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GuidelinesPrimary Care STG

Pulmonary Tuberculosis (TB) in Adults

Pulmonary Tuberculosis

Diagnosis

General Measures

Medicine Treatment 

A15.0-3/A15.7-8/A16.0-2/A16.4/A16.7-9 + (B20.0)

DIAGNOSIS

Pulmonary TB is diagnosed on sputum by TB nucleic acid amplification tests (TB-NAAT) such as Xpert® MTB/RIF Ultra, sputum smear, or culture.

  • Send 1 sputum specimen for TB-NAAT
    •  If TB-NAAT is unsuccessful: collect another sample and repeat TB-NAAT
    • If TB-NAAT is trace (only applies to Xpert® MTB/RIFUltra): If the clinical presentation and chest X-ray are suggestive of TB, treat for drug-sensitive TB (DS-TB), and collect sputum specimen for TB culture and drug sensitivity testing (DST). If the patient is asymptomatic, with no abnormalities on chest X-ray, continue routine care with close follow-up for features of TB
    • If TB-NAAT is positive and susceptible to rifampicin: treat for DS-TB and send a sputum specimen for baseline smear microscopy (the smear is used for reporting, not for diagnosis)
    • If TB-NAAT is positive, susceptible to rifampicin and resistant to isoniazid: treat for isoniazid monoresistant TB (See Isoniazid mono-resistant tuberculosis in adults). Collect sputum sample for reflex testing of fluoroquinolone susceptibility
    • If TB-NAAT is positive and rifampicin unsuccessful: start DS-TB treatment and collect another sputum sample for smear, culture and drug sensitivity testing (DST). Follow-up culture and DST results
    • If TB-NAAT is positive and resistant to rifampicin (with or without isoniazid resistance): treat for rifampicin resistant TB and send sputum sample for further reflex testing and DST
    • If TB-NAAT is negative and patient is living with HIV: send sputum for TB culture and perform chest X-ray. If CD4 < 200 within the last 6 months and they have signs and symptoms of TB (pulmonary or extrapulmonary), the patient has advanced HIV disease or the patient is currently seriously ill and requiring hospitalization, perform urine LAM (U-LAM) test
    • If TB-NAAT is negative and patient is HIV negative: treat with antibiotics and consider further investigation only if symptoms persist

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Note:

Patients with a history of TB can remain TB-NAAT positive for several years after completion of appropriate anti-TB treatment.  To diagnose a new episode of TB in previously treated patients, send sputum for smear microscopy and culture instead.

GENERAL MEASURES

  • Counsel patients about the disease and infection control in the home. Explain the importance of completing treatment
  • Advise against the use of tobacco and excessive alcohol
  • If more than two doses of treatment are missed, extra effort should be made to identify and manage any problems the patient might have

MEDICINE TREATMENT

  • Administer total daily amount of each medicine in one dose and not as divided doses

Important medicine interactions

Rifampicin may reduce the efficacy of low dose combined oral contraceptives and progestin-only implants, resulting in possible unplanned pregnancies (See PHC Chapter 7: Family planning).

  • Use of alternative contraceptive methods, such as IUD or DMPA, should be advised

OR

CAUTION

- Antiretroviral medicines frequently interact with TB medicines
- Consult the National Department of Health antiretroviral treatment guidelines

Dose adjustment in renal impairment (eGFR < 30 mL/min) 

  • Ethambutol 15 – 25mg/kg three times weekly
  • Pyrazinamide 20 – 30 mg/kg three times weekly
  • Rifampicin and isoniazid do not require dose adjustment

Intensive phase of treatment:

  • Alternate day dosing of RH and RHZE
    • Administer standard weight-based dosing of RH on Tuesday, Thursday, Saturday, Sunday
  • AND
    • Administer standard weight-based dosing with RHZE on Monday, Wednesday, Friday

Continuation phase of treatment:

  • Rifampicin and isoniazid
    • Do not require dose adjustment. Continue daily weight-based dosing of RH

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Adverse effects of TB medicines include: 

  • Nausea
    • Taking medicines with meals can minimise nausea
    • Hepatitis must be excluded, if there is new onset nausea. Request serum alanine aminotransferase test urgently in these patients
  • Hepatitis (drug induced liver injury)
    • Rifampicin, isoniazid and pyrazinamide may cause hepatitis. Cotrimoxazole and antiretrovirals (efavirenz, nevirapine, lopinavir + ritonavir) can also cause hepatitis
    • Patient may present with jaundice and/or complaining of hepatitis symptoms (e.g. nausea, malaise, abdominal pain)
    • Refer to hospital for urgent (same day) ALT and further management
    •  If jaundiced, stop TB treatment and medicines known to cause hepatitis before referring. See: Antiretroviral therapy, adults and adolescents (10-19 years old)
  • New onset skin rash
    • Refer if suspected drug rash
  • Neuropathy
    • Can be prevented by taking pyridoxine
  • Arthralgia
    • Exclude gout, and treat symptomatically

See: TB chemoprophylaxis/isoniazid preventive therapy (IPT) in adults

See: TB control programme: medicine regimens in adults

Click here to access the pdf.

Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-4-Version 1.0_16 September 2024

Chapter 17: Respiratory Conditions_17.4 Pulmonary Tuberculosis (TB)_17.4.1 Pulmonary Tuberculosis (TB) in Adults

Drugs mentioned

ICD-10 codes

NeoHealth® ID 19235 · updated 6/25/2025