A joint panel of international experts has issued guidelines recommending shorter, all-oral drug regimens for drug-susceptible (DS) and drug-resistant (DR) tuberculosis (TB) in adults and children.

The guidelines, issued by the American Thoracic Society, the US Centers for Disease Control and Prevention, the European Respiratory Society, and the Infectious Diseases Society of America and published this week in the American Journal of Respiratory and Critical Care Medicine, are based on reviews of recent clinical trial data and adapted from the World Health Organization's (WHO's) 2022 consolidated guidelines on TB. The joint panel included 25 specialists in pulmonary medicine, infectious diseases, pediatrics, epidemiology, and public health, along with a patient advocate.

The new DS-TB recommendations include a novel, 4-month regimen of isoniazid, rifapentine, moxifloxacin, and pyrazinamide for adults with isoniazid- and rifampin-susceptible TB, and a 4-month regimen of isoniazid, rifampin, pyrazinamide, and ethambutol for children with nonsevere, isoniazid- and rifampin-susceptible TB. Both recommendations replace the standard 6-month regimens.

For the treatment of rifampin- and fluoroquinolone-resistant TB in adults and children, the guidelines call for a 6-month bedaquiline, pretomanid, and linezolid (BPaL) regimen to replace the 15-month or longer regimens previously used for DR-TB. The BPaL regimen is also recommended for adults and children who have rifampin-resistant, fluoroquinolone-susceptible TB.

The BPaL regimen has been recommended by the WHO for patients with DR-TB since 2022, based on clinical trial data showing significantly higher efficacy than the 15-month or longer regimens, which also included injectable drugs with severe and painful side effects. 

Fewer pills, adverse effects

While calling for further studies on the cost-effectiveness, acceptability, and feasibility of the shorter regimens, the panelists say the recommendations should be well-received by clinicians and TB patients.

"Shorter treatment duration, oral regimens, reduced number of medications, reduced pill burden, and less adverse drug effects are valued by patients and providers," they wrote. "Individuals with DS-TB may be eligible for effective regimens that reduce treatment duration by one-third. For DR-TB, new all-oral 6-month regimens are more effective and safer than SoC [standard of care] regimens used for decades and may reduce morbidity and mortality."

A population-based cohort study in the United Kingdom found that penicillin allergy labels are common, and that patients with penicillin allergies are more likely to receive alternative broad-spectrum antibiotics and have a higher risk of adverse events, researchers reported yesterday in the Journal of Infection.

Using the IQVIA Medical Research Data UK database, a team led by researchers with the University College of London examined the incidence and prevalence of penicillin and other antibiotic allergy label records among UK adults from 2000 through 2018. They also looked at the characteristics associated with receiving a penicillin allergy label and compared the risks of resistant infections and adverse events between patients with and without allergy labels.

Of the 2,393,072 patients at general practices who received a new penicillin prescription during the study period, 15,377 received a penicillin allergy label and 2,342,298 had no allergy recorded. The incidence of penicillin allergy label records gradually increased, from 0.22% in 2000 to 0.46% in 2004, then decreased over the following 10 years to 0.2% and remained below this level until 2018. Prevalence increased from 4.77% in 2000 to a peak of 8.25% in 2011, then reduced to 7.59% by 2018. 

Older age, being female, living in less deprived areas, belonging to a larger general practice, and having co-morbidities were associated with a higher chance of receiving a penicillin or other antibiotic allergy label. 

Increased risk of resistant infections, adverse events

Patients with antibiotic allergy labels were more likely to receive alternative broad-spectrum antibiotics, including clindamycin (incidence rate ratio [IRR], 5.99; 95% confidence interval [CI], 4.31 to 8.33) and macrolides (IRR, 5.69; 95% CI, 5.49 to 5.89) and had a higher risk of infection with methicillin-resistant Staphylococcus aureus (hazard ratio [HR], 1.21; 95% CI, 1.01 to 1.55) and Clostridioides difficile (HR, 1.66; 95% CI, 1.28 to 2.15).

"Penicillin allergy is a common contraindication to the use of this critical class of antibiotics, forcing clinicians to use alternative treatments, and putting patients at increased risk of AMR [antimicrobial resistance] or adverse effects," the study authors wrote. "Access to penicillin allergy de-labelling services is vital to ensure patients are not denied penicillin treatments unnecessarily."

Pakistan this week confirmed three wild poliovirus type 1 (WPV1) infections, and two African nations reported more vaccine-derived cases—all included in last year's totals—the Global Polio Eradication Initiative reported yesterday in its weekly update.

The new WPV1 cases are in Sindh, Balochistan, and Khyber Pakhtunkhwa provinces, with onset of paralysis in November and December. They bring Pakistan's 2024 case count to 67.

Three new cases in Africa

In Africa, the Democratic Republic of the Congo (DRC) confirmed 2 circulating vaccine-derived poliovirus type 2 (cVDPV2) cases in Haut-Katanga province. Those patients first developed paralysis in July and November and bring the DRC's cVDPV2 2024 total to 14. The country has also reported 9 vaccine-derived type 1 cases for the year.

Finally, South Sudan logged 1 new cVDPV2 case, the country's 10th of 2024. The patient, from Unity state, began experiencing paralysis in November.