Tuberculosis parenteral therapeutic regimens for critical patients or non-functional intestinal tract: Brief review and proposal of protocol

Standard anti-tuberculosis regimens (Rifampicin, Isoniazid, Pyrazinamide, and Ethambutol [RHZE]) remain challenging for critically ill patients and those with a non-functioning gastrointestinal tract. In Brazil, these challenges are amplified by the lack of Intravenous (IV) rifampicin, isoniazid, and ethambutol, which often results in suboptimal outcomes. This brief communication synthesized evidence on parenteral therapies and proposed a structured, five-step protocol for critically ill patients unable to receive oral drugs. A narrative review of the guidelines and key studies was also conducted. IV formulations of RHZE are approved in only some countries and are not available everywhere. Alternative IV drug classes, such as fluoroquinolones, aminoglycosides, carbapenems, and oxazolidinones, can address malabsorption or intolerance to oral RHZE. However, no standardized regimen exists for this population. Our five-step protocol advises: (1) Characterizing each TB case, (2) determining IV necessity, (3) Consulting specialized TB services, (4) Designing a safe and effective regimen, and (5) Re-evaluating therapy for transition to oral treatment. Given the morbidity and mortality from severe TB in Intensive Care Units (ICU), a formalized approach is essential. Further research and policy initiatives regarding IV first-line drugs are crucial to improve treatment outcomes in this vulnerable group. This strategy unifies practice across diverse clinical settings.