Critical care management of tuberculosis: challenges, evidence, and evolving strategies

Abstract

Background & objectives: Tuberculosis (TB) continues to be a significant global health issue, as an increasing number of individuals are presenting with severe, life-threatening conditions that require admission to intensive care units (ICUs). The management of critical care environments is increasingly complicated by the rise of drug-resistant tuberculosis, co-infection with HIV, and late-stage diagnoses. Despite its increasing significance, there is a paucity of focused research on the critical care aspects of tuberculosis.

This review aims to systematically examine the current data and clinical guidelines pertaining to the treatment of tuberculosis in critical care settings. The focus is on diagnostic challenges, treatment choices, supportive methods, and outcome forecasts relevant to critically ill TB patients.

Methodology: A structured literature evaluation was conducted, focusing on publications from 2000 to 2025, using databases such as [PubMed], Scopus, and Web of Science. This study examines the management of tuberculosis in intensive and critical care settings, focusing on multidrug-resistant tuberculosis (MDR-TB), the role of mechanical ventilation, and the implications of sepsis in affected patients. A review of clinical recommendations, cohort studies, retrospective analyses, and relevant case series facilitated the summarization of the database for ICU care techniques in tuberculosis patients.

Results: Critically ill tuberculosis patients primarily exhibit severe respiratory failure, miliary spread, tuberculosis sepsis, or central nervous system involvement. Suboptimal outcomes stem from diagnostic delays caused by ambiguous clinical features and the limitations of conventional microbiological diagnostics. In ICU cohorts with tuberculosis, mortality rates range from 30% to 70%, with elevated rates observed in patients requiring mechanical ventilation or experiencing multi-organ failure. Delayed initiation of antitubercular treatment (ATT) in the ICU often results in altered pharmacokinetics, that hinder medication distribution. Drug-resistant tuberculosis continues to pose significant challenges regarding therapy selection and infection control. Supportive care interventions, including mechanical ventilation, fluid resuscitation, and nutritional support, are critically important yet often underappreciated.

Conclusion: Tuberculosis in the ICU represents a distinct clinical entity characterized by elevated mortality rates, diagnostic delays, and complex therapeutic decisions. Enhancing outcomes relies on early detection, prompt initiation of antitubercular therapy, customized pharmaceutical interventions, and multidisciplinary supportive care. Prospective studies are essential to establish ICU-specific tuberculosis care guidelines, especially for individuals with drug resistance and co-infections.

Abbreviations: APACHE II: Acute Physiology and Chronic Health Evaluation II, ARDS: acute respiratory distress syndrome ATT: antitubercular treatment, CRP: C-reactive protein, DR-TB: drug-resistant tuberculosis, ECMO: extracorporeal membrane oxygenation, ICU: intensive care units, MDR-TB: multidrug-resistant tuberculosis, TB: Tuberculosis, XDR extensively drug-resistant, TDM: Therapeutic antibiotic monitoring

Keywords: Tuberculosis; Critical Care; Intensive Care Unit (ICU); Antitubercular Therapy; Drug-Resistant TB

Citation: Ekramy M. Elmorsy, Basil D. M. Alruwaili, Hatem R. H. Alrwaili, Anwar S. J. Alrawaili, Abdulelah M. M. Alanazi, Fahad N. K. Alanazi, and Ibraheem D. H. Alanazi. Critical care management of tuberculosis: challenges, evidence, and evolving strategies. Anaesth. pain intensive care 2025;29(5):405-417. DOI: 10.35975/apic.v29i5.2867

Received: June 11, 2025; Revised: June 28, 2025; Accepted: July 11, 2025