Implementation considerations: treatment of TB meningitis

Children with TBM should preferably be hospitalized for initiation of treatment and close monitoring. Children aged under 2 years with miliary TB should be evaluated for TBM regardless of the presence of CNS symptoms. If these children are not evaluated for TBM for any reason, extension of treatment to 12 months may be considered.

The short intensive regimen is an option for children with bacteriologically confirmed or clinically diagnosed (probable) drug-susceptible TBM. The regimen is suitable for children and adolescents with no evidence of drug resistance and children and adolescents who have a low likelihood of drug resistant TB (e.g. those without risk factors for any form of DR-TB).

Data were limited on children and adolescents living with HIV treated with the short intensive regimen, and so the standard 12-month regimen should be used in children and adolescents living with HIV with TBM. In children and adolescents living with HIV, ART should be delayed at least 4 weeks (and initiated within 8 weeks) after treatment for TBM is initiated (see Section 7.1). In South Africa, where this regimen is used, children and adolescents living with HIV receive 9 months of HRZEto (with all medicines used throughout), but evidence was insufficient for assessment by WHO in 2021.

One key implementation consideration is administration of the short intensive regimen with the correct dosages of the included medicines, using currently available child-friendly and FDC formulations when possible. Historically, the regimen was dosed in South Africa using a child-friendly FDC of isoniazid and rifampicin (60 mg/60 mg) with pyrazinamide and ethionamide added as single medicines. An expert consultation on dosing convened by WHO in October 2021 considered the limited availability of this 60 mg/60 mg FDC globally, and the wide availability of an isoniazid/rifampicin (50 mg/75 mg) dispersible tablet, including through the Stop TB Partnership Global Drug Facility (GDF).¹⁶ An interim dosing strategy was developed based on the available child-friendly formulations for isoniazid/rifampicin, pyrazinamide and ethionamide after this consultation (see Table 5.6).

The feasibility of introducing the short intensive regimen is dependent on the setting. Acceptability, affordability and access to the component medicines (including the child-friendly ethionamide formulation) are important factors to consider. For the short intensive regimen, ethionamide should not be replaced with ethambutol if ethionamide is not available.


¹⁶ GDF is a global provider of quality-assured TB medicines, diagnostics and laboratory supplies to the public sector, operating under the Stop TB Partnership Operational Strategy (http://www.stoptb.org/gdf/).

Book navigation