Longer bedaquiline-based TB regimens outperform shorter ones in India

Drug-resistant tuberculosis (DR-TB) is a major challenge for treatment programs, and global guidance has shifted toward all-oral regimens. Under India’s programmatic conditions, the World Health Organization (WHO) recommends two distinct all-oral approaches for rifampicin-resistant (RR), multidrug-resistant (MDR), and extensively drug-resistant (XDR) TB: a longer M/XDR-TB regimen lasting about 18–20 months, and a shorter bedaquiline-containing MDR/RR-TB regimen of roughly 9–11 months. The comparative performance of these two options in real-world Indian settings has not been well established. To address that gap, a prospective observational cohort led by corresponding author Ram Awadh Singh Kushwaha enrolled 906 newly diagnosed MDR-TB patients at a tertiary care center in Lucknow, India, during January to December 2022. Patients were treated according to program decisions: 691 received the longer M/XDR-TB regimen and 215 received the shorter bedaquiline-containing MDR/RR-TB regimen. The research team set out to compare early microbiological response and final clinical outcomes between the two strategies, gathering culture data at six months and tracking final treatment results to evaluate which approach delivered better results in this high-burden setting.

The study focused on two main outcomes: six-month culture conversion, a standard microbiological milestone, and final treatment outcome, a summary of clinical success or failure. Investigators recorded these outcomes for all 906 patients and analyzed differences between the longer and shorter regimens. They used multivariable logistic regression to account for potential confounders, adjusting for age, sex, baseline smear status, and comorbidities. At six months, culture conversion was higher in the longer regimen group: 79.8% versus 67.9% with the shorter regimen, an absolute difference of 11.9% (p<0.001; aOR 1.51, 95% CI 1.12–2.04). Final favorable treatment outcomes also favored the longer regimen: 77.9% versus 69.2%, an 8.7% absolute difference (p=0.010; aOR 1.37, 95% CI 1.05–1.79). Subgroup analyses found statistically significant differences in pulmonary TB and among women, and pulmonary TB independently predicted a favorable outcome (aOR 1.46, 95% CI 1.01–2.13). These figures come directly from the cohort analysis conducted at the Lucknow tertiary care center during 2022.

Taken together, the results from this single-center prospective cohort indicate that the longer all-oral M/XDR-TB regimen produced superior microbiological and clinical outcomes compared with the shorter bedaquiline-containing MDR/RR-TB regimen in this study population. For clinicians and program managers working in high-burden settings, these findings suggest that regimen selection should consider patient profile and resistance patterns rather than rely solely on shorter treatment duration. The data also underline that differences emerged in key subgroups—pulmonary TB and women—pointing to the value of individualized decision-making. Because this was a single-center observational study, the authors highlight the need for ongoing, real-world monitoring of tolerability and safety when scaling either regimen. Robust tracking of adverse effects and how patients tolerate these regimens in routine care will be critical to inform broader policy choices and to ensure that gains in culture conversion and final outcomes are maintained when applied across diverse programmatic settings.