Anti‑tuberculosis alternatives you can trust

First‑line TB drugs like isoniazid and rifampin work for most patients, but resistance is on the rise. If your lab shows MDR (multidrug‑resistant) or XDR (extensively drug‑resistant) TB, you’ll need a different playbook. Below are the most common alternatives, how they fit together, and what to watch out for.

Newer drugs that fill the gaps

Bedaquiline was the first new TB drug in decades. It targets the bacterial ATP synthase, a piece of the cell that older meds ignore. Studies show faster sputum conversion, especially in MDR cases. Give it with at least one other active drug to prevent resistance from building.

Delamanid works on a different pathway – it blocks mycolic acid synthesis. It’s a good partner for bedaquiline, and together they cover a wide range of resistant strains. Both drugs need baseline ECG monitoring because they can lengthen the QT interval.

Linezolid, originally an antibiotic for Gram‑positive infections, has become a staple in tough TB regimens. It’s cheap and widely available, but it can cause neuropathy and bone‑marrow suppression if you stay on it too long. Keep blood counts in check and limit use to the intensive phase when possible.

Building an effective combination

Don’t rely on a single alternative. The WHO recommends a core of at least four active drugs, with at least one new agent like bedaquiline or delamanid. A typical MDR regimen might look like:

• Bedaquiline (or delamanid) – 6 months
• Linezolid – 6–12 months, dose adjusted for side effects
• Levofloxacin or moxifloxacin – 12 months
• Cycloserine – up to 12 months
• Additional agents like clofazimine or ethambutol if susceptibility allows

Make sure you have a confirmed susceptibility report before dropping any drug. If you can’t get full susceptibility data, use the “best‑guess” approach: pick drugs with the lowest known resistance rates in your region.

Adherence matters more than the exact pills you pick. Directly observed therapy (DOT) or digital pill‑tracking apps can keep patients on schedule. Side‑effect counseling upfront reduces drop‑outs – tell them what to expect with neuropathy, visual changes, or GI upset and how you’ll manage it.

Finally, remember that nutrition, smoking cessation, and HIV management all boost treatment success. A well‑fed patient with stable blood sugar and a controlled viral load clears bacteria faster and tolerates drugs better.

When standard TB therapy fails, you’ve got a toolbox of alternatives. Use the newer drugs wisely, combine them into a robust regimen, and keep a close eye on side effects and adherence. With the right plan, even resistant TB can be beat.