Clinical Guides
Tuberculosis
An India-contextualised, NTEP-aligned educational review draft covering tuberculosis recognition, testing, notification, molecular resistance pathways, HIV, pregnancy, monitoring, contacts, infection control and public-health referral, with continuity across providers and districts and clear safety-netting for patients and families; drug regimens are stated only at programme level through NTEP/PMDT services and this draft never replaces the current national technical guideline.
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Tuberculosis
An India-contextualised, NTEP-aligned educational review draft covering tuberculosis recognition, testing, notification, molecular resistance pathways, HIV, pregnancy, monitoring, contacts, infection control and public-health referral, with continuity across providers and districts and clear safety-netting for patients and families; drug regimens are stated only at programme level through NTEP/PMDT services and this draft never replaces the current national technical guideline.
Summary
Tuberculosis (TB) is caused by Mycobacterium tuberculosis and may affect the lungs or any extrapulmonary site. A prolonged cough, fever, night sweats, weight loss, haemoptysis, lymphadenopathy, meningism, spinal pain or unexplained organ disease should prompt a structured assessment rather than a presumptive label. India’s National Tuberculosis Elimination Programme (NTEP) uses rapid molecular testing, drug-susceptibility information, notification and treatment support as connected public-health actions. A positive test is not the end of assessment: define site, severity, resistance, HIV status, pregnancy, comorbidity and infectiousness.
For drug-susceptible TB, NTEP’s standard adult daily regimen is 2 months of isoniazid, rifampicin, pyrazinamide and ethambutol followed by 4 months of isoniazid, rifampicin and ethambutol (2HRZE/4HRE), delivered in weight-band fixed-dose combinations according to current programme guidance. TB meningitis and osteoarticular TB require programme-led specialist pathways. Drug-resistant TB is treated only through PMDT/NTEP after molecular resistance testing and expert selection; eligible patients may receive the NTEP-endorsed six-month BPaLM regimen (bedaquiline, pretomanid, linezolid and moxifloxacin), while other resistance patterns require the current national regimen. Do not prescribe from this educational draft or use it to alter a programme regimen without review by the designated team and current national guidance.
Before treatment begins, confirm that the person understands the difference between a test result and a complete care plan. A laboratory result needs a specimen date, site, assay and resistance interpretation. A notification needs a named provider and follow-up. A regimen needs weight, comorbidity, pregnancy, HIV medicines, previous treatment and a monitoring schedule. Build these links into the first encounter so that a patient who moves district or provider does not receive duplicate or interrupted therapy. Explain that cough improvement is encouraging but does not alone prove cure; microbiological follow-up and programme review remain important. Respectful language, privacy, food support, transport and counselling improve safety and should be recorded as part of care.
How Common Is It?
TB remains a major public-health problem in India, but a single prevalence number can mislead because surveys, notification, site, age and testing access measure different populations. A person can have TB with a normal chest radiograph, negative smear or few symptoms; conversely, an abnormal radiograph does not prove active TB. Ask how the case was detected, what specimen was tested, whether disease is microbiologically confirmed and whether a resistance result is available.
The practical epidemiology is about transmission and missed disease. Household exposure, congregate settings, undernutrition, diabetes, HIV, immunosuppression, silicosis, smoking and previous TB or treatment interruption increase risk. In India, private and public providers both participate in notification and treatment systems; patients may move between facilities or purchase medicines, so one reconciled treatment record is safer than duplicate courses. Avoid stigma: TB is treatable, and confidentiality, consent and language access support adherence and contact evaluation.
Risk Factors
Ask about close contact with pulmonary TB, previous TB treatment, residence or work in crowded settings, shelter or prison exposure, healthcare work, mining or silica, diabetes, HIV, renal or liver disease, malnutrition, smoking, alcohol and immunosuppressive medicines. Pregnancy and the postpartum period can alter presentation and need coordinated care, not delayed testing. Children, older adults and people with HIV may have atypical symptoms or extrapulmonary disease.
Resistance risk includes prior treatment, interrupted or irregular therapy, contact with drug-resistant TB, persistent positive tests, treatment failure and exposure to an ineffective regimen. Do not infer resistance from severity alone. Record every previous drug, duration, adherence barrier and available laboratory result. Rifampicin resistance on a rapid molecular test is a programme emergency for referral and confirmatory testing; it is not a reason to invent an individual regimen. Consider infection-control risk at the point of care and arrange separation, ventilation and mask use according to local policy while evaluation proceeds.
