6.3.5 Patients with extrapulmonary TB

The WHO recommendations on longer MDR-TB regimens also apply to patients with extrapulmonary disease. Adjustments may be required, depending on the specific location of disease. Treatment of MDR/RR-TB meningitis is best guided by DST of the infecting strain and by the ability of TB medicines to cross the blood–brain barrier. Group A fluoroquinolones (e.g. levofloxacin, moxifloxacin and linezolid) have good penetration across the blood–brain barrier (i.e. the CNS), as do ethionamide (or prothionamide), cycloserine (or terizidone) and imipenem–cilastatin (109–111). Seizures may be more common in children with meningitis treated with imipenem, and meropenem is preferred for cases of TB meningitis and in children (112–114). High-dose isoniazid and pyrazinamide can also reach therapeutic levels in the cerebrospinal fluid (CSF) and may be useful if the strains are susceptible. Neither p-aminosalicylic acid nor ethambutol penetrate the CNS well and they should not be considered effective agents for MDR-TB meningitis. Amikacin and streptomycin only penetrate the CNS in the presence of meningeal inflammation. Data are sparse on the CNS penetration of clofazimine, bedaquiline or delamanid.

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