Chinese guideline for the chemotherapy of multidrug-resistant/rifampicin-resistant tuberculosis (2026 edition)

Multidrug-resistant tuberculosis (MDR-TB) and rifampicin-resistant tuberculosis (RR-TB) pose significant challenges to global tuberculosis prevention and treatment efforts. At present, the chemotherapy of MDR/RR-TB is still hampered by prolonged treatment duration and suboptimal success rates. In 2019, the Chinese Medical Association Tuberculosis Branch issued the Chinese Expert Consensus on the Treatment of MDR-TB and RR-TB, which has provided essential guidance for standardizing the diagnosis, treatment, and clinical management of MDR/RR-TB in China. In response to recent advances in global evidence-based medicine and in consideration of China's specific context, the Chinese Medical Association Tuberculosis Branch recently convened a panel of experts to develop the Chinese Guidelines for the Chemotherapy of MDR/RR-TB (2026 Edition). This guideline provides updated recommendations regarding the definition of drug-resistant tuberculosis, selection and adjustment of short-course and long-course regimens, treatment monitoring, management of special populations, and standardized management of adverse drug reactions. Each recommendation is supported by an evidence-based rationale, the clinical questions addressed, and practical implementation suggestions. A total of 14 recommendations are presented, aiming to provide a robust clinical evidence base and to support informed decision-making for the standardized treatment of MDR/RR-TB. The key recommendations are as follows.Recommendation 1: For adolescents (aged 14 years and above) and adults with MDR/RR-TB, the 6-month regimen comprising bedaquiline, pretomanid, linezolid, and moxifloxacin (BPaLM) is recommended over the 9-month or longer (18-month) regimens (1, B).Recommendation 2: For MDR/RR-TB patients with or without fluoroquinolones resistance (including children of all ages, pregnant and breastfeeding women), the 6-month regimen comprising bedaquiline, delamanid, linezolid, levofloxacin, and clofazimine (BDLLfxC) is recommended (1, B).Recommendation 3: For MDR/RR-TB patients susceptible to fluoroquinolones, the 9-month all-oral regimen comprising bedaquiline, levofloxacin (or moxifloxacin), protionamide (or linezolid for two months), clofazimine, ethambutol, high-dose isoniazid, and pyrazinamide [4-6 Bdq (6m)-Lfx (Mfx)-Pto (Lzd2m)-Cfz-E-Hhigh-dose-Z/5Lfx (Mfx)-Cfz-E-Z] is recommended over longer (18-month) regimens (2, B).Recommendation 4: For MDR/RR-TB patients susceptible to fluoroquinolones, the modified 9-month all-oral regimens (BLMZ, BLLfxCZ and BDLLfxZ) are recommended over the currently recommended longer (18 months) regimens. The recommended order of priority among these regimens is BLMZ>BLLfxCZ>BDLLfxZ(2, B).Recommendation 5: When drug accessibility is limited, for MDR/RR-TB patients susceptible to both fluoroquinolones and amikacin, the 9- to 12-month short-course regimen containing an injectable agent may be used in place of the longer regimens (18 months) (2, B).Recommendation 6: For MDR/RR-TB patients susceptible to fluoroquinolones, the 9-month regimen comprising bedaquiline, linezolid, levofloxacin, clofazimine, and cycloserine may be used in place of the longer regimens (18 months) (2, D).Recommendation 7: For MDR/RR-TB patients receiving long-course treatment, the regimen should include all three Group A agents and at least one Group B agent so that treatment starts with at least four anti-tuberculosis drugs likely to be effective, and that at least three agents are included for the rest of the treatment if bedaquiline is stopped. If only one or two Group A agents are used, both Group B agents are to be included. If the regimen cannot be composed from agents from Groups A and B alone, Group C agents should be added to complete it (1, B).Recommendation 8: The optimal regimen for MDR/RR-TB patients should be individualized based on reliable baseline drug-susceptibility testing results, previous treatment history, and clinical characteristics. Short-course regimens are preferred; for patients who are not eligible for short-course regimens, individualized longer regimens may be selected based on drug susceptibility testing results (Good Practice Statement, GPS).Recommendation 9: Short-course regimens are fixed, standardized combination treatments. When adverse drug reactions occur, dose adjustment is permitted; however, early discontinuation or substitution of any drug to modify the regimen is not recommended (with the exception of linezolid-related adverse events). Adjustments due to treatment failure or intolerance should be made after consultation with a clinical expert panel (GPS).Recommendation 10: MDR/RR-TB patients undergoing treatment should be monitored for clinical efficacy and adverse events through symptom assessment, physical examination, laboratory tests, and chest imaging. When necessary, examinations such as electrocardiography, hearing tests, and visual field assessments should also be performed. Where feasible, patients on long-course regimens should ideally undergo monthly sputum smear microscopy and Mycobacterium tuberculosis culture during treatment. Patients on short-course regimens may be monitored at an appropriately increased frequency (1, B).Recommendation 11: The treatment principles for MDR/RR-TB in individuals of all ages-including children, adolescents, pregnant and breastfeeding women, and the elderly-are consistent with those for general MDR/RR-TB patients. Short-course regimens are still preferred (1, B).Recommendation 12: The design principles of anti-tuberculosis regimens for patients with MDR/RR-TB and HIV/AIDS co-infection should follow the same principles as those for HIV-negative patients, with careful consideration of drug-drug interactions between anti-tuberculosis and antiretroviral agents (1, A).Recommendation 13: Patients co-infected with MDR/RR-TB and HIV/AIDS should receive antiretroviral therapy concurrently with anti-tuberculosis treatment (regardless of CD4+ T-cell count), ideally within 8 weeks. For those with central nervous system tuberculosis, antiretroviral therapy should be initiated between 4 and 8 weeks after starting anti-tuberculosis treatment (2, D).Recommendation 14: MDR/RR-TB patients with chronic hepatitis B virus (HBV) infection who meet criteria for antiviral therapy should initiate anti-HBV treatment as soon as possible. Anti-tuberculosis treatment may initiate concurrently or after liver function has stabilized. For those with chronic hepatitis C virus infection, concurrent initiation of anti-tuberculosis treatment and direct-acting antiviral agents is recommended (2, D).