Diagnosis
History
Record cough duration, sputum, haemoptysis, fever, night sweats, weight change, appetite, breathlessness, chest pain and prior TB. Ask site-specific symptoms: headache or confusion, lymph-node swelling, back pain, urinary or genital symptoms, abdominal complaints, bone or joint pain and eye symptoms. Establish HIV status or offer testing, diabetes, pregnancy, medicines, prior treatment and exposure to resistant TB. Ask about household contacts and children.
Examination
Assess temperature, respiratory rate, oxygen saturation, weight, nutritional state and general toxicity. Examine lungs, lymph nodes, neurological status, spine, abdomen, joints and skin as indicated. Look for meningism, focal deficit, severe hypoxia, sepsis, haemoptysis or airway compromise. Use appropriate respiratory precautions. A normal examination cannot exclude TB, and a positive immunological test cannot distinguish latent infection from active disease.
Investigations
NTEP prioritises quality-assured rapid molecular testing such as NAAT/CBNAAT or Truenat on an appropriate specimen, with rifampicin-resistance information and further drug-susceptibility testing when indicated. Sputum smear and culture retain roles in programme algorithms. Chest radiography supports assessment but is not a stand-alone diagnosis. Extrapulmonary TB requires site-specific sampling, imaging and specialist interpretation; do not rely on a blood test alone. Test for HIV, assess diabetes and obtain baseline blood tests relevant to the planned programme regimen. In suspected TB meningitis, spinal disease or severe illness, refer urgently and do not delay emergency care for routine sampling.
Differential Diagnosis
Chronic bacterial infection, fungal disease, nontuberculous mycobacteria, lung cancer, lymphoma, sarcoidosis, bronchiectasis, asthma, COPD, COVID-19 or other endemic infections can resemble pulmonary TB. Pneumonia that fails to improve needs reassessment rather than automatic TB treatment. Weight loss and fever may reflect malignancy, HIV-associated disease, hyperthyroidism or inflammatory illness. In children, pneumonia, malnutrition, HIV, foreign body and other infections overlap with TB.
At extrapulmonary sites, malignancy, bacterial abscess, inflammatory bowel disease, spinal infection, brucellosis, fungal disease and noninfectious lymphadenopathy require consideration. A positive TB NAAT from one site must be interpreted with clinical and radiological context, contamination risk and the possibility of more than one disease. Do not use a negative smear to rule out TB when clinical suspicion is high, and do not treat an isolated latent-infection test as active disease. Urgent differentials include massive haemoptysis, respiratory failure, meningitis, spinal cord compression and sepsis.
Management
Notify a diagnosed TB case through the NTEP notification system and link the person to a designated TB centre or approved treatment provider. Explain infectiousness, cough etiquette, ventilation, mask use and the need to evaluate household contacts, especially children and people with HIV. Choose treatment only after site, bacteriological result, rifampicin resistance, previous therapy, pregnancy, HIV, liver and kidney status are reviewed. Support adherence with a patient-centred plan, not blame.
For drug-susceptible TB, NTEP’s standard adult daily regimen is 2HRZE/4HRE: two months isoniazid, rifampicin, pyrazinamide and ethambutol, then four months isoniazid, rifampicin and ethambutol, using current weight-band FDCs and programme supervision. Do not extend, shorten or substitute this regimen independently; TB meningitis, bone/joint TB, children, pregnancy, liver disease and other situations require current NTEP specialist guidance. For rifampicin-resistant or MDR/RR-TB, refer through PMDT for molecular confirmation and regimen selection. NTEP’s eligible six-month BPaLM regimen is bedaquiline, pretomanid, linezolid and moxifloxacin; eligibility, exclusions, duration and monitoring are programme decisions.
Prescribing Information
This guide does not authorise a prescription or a private regimen. Confirm the current NTEP/PMDT version, weight band, FDC strength, site classification, resistance result, pregnancy, age, HIV medicines, liver and renal function before treatment. Pyridoxine is used with isoniazid when indicated by NTEP, especially where neuropathy risk is increased. Check vision and colour discrimination before and during ethambutol treatment; ask about optic symptoms. Rifampicin causes orange-red body fluids and important drug interactions, including with hormonal contraception and many antiretrovirals. Isoniazid, rifampicin and pyrazinamide can cause liver injury; counsel about anorexia, nausea, vomiting, dark urine, jaundice and severe abdominal symptoms.
BPaLM is not a general substitute for first-line TB treatment. Pretomanid and bedaquiline require programme eligibility, ECG and interaction review; linezolid requires monitoring for cytopenia, neuropathy and optic toxicity; moxifloxacin can prolong QT and has other adverse effects. Other resistance patterns require the current PMDT regimen, not an improvised combination. Review adherence, adverse effects, microbiological response and drug-susceptibility data through the designated centre. Never add a single drug to a failing regimen or share medicines.
