Infectious Disease Provider Perspectives on Shorter Tuberculosis Treatment Regimens

Since 2020, Infectious Diseases Society of America/American Thoracic Society/Centers for Disease Control and Prevention guidelines have preferentially recommended ≤4-month rifamycin-based regimens for tuberculosis infection. Since 2022, recommendations have included all-oral 6-month regimens (bedaquiline, pretomanid, and high-dose linezolid [BPaL] or BPaL plus moxifloxacin [BPaL-M]) for drug-resistant disease and a 4-month regimen (rifapentine, isoniazid, and moxifloxacin [HPMZ]) for drug-susceptible disease. Yet implementation of new regimens often lags behind guidelines. This survey aimed to characterize tuberculosis treatment practices of infectious disease clinicians and barriers to utilizing these regimens.

A survey about tuberculosis treatment practices was distributed to 1501 North American adult infectious disease physician members of the IDSA's Emerging Infections Network. Percentages of respondents were calculated for each question. Open comment data were qualitatively analyzed.

Three hundred forty-nine clinicians completed the survey. Ninety-three percent of respondents preferentially opted for ≤4-month regimens for tuberculosis infection, with only 12% expressing concerns about treatment effectiveness. In contrast, 1% selected HPMZ for pulmonary drug-susceptible disease, and 5% reported experience with HPMZ. For confirmed drug-resistant disease, 39% reported that they would use BPaL or BPaL-M, with 40% unsure about regimen choice. Forty-three percent reported uncertainty about effectiveness of 4- and 6-month regimens for drug-susceptible disease and drug-resistant disease. Qualitative analysis highlighted barriers to the use of newer regimens for tuberculosis disease, including concerns about treatment toxicities related to HPMZ or linezolid, medication interactions, and rifapentine and bedaquiline availability.

While infectious disease physicians preferentially use shorter regimens for tuberculosis infection, uptake of newer regimens for tuberculosis disease is low due to concerns about effectiveness and treatment toxicities. Enhanced adverse effect management and monitoring and shared decision-making can optimize the implementation of newer tuberculosis disease treatment regimens.