Pulmonary tuberculosis

Red Flags

Massive haemoptysis (>200 mL in 24h or any haemoptysis with respiratory compromise) — interventional bronchoscopy or arterial embolisation^[1]
Drug-resistant TB on Xpert MTB/RIF (rifampicin resistance) — refer to Programmatic Management of Drug-Resistant TB (PMDT) centre; do NOT start standard first-line^[1]
Severe ATT-induced hepatitis (ALT >5× ULN or symptomatic) — pause ATT; sequential reintroduction under specialist supervision^[1]
TB-HIV co-infection — start TB therapy first; ART within 2 weeks if CD4 <50, within 8 weeks if higher; manage IRIS^[1]

First-line treatment

Interventions

Directly observed treatment^[1]
All ATT under DOT (treatment supporter, in-person or video). Drug procurement through NTEP free at point of care; Nikshay Poshan Yojana provides nutritional support
Sputum monitoring^[1]
Repeat sputum at end of intensive phase (2 months), 5 months, and end of treatment (6 months). Conversion drives extension of intensive phase or treatment failure declaration

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
HRZE fixed-dose combination (intensive phase)^[1]	First-line antitubercular FDC	Weight-band: 30–37 kg: 2 FDC tabs; 38–54: 3; 55–69: 4; ≥70: 5 daily for 2 months	Weight-band paediatric FDC per NTEP	2HRZE intensive phase. NTEP uses daily regimen (replaced thrice-weekly)
HR (continuation phase)^[1]	Isoniazid + rifampicin FDC	Weight-band: 30–37 kg: 2 tabs; 38–54: 3; 55–69: 4; ≥70: 5 daily for 4 months	Weight-band paediatric FDC	4HR continuation phase. Total 6-month regimen 2HRZE/4HR for new pulmonary TB
Pyridoxine (vitamin B6)^[1]	Adjunctive co-prescription	10 mg PO daily during ATT	5–10 mg daily	Prevents isoniazid-induced peripheral neuropathy; especially in pregnancy, malnutrition, alcohol use
1HP (rifapentine + isoniazid) for TPT^[1]	TB preventive therapy	Rifapentine 600 mg + isoniazid 300 mg PO daily × 28 days	Weight-band per NTEP	TB preventive therapy for contacts and PLHIV; 1HP shorter and effective; 3HP and 6H also available

HRZE fixed-dose combination (intensive phase)^[1]

First-line antitubercular FDC

Adult: Weight-band: 30–37 kg: 2 FDC tabs; 38–54: 3; 55–69: 4; ≥70: 5 daily for 2 months
Paediatric: Weight-band paediatric FDC per NTEP

2HRZE intensive phase. NTEP uses daily regimen (replaced thrice-weekly)

HR (continuation phase)^[1]

Isoniazid + rifampicin FDC

Adult: Weight-band: 30–37 kg: 2 tabs; 38–54: 3; 55–69: 4; ≥70: 5 daily for 4 months
Paediatric: Weight-band paediatric FDC

4HR continuation phase. Total 6-month regimen 2HRZE/4HR for new pulmonary TB

Pyridoxine (vitamin B6)^[1]

Adjunctive co-prescription

Adult: 10 mg PO daily during ATT
Paediatric: 5–10 mg daily

Prevents isoniazid-induced peripheral neuropathy; especially in pregnancy, malnutrition, alcohol use

1HP (rifapentine + isoniazid) for TPT^[1]

TB preventive therapy

Adult: Rifapentine 600 mg + isoniazid 300 mg PO daily × 28 days
Paediatric: Weight-band per NTEP

TB preventive therapy for contacts and PLHIV; 1HP shorter and effective; 3HP and 6H also available

Safety-net

Take all four (or two) ATT pills together every day even when feeling well — interruption causes resistance and relapse^[1]
Watch for jaundice, severe vomiting, vision changes, or numb hands/feet — same-day medical review (drug toxicity)^[1]
Cover your mouth when coughing during the first 2 weeks of treatment to protect family contacts; ensure household members are screened^[1]

Referral criteria

Rifampicin-resistant TB on XpertPMDT centre — switch to all-oral shorter MDR regimen^[1]
Treatment failure (smear-positive at 5 months) or recurrenceTB specialist for repeat DST and second-line evaluation^[1]
Severe ATT hepatitis or other major adverse eventTB specialist or hospital admission for sequential reintroduction^[1]
TB-HIV co-infectionJoint NTEP and ART centre^[1]

Clinical summary

Diagnosis, treatment, and follow-up of drug-sensitive pulmonary TB under the National TB Elimination Programme; daily fixed-dose combination regimen with DOT.

References

1.NTEP Technical and Operational Guidelines for TB Control 2024; WHO Consolidated TB Treatment Guidelines (2024)