Dear Colleague Letters

CDC and the National Tuberculosis Controllers Association Release New Guidelines for Treatment of Latent TB Infection

February 13, 2020

New LTBI Guidelines

Dear Colleague:

Treatment of latent tuberculosis (TB) infection is essential to controlling and eliminating TB in the United States because it substantially reduces the risk that latent TB infection will progress to TB disease. Up to 13 million people in the United States have latent TB infection. Without treatment, they are at risk for developing TB disease in the future; however, treatment greatly reduces this risk.

  • Today, the U.S. Centers for Disease Control and Prevention (CDC) and the National Tuberculosis Controllers Association (NTCA) published “Guidelines for the Treatment of Latent Tuberculosis Infection” in CDC’s Morbidity and Mortality Weekly Report Recommendations and Reports. This is the first comprehensive update to U.S. latent TB infection treatment guidelines since 2000. CDC and NTCA preferentially recommend short-course, rifamycin-based, 3- or 4-month latent TB infection treatment regimens over 6- or 9-month isoniazid monotherapy.

Highlights from the new guidelines include:

  • To treat latent TB infection, CDC and NTCA preferentially recommend:
    • Three months of once-weekly isoniazid plus rifapentine (3HP). 3HP is strongly recommended for adults and children older than 2 years, including HIV-positive persons.
    • Four months of daily rifampin (4R). 4R is strongly recommended for HIV-negative adults and children of all ages.
  • Three months of daily isoniazid plus rifampin (3HR) is conditionally recommended for adults and children of all ages and for HIV-positive persons.
  • If short-course treatment is not a feasible or available option (e.g., due to drug interactions with rifamycins), CDC and NTCA recommend six or nine months of daily isoniazid (6H/9H) as alternative, effective latent TB infection treatment regimens.
  • More than 80% of people who develop TB disease in the United States each year get sick from longstanding, untreated latent TB infection. Short-course latent TB infection treatment regimens are effective, safe, have a lower risk of hepatotoxicity, and have higher completion rates than longer 6 to 9 months of isoniazid monotherapy. The availability of short-course regimens can also enable providers to treat larger numbers of people who are at risk for TB disease.

Our public health system and private providers play a crucial role in expanding the testing and treatment of latent TB infection. Clinicians can work with patients to determine the best latent TB infection treatment regimen, prescribe shorter regimens, and provide support and resources to help patients complete latent TB infection treatment successfully.

We encourage clinicians, pharmacists, and public health professionals to review the new guidelines for the treatment of latent TB infection. Clinicians can contact state and local TB control offices for additional information on diagnosing and treating latent TB infection.

Additionally, CDC has resources and tools for latent TB infection for health care providers, public health professionals, and patients.

Thank you for your work and continued commitment to turn TB elimination into a reality.

/Philip LoBue/
Philip LoBue, MD, FACP, FCCP
Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Centers for Disease Control and Prevention