Bedaquiline, Pretomanid, Linezolid, and Moxifloxacin Treatment for Multi-Drug Resistant Extrapulmonary Tuberculosis in Canada: A Report.
Jollee St Fung, Victoria J Cook, James Johnston, William J Connors
Journal of the Association of Medical Microbiology and Infectious Disease Canada = Journal officiel de l'Association pour la microbiologie medicale et l'infectiologie Canada · 2025-06
Abstract
BACKGROUND: Updated global tuberculosis (TB) guidelines recommend the novel oral 6-month bedaquiline, pretomanid, linezolid, and moxifloxacin (BPaLM) regimen for multidrug-resistant TB (MDR-TB) based on superior efficacy and reduced toxicity demonstrated in clinical trials. These trials were dominated by isolated pulmonary TB; thus, data for BPaLM effectiveness for extrapulmonary tuberculosis (EPTB) remains limited.
METHODS: We describe the safe and effective use of BPaLM in a patient for the treatment of MDR-TB involving an extrapulmonary site.
RESULTS: Bedaquiline and pretomanid were obtained through the Health Canada Special Access Program and from the manufacturers 3 weeks later. The patient with gastrointestinal and subclinical pulmonary TB tolerated the 6 months of BPaLM well with no treatment interruptions. There was sustained microbiological and clinical response at 6 months after treatment completion.
CONCLUSION: Shorter duration, improved effectiveness, and reduced toxicity suggests that BPaLM should be considered when determining the ideal treatment regimen for MDR-TB. A more streamlined process for the procurement of bedaquiline and pretomanid will help minimize treatment initiation delay and overall isolation period. Further research is also needed to clarify longer-term outcomes and optimal dosing of BPaLM for EPTB, especially in more severe forms of disease or with malabsorption concerns.