Implementing shorter all-oral treatment durations for multidrug-resistant tuberculosis in the UK: from concept to application

Multidrug-resistant tuberculosis (MDR-TB) is a global public health threat associated with high mortality and challenging treatment regimens. The UK, like many countries, faces a growing incidence of MDR-TB, with 105 (1.9% of all notified cases) treated as MDR-resistant or rifampicin-resistant TB in 2024. Recent clinical trials have demonstrated the efficacy and safety of shorter, all-oral regimens such as BPaLM (bedaquiline, pretomanid, linezolid, moxifloxacin), yet their implementation in the UK presents unique challenges, particularly around the antimicrobial stewardship (AMS) agenda, such as the lack of licensed drugs, pharmacokinetic/dynamic concerns, fragile supply chains and high cost of second-line antituberculosis drugs. This narrative review outlines how the UK has addressed implementation hurdles through coordinated efforts by the British Thoracic Society MDR-TB Clinical Advice Service and National Health Service England. This collaboration has facilitated the adoption of new regimens, with 54 out of 60 requests for using pretomanid-containing regimens approved in the UK up to January 2026. Furthermore, resources like the TB Drug Monographs and the shift to video-observed therapy have streamlined care delivery. The UK has effectively navigated the transition to shorter, all-oral MDR-TB regimens, significantly enhancing patient care and operational efficiency. The integration of clinical guidance, AMS principles, policy reform and specialised monitoring tools provides a robust framework for managing evolving treatment landscapes and delivering patient-centred care.