10.4 Special situations

10.4.1 Women (pregnant or breastfeeding or of childbearing age) 

Pregnant and breastfeeding women should be treated without delay.

STRs are recommended except BPaLM/BPaL regimens due to limited data regarding the safety of pretomanid in this population.

Among endTB regimens, the preferred regimen is endTB1 as it includes only 4 drugs (instead of 5 for endTB2 and endTB3). 

Pregnant women

For more information on use of TB drugs in pregnant women, see Appendix 11. 

Pregnancy outcome and any congenital anomalies in the neonate should be documented.

Breastfeeding women

Use of infant formula is recommended as many second-line drugs should be avoided in breastfeeding women (Appendix 11). Mothers must be informed of its benefits and risks and provided with infant formula, clean water, fuel for boiling water and a heating device (stove, saucepan and bottles). They must also receive training on how to prepare and use the formula. When infant formula cannot be used safely, infants must be breastfed.

If the mother is smear-positive, mother-infant contact should be maintained, but kept to a minimum. Appropriate infection prevention and control measures should be taken during contact. Care of the infant should be largely entrusted to family members until the mother becomes smear-negative.

Women of childbearing age

A pregnancy test should be performed before starting treatment and, if necessary, repeated during treatment. A highly effective contraception method (e.g. intra-uterine device or implantable hormonal contraceptive) should be offered prior to starting treatment.

10.4.2 Children and adolescents

Children and adolescents should be treated without delay based on the index case resistance profile when DST is not available (e.g. clinically diagnosed TB, EPTB).

STRs are recommended except BPaLM/BPaL regimens in patients under 14 years due to limited evidence regarding appropriate dosing of pretomanid in this population[1]Citation 1.World Health Organization. WHO consolidated guidelines on tuberculosis.Module 5: management of tuberculosis in children and adolescents. Geneva: World Health Organization; 2022.https://apps.who.int/iris/rest/bitstreams/1414329/retrieve.

Children and adolescents generally tolerate DR-TB drugs well[2]Citation 2.The Sentinel Project for Pediatric Drug-Resistant Tuberculosis. Management of Drug-Resistant Tuberculosis in Children: A Field Guide. Boston, USA. November 2021, Fifth edition.http://sentinel-project.org/wp-content/uploads/2022/04/DRTB-Field-Guide-2021_v5.1.pdf.

Children with non-severe TB receiving an LTR can usually be treated for less than 18 months[1]Citation 1.World Health Organization. WHO consolidated guidelines on tuberculosis.Module 5: management of tuberculosis in children and adolescents. Geneva: World Health Organization; 2022.https://apps.who.int/iris/rest/bitstreams/1414329/retrieve. Some experts suggest that even severe TB could be treated for less than 18 months[2]Citation 2.The Sentinel Project for Pediatric Drug-Resistant Tuberculosis. Management of Drug-Resistant Tuberculosis in Children: A Field Guide. Boston, USA. November 2021, Fifth edition.http://sentinel-project.org/wp-content/uploads/2022/04/DRTB-Field-Guide-2021_v5.1.pdf.

10.4.3 Patients with malnutrition or risk of malnutrition

See Chapter 9.

10.4.4 Extrapulmonary tuberculosis

Patients with some forms of EPTB are not eligible for STRs (Section 10.2.1) and should be treated with an LTR as described in Section 10.2.2.

For patients with TB of the CNS, drug penetration into the CNS should be taken into account.

Table 10.5 – Choice of TB drugs for TB of the CNS[3]Citation 3.World Health Organization. WHO operational handbook on tuberculosis. Module 4: treatment - drug-resistant tuberculosis treatment, 2022 update. Geneva 2022.https://www.who.int/publications/i/item/9789240065116, [4]Citation 4.Sun F, Ruan Q, Wang J, Chen S, Jin J, Shao L, et al. Linezolid manifests a rapid and dramatic therapeutic effect for patients with life-threatening tuberculous meningitis. Antimicrob Agents Chemother. 2014;58(10):6297–301.
https://doi.org/10.1128/AAC.02784-14, [5]Citation 5.Thwaites GE, Bhavnani SM, Chau TTH, Hammel JP, Torok ME, Van Wart SA, et al. Randomized pharmacokinetic and pharmacodynamic comparison of fluoroquinolones for tuberculous meningitis. Antimicrob Agents Chemother. 2011;55(7):3244–53.
https://doi.org/10.1128/AAC.00064-11

If the regimen contains a carbapenem, use preferably meropenem in patients with TB meningitis (less risk of seizures than with imipenem/cilastatin).