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Pulmonary tuberculosis

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Updated 2025 ATS/CDC/ERS/IDSA guidelines for the treatment of drug-susceptible and drug-resistant tuberculosis.

Background

Overview

Definition
Tuberculosis is an infectious disease caused by the Mycobacterium tuberculosis bacteria.
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Pathophysiology
Tuberculosis is caused by AFB Mycobacterium tuberculosis.
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Epidemiology
The incidence of tuberculosis in the US is estimated at 2.8 cases per 100,000 person-years.
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Disease course
The early infiltration either regresses asymptomatically or spreads via bronchi as obstructive lobular pneumonia that develops into caseous pneumonia and fragments to produce cavities or becomes the focus of post-primary granulomas and fibrocaseous disease. The dissemination of tuberculosis can lead to extrapulmonary granulomas. Active pulmonary infection results in either transmission of infection to other humans via coughing or the host may die of illness.
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Prognosis and risk of recurrence
Directly observed treatment, short course (DOTS) has a success rate of > 95%. Approximately 20% of cases of MDR-TB are classified as XDR-TB in some areas.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of pulmonary tuberculosis are prepared by our editorial team based on guidelines from the Infectious Diseases Society of America (IDSA/ERS/ATS/CDC 2025,2019), the World Health Organization (WHO 2024,2022,2021,2020,2017), the U.S. Preventive Services Task Force (USPSTF 2023), the Center for Disease Control (CDC/NTCA 2020), the American College of Chest Physicians (ACCP 2018), the ...
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Screening and diagnosis

Screening for latent tuberculosis: as per USPSTF 2023 guidelines, obtain screening for latent tuberculosis infection in populations at increased risk.
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Diagnostic investigations

Indications for testing: as per ACCP 2018 guidelines, consider obtaining evaluation for pulmonary tuberculosis in patients with cough in high tuberculosis prevalence countries or settings, regardless of cough duration,
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particularly in high-risk groups, such as inmates, patients with HIV, or close contacts of pulmonary tuberculosis.
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  • Chest imaging

  • Respiratory specimen collection

  • Smear and culture

  • Nucleic acid amplification testing (initial testing)

  • Nucleic acid amplification testing (repeated testing)

  • Genotyping

Medical management

Setting of care: as per WHO 2017 guidelines, consider offering the following treatment administration options in patients on tuberculosis treatment:
community- or home-based directly observed treatment over health facility-based directly observed treatment or unsupervised treatment
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directly observed treatment administered by trained lay providers or health-care workers over directly observed treatment administered by family members or unsupervised treatment
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video-observed treatment over directly observed treatment when the video communication technology is available and can be appropriately organized and operated by healthcare providers and patients.
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  • Management of latent tuberculosis

  • Management of drug-susceptible tuberculosis

  • Management of drug-resistant tuberculosis (isoniazid-resistant, rifampin-susceptible)

  • Management of drug-resistant tuberculosis (multidrug-resistant, choice of regimen)

  • Management of drug-resistant tuberculosis (multidrug-resistant, duration of treatment)

  • Management of drug-resistant tuberculosis (extensively drug-resistant)

  • Management of contacts

Surgical interventions

Pulmonary resection: as per WHO 2022 guidelines, consider performing elective partial lung resection (lobectomy or wedge resection) alongside a recommended MDR-TB treatment regimen in patients with rifampin- or MDR-TB.
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Specific circumstances

Patients with culture-negative tuberculosis: as per ATS/CDC/IDSA 2016 guidelines, consider administering a 4-month regimen for the treatment of HIV-negative adult patients with AFB smear- and culture-negative pulmonary tuberculosis.
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  • Patients with HIV infection (screening)

  • Patients with HIV infection (diagnosis)

  • Patients with HIV infection (HIV infection testing)

  • Patients with HIV infection (preventive treatment)

  • Patients with HIV infection (tuberculosis treatment)

  • Patients with HIV infection (antiretroviral therapy)

Patient education

Patient support: as per WHO 2017 guidelines, provide health education and counseling on the disease and treatment adherence in patients receiving tuberculosis treatment.
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Follow-up and surveillance

Assessment of treatment response: as per WHO 2022 guidelines, obtain sputum culture in addition to sputum smear microscopy to monitor treatment response in patients with MDR-TB/rifampin-resistant tuberculosis on longer regimens. Consider repeating sputum culture at monthly intervals.
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