin
  • Isoniazid, Pyrazinamide, rifampicin
  • Reserved drugs for tuberculosis are Amikacin, Kapriomycin, Ciprofloxacin, Cycloserine, Ethionamide, Kanamycin, Ofloxacin, p-aminosalycilic acid.


  • Continue anti-TB drugs, check drug doses Give drugs with small meals or last thing at night
  • Aspirin
  • Pyridoxine 100 mg daily
  • Reassurance, Patients should be told when starting treatment that this commonly happens and is normal.

Stop responsible drug(s) Stop anti-TB drugs

  • Stop streptomycin use ethambutol
  • Stop anti-TB drugs
  • Urgent liver function tests and prothrombin time

Management of Drug Induced HepatitisToxic Hepatitis and Drug Induced Hepatitis Diagnosis and Treatment. Read more ... »:

  • Isoniazid, Pyrazinamide, Rifampicin, and rarely Etham­butol can damage the liver.
  • When a patient develops hepatitis during tubercular treatment, all An should be stopped till liver func­tion tests become normal, or An is not given for 2 weeks after jaundice has disappeared. Rifampicin can give rise to jaundice without hepatitis and symptoms.
  • For patients with drug-induced hepatitis Streptomy­cin, and Ethambutol may be given.

Anti Tuburculous Drug Isoniazid

  • • Highly bactericidal
  • · Given orally (1M also available)
  • · Dose 5 mgjkg or 300 mgjday
  • · Preventive dose 300 mgjday for 6 months
  • · Contraindications – Active liver disease,


  • In malnutrition, alcoholics, and diabetics, patient should be given pyridoxine 10 mgjday with Isoniazid.

Adverse Effects :

  • Peripheral neu ropathy Optic neuritis
  • Toxic psychosis Generalized convulsions Hepatitis.

Side effects :

  • Nausea
  • Vomiting Dizziness
  • Blurred vision Slurring of speech Seizures.

Rifampicin —

  • Strong bactericidal drug
  • Should be given 30 minutes before meals Dose is 10 m k or 150 – 600 mg daily
  • The drug causes red coloration of urine, tears, saliva, sweat, sputum and contact lenses. Contraindications:
  • Hypersensitivity Liver dysfunction.

Adverse effects :

  • Gastro-intestinal disturbances Fever
  • Flu-like syndrome Thrombocytopenia Skin rashes Exfoliative dermatitis Oliguria
  • Dyspnoea
  • Hemolytic anaemia
  • Hepatitis (which may be fatal).


  • Weak bactericidal, potent sterilizing activity. Dose – 30 mgLkgLQay.

Contraindications :

  • Hypersensitivity Hepatic impairment.

Adverse effects :

  • Gastrointestinal disturbances Increased serum transaminases Hyperuricemia
  • Gout
  • Arthralgia.

Streptomycin It is bactericidal.

  • Given by deep intramuscular injection.
  • Dose – 15 mg/kg/day or 750 mg – 1 gm /day. Contraindications :
  • Hypersensitivity Auditory nerve deafness Myasthenia gravis
  • Should not be used in pregnancy as it causes deafness and nephrotoxicity in the fetus.


Adverse effects :


  • Injection abscess Hypersensitivity
  • Impairment of vestibular function – Headache, vomiting, vertigo and tinnitus
  • Nephrotoxicity
  • Hemolytic anaemia
  • Aplastic anaemia
  • Agranulocytosis
  • Thrombocytopenia
  • Streptomycin should not be given to patients who are to receive neuromuscular blocking agents during anaesthesia.


Ethambutol —

  • Its role is to prevent emergence of resistant strains. Dose – 15 mgLl<g/daL



  • . Hypersensitivity
  • .• Optic neuritis
  • Creatinine clearance < 50 ml/min.


Adverse effects :


  • Optic neuritis – Visual impairment and loss of colour vision
  • Blindness
  • Peripheral neuritis

11 thoughts on “Tuberculosis Treatment Complete DRUGS – ATT (ANTITUBERCULAR TREATMENT)with MDR

  1. Uttam Kumar Dasgupta says:

    Please post recent developments in diagnosis and mangement of side-effects of ATT.

  2. mahendra bahadur chitrakar says:

    It is great things to know but I was seeking about to know mdrtb as i am one of the paitaint of mdrtb with deivaties. thanks

    • Now it is the latest Treatment of ATT (ANTITUBERCULAR TREATMENT)with MDR according to WHO as soon new updates will come ,I will Update the article.

  3. This is the best TB treatment according to WHO.

  4. Narendra says:

    My baby was given 4 month intensive treatment (3 drugs RHZ) instead of two month.Baby was 10 kg in wt at the time of start of treatment now she is 11 kg. My concern is what are the side effects of treatment and what should I do to minimize them.

  5. Viranjay Singh says:

    Dear Sir,

    Please post an article on the side affect and problems taking the medicine for MDR-TV, specilly with 1 medicine from line 1 and 4 from line 2.

  6. sir my mother is taking HRZE every morning empty stomach daily for wrist joint tb started since 20 days,now complaing of epigastric pain and giddiness after taking drugs,not able to contact her consulting dr as she is out of stn..kindly advice?

    • It is better to use any antacid tablet like ranitidine 150mg, with att drugs will be helpful because att drugs causes the gastritis some time.

  7. I am a TB patient taking medicine for TB ,last april 10 th my medications two month finished, the starting medicines are RCnex 650,ethmbatol-800, PZA-750 BD and benedone-20. after april 10 only iam takinig RCnrx-650 and benedone- 20 Is it correct medication? Can i continue this. How long time i have to take.

  8. SHAHID QUADRI says:

    which drug in HRZE causes skin rash

  9. subrata biswas says:

    my father aged 62 yrs getting Att treatment just started 4 days ago,he was suffering from fever long time(2 months) ,doctor at first treated with inj pipercillin with tazobactom after the failure of oflox and cefixime orally,patient few days after feel good ,but problem of fever came again then he treated with gram + antibiotic linezolide,after completing 6 days course patient became well and he finaly discharged from hospital with Att regimen as dr suggested ,my father has a history of TB 30 yrs ago,,,my father also has got a 4.3×3.3 cm size cyst in left kidney detected 15 days ago,dr suggested it would not create any problem,,,,,Now my father taking ATT regimen of first two months still suffering from fever ,my Q is why fever is coming again? is it common until medication is not completed/ please suggest.

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