When to Refer
Refer urgently for suspected TB meningitis, spinal cord compression, severe hypoxia, massive haemoptysis, sepsis, altered consciousness, pregnancy with severe illness, paediatric TB requiring specialist assessment, renal or hepatic failure or inability to take oral treatment. Refer promptly to NTEP/PMDT for rifampicin resistance, MDR/RR-TB, treatment failure, relapse, persistent positivity, major interactions, serious adverse effects or uncertainty about disease site.
The designated centre should coordinate laboratory testing, notification, regimen supply, adherence support, HIV and diabetes services, contact investigation and follow-up. Include all reports, specimen dates, prior treatment, drug exposure, weight, comorbidity, pregnancy status, HIV medicines, adverse effects and social barriers. In resource-limited settings, referral includes a safe transport plan, infection-control precautions and clear ownership during transfer. Do not discharge a person with suspected resistant TB to self-source medicines.
Referral is also appropriate when the diagnosis is uncertain after an initial test, when the patient cannot provide a usable specimen, or when radiology and microbiology disagree. Ask the receiving service to confirm that the referral was received and record the next action, because a hand-written instruction to attend elsewhere is not continuity of care. Where a person is infectious, arrange transport that limits exposure, explain mask use without blame and notify the family only through a confidential programme process. A patient who is homeless, migrating for work, caring for children or unable to pay for travel may need community-health-worker support, medication transfer planning and a named contact. These practical interventions are part of TB treatment, not optional extras.
Red Flags
Emergency assessment is required for severe breathlessness, oxygen desaturation, shock, confusion, seizures, meningism, focal neurological deficit, paraplegia, rapidly progressive spinal pain, massive haemoptysis, severe chest pain or sepsis. A person with pulmonary TB who is deteriorating may have drug resistance, bacterial or fungal co-infection, pneumothorax, pulmonary embolism, immune reconstitution disease or treatment toxicity.
During treatment, stop and urgently contact the programme for jaundice or severe hepatitis symptoms, visual loss or colour-vision change, severe rash, mucosal lesions, facial swelling, persistent vomiting, bleeding, severe anaemia symptoms, new neuropathy, marked weakness, palpitations or syncope. Do not simply stop one drug or restart a partial regimen without NTEP/PMDT advice. Persistent positive microbiology or clinical worsening requires adherence, absorption, resistance and alternative-diagnosis review. Ask directly about depression, stigma, violence, food insecurity and self-harm risk; social danger can be a clinical red flag.
Indian Clinical Context
NTEP is the authoritative programme framework for India: use its current technical and operational guidance, designated microscopy/NAAT laboratories, Nikshay notification and treatment-support systems. The standard drug-susceptible adult regimen stated here (2HRZE/4HRE) is a programme-level summary, not a substitute for the current weight-band FDC chart. Drug-resistant TB must be routed through PMDT. Do not represent a private online prescription, a historical regimen or a foreign guideline as current Indian policy.
Counselling should address transport, wages, nutrition, migrant work, caregiving, language, privacy, stigma and phone access. Coordinate HIV testing and ART timing with the HIV programme; rifampicin interactions are clinically important. Screen or refer for diabetes and nutritional support. Pregnancy requires prompt NTEP/obstetric review because TB itself is dangerous and regimen choices need current programme guidance. Contact tracing and preventive treatment decisions belong to the designated programme pathway, particularly for children and people living with HIV.
NMC Competency Mapping
This topic supports supervised competency in recognising TB syndromes, selecting an appropriate specimen, interpreting rapid molecular results, assessing infectiousness, notifying a case, counselling without stigma and arranging contact evaluation. Learners should distinguish active disease from latent infection, understand why a normal smear does not exclude TB, and know that rifampicin resistance changes the pathway to PMDT. They should identify meningitis, spinal disease, haemoptysis, hypoxia and treatment toxicity as emergencies.
A safe OSCE answer includes respiratory precautions, history of exposure and previous treatment, examination, NAAT/appropriate microbiology, chest imaging, HIV and diabetes assessment, NTEP notification, adherence and adverse-effect counselling, and a clear referral owner. Learners must not independently construct a drug-resistant regimen, add drugs to a failing regimen, or promise confidentiality by bypassing lawful notification requirements. Colleges should map the guide to current NMC Community Medicine, Medicine, Paediatrics, Pharmacology, Microbiology and Ethics competencies.
