Evaluating treatment outcomes stratified by regimen among drug-resistant TB patients in Sierra Leone

Setting Sierra Leone has a high burden of drug-resistant TB (DR-TB), managed at three treatment centres. Objective To compare treatment success between BPaL (bedaquiline, pretomanid, and linezolid)/BPaLM (bedaquiline, pretomanid, linezolid, and moxifloxacin) and the standardised short and the individualised long regimens among DR-TB patients and identify predictors of unsuccessful outcomes. Design Retrospective cohort study utilising routinely collected national DR-TB data from January 2022 to December 2024. Results Among 598 DR-TB patients registered from 2022 to 2024, 571 with complete outcomes were analysed. Overall treatment success was 80.2%, highest with BPaL/BPaLM (87.1%) compared with the standardised short (78.8%) and individualised long regimens (70.4%). Adjusted analyses showed BPaL/BPaLM remained strongly associated with higher success than the individualised long (adjusted risk ratio [aRR] 2.89; 95% confidence interval [CI] 1.80-4.64) and standardised short regimens (aRR 1.46; 95% CI 1.04-2.05). HIV co-infection and underweight body mass index independently predicted poor outcomes. Findings were consistent across propensity-weighted and sensitivity analyses. Conclusion Under routine programmatic conditions in Sierra Leone, BPaL/BPaLM achieved higher treatment success than standardised short or individualised long regimens. However, HIV co-infection and undernutrition predicted poorer outcomes, underscoring the need for integrated nutritional support, expanded drug-susceptibility testing, and strengthened TB/HIV services.