Abstract
BACKGROUND: Drug-resistant tuberculosis (DR-TB) remains a formidable public health challenge, posing a significant threat to human life and health security. Comprehensive comparative evidence on the efficacy and safety of various DR-TB treatment strategies remains limited. This study aimed to systematically evaluate and compare the effectiveness of different DR-TB treatment regimens and to assess their safety profiles based on the frequency of adverse events and drug-specific reactions. METHODS: We systematically searched PubMed, Web of Science, and Embase for relevant studies published between 2006 and 2025. Data on drug-resistant tuberculosis and treatment regimens were extracted. Pooled rates and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Publication bias was assessed using Begg’s and Egger’s tests. RESULTS: A total of 97 studies were included for systematic review and meta-analysis. This analysis found that Europe had the highest cure rate for DR-TB (84%; 95% CI: 76%-91%). The cure rate was highest for the 6-month treatment regimen (BPaL) (93%; 95% CI: 88%-96%), followed by the HRZE treatment regimen (86%; 95% CI: 82%-89%), and the lowest for the 18–24 month long-term treatment regimen including injectable agents (62%; 95% CI: 55%-70%). The overall incidence of adverse events (AEs) was 65% (95% CI: 50%-78%), and the incidence of serious adverse events (SAEs) was 17% (95% CI: 12%-24%). The BPaL regimen was associated with a lower incidence of adverse events, with the most frequently reported events being Peripheral neuropathy (98, 9.8%), Bone marrow suppression (52, 5.2%), Hematological abnormalities (51, 5.1%). Begg’s and Egger’s tests showed that no significant publication bias was detected. CONCLUSIONS: In conclusion, our analysis demonstrates significant geographic and regimen-specific disparities in the treatment outcomes for DR-TB. The findings suggest that 6-month all-oral BPaL regimen is associated with superior efficacy compared to traditional long-term regimens, while also presenting a more favorable safety profile due to lower rates of adverse events. The variation in cure rates across continents underscores the influence of programmatic factors and healthcare systems. Where feasible, national tuberculosis control programs should prioritize shorter, safer regimens, while strengthening pharmacovigilance and healthcare workforce training