Key Exam Pearls for NEET PG
TB diagnosis is a clinical, microbiological and public-health process. NTEP prioritises rapid molecular testing with rifampicin-resistance information; chest radiography and smear do not stand alone. Standard adult drug-susceptible treatment is 2HRZE/4HRE: two months isoniazid, rifampicin, pyrazinamide and ethambutol followed by four months isoniazid, rifampicin and ethambutol, through weight-band FDCs and programme care. Notify and link to NTEP. Rifampicin-resistant/MDR-TB goes to PMDT; eligible patients may receive six-month BPaLM (bedaquiline, pretomanid, linezolid, moxifloxacin) under current national criteria, while other resistance patterns need the current programme regimen. Think of HIV, diabetes, pregnancy, contacts, adherence and adverse effects. Suspected TB meningitis, spinal cord compression, severe haemoptysis, hypoxia or sepsis is an emergency. Never use a single drug, share tablets or improvise a resistant-TB regimen.
Frequently Asked Questions
What is the NTEP standard regimen for drug-susceptible adult TB?
At programme level, NTEP’s standard daily adult regimen is 2HRZE/4HRE: two months of isoniazid, rifampicin, pyrazinamide and ethambutol, followed by four months of isoniazid, rifampicin and ethambutol. It is supplied using current weight-band fixed-dose combinations and delivered through the designated TB treatment system. This summary is not a prescription: the treating NTEP provider must confirm site, age/weight band, pregnancy, HIV medicines, liver and kidney status, previous treatment, drug-susceptibility results and the current technical guideline. TB meningitis, osteoarticular disease, children, severe liver disease and other special situations may require a different programme-led plan. Never stop one medicine, add a single medicine or use a private regimen after missed doses without contacting the designated centre. Adherence support should address nausea, work, food, transport, stigma and language rather than treating missed doses as a moral failure.
What happens when a rapid test shows rifampicin resistance?
Rifampicin resistance changes the pathway to drug-resistant-TB evaluation. The patient should be urgently linked to NTEP/PMDT for confirmatory molecular and drug-susceptibility testing, clinical assessment, infection-control advice and regimen selection. Do not assume that every person is eligible for the same short regimen, and do not start a borrowed or improvised combination. NTEP has an eligible six-month BPaLM regimen containing bedaquiline, pretomanid, linezolid and moxifloxacin, but eligibility, exclusions, monitoring and the current national version must be checked by the programme. Other resistance patterns require the current PMDT regimen and expert review. Record prior treatment, contact with resistant TB, all laboratory dates, pregnancy, HIV medicines, ECG and comorbidity. A person with severe illness, haemoptysis, hypoxia or neurological symptoms needs emergency care as well as programme linkage. Household and healthcare contacts need a public-health plan, not informal disclosure.
How should TB and HIV be managed together?
Offer HIV testing to people with TB according to programme policy and link a person with HIV to the HIV care programme. TB and HIV treatment should be coordinated rather than managed by stopping one service: timing of antiretroviral therapy, rifampicin interactions, immune reconstitution inflammatory syndrome, cotrimoxazole where indicated, nutritional needs and opportunistic infections require clinician-led decisions. Rifampicin interacts with many antiretrovirals, so the HIV and TB teams must reconcile the exact medicines. Severe headache, confusion, focal deficit, hypoxia, worsening fever or visual symptoms may indicate disseminated or central-nervous-system disease and needs urgent assessment. Pregnancy, breastfeeding, renal or liver disease and prior TB treatment further alter the plan. Do not publish a universal ART start date or drug substitution in an educational guide; use the current NTEP/NACO protocol and a named treating team.
What should a household contact do after exposure to pulmonary TB?
The household should be contacted through the NTEP case-investigation pathway, with confidentiality and consent respected. Symptom screening and testing are prioritised for children, people living with HIV and other vulnerable contacts; evaluation may include examination, chest imaging and microbiological testing according to age, symptoms and programme guidance. A positive infection test alone does not prove active TB, and a negative test does not eliminate the need to reassess symptoms or repeat testing when clinically indicated. Contacts should improve ventilation, follow cough and mask advice while infectiousness is being assessed, and avoid stigma or blame. Preventive treatment is considered only after active TB is excluded and according to the current NTEP eligibility and regimen guidance. Do not share the index patient’s medicines or self-start antibiotics. Urgent care is needed for breathlessness, haemoptysis, severe illness, meningitic symptoms, neurological deficit or a sick young child. The designated programme team should explain results and own follow-up. Record each contact’s result, review date, symptoms, age, HIV or immunosuppression risk and the named person responsible for re-contact; a verbal referral without ownership can miss disease. Families should be told how to seek help if symptoms emerge between scheduled visits.
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