The BPaL regimen can be prescribed for those who have proven fluoroquinolone resistance. In cases of possible fluoroquinolone resistance (e.g. a history of >4 weeks of fluoroquinolone use or close contact with a person infected with a fluoroquinolone-resistant strain), it is best to use the BPaLM regimen until DST for fluoroquinolones is available, to decide whether or not moxifloxacin should be continued. Where DST is pending, BPaLM can be commenced, subsequently dropping moxifloxacin from the regimen once fluoroquinolone resistance is confirmed. The BPaL regimen uses the same doses for pretomanid, bedaquiline and linezolid as the BPaLM regimen.
If fluoroquinolone resistance is acquired while an individual is on the BPaLM regimen, in the absence of evidence of acquired resistance to other drugs, moxifloxacin can be omitted and BPaL should be continued, because there is no added benefit to continuing a noneffective drug that may have toxicities. If resistance to bedaquiline, linezolid or pretomanid is confirmed or suspected, the treatment is considered to have failed and individuals should be referred to the longer individualized regimen (Chapter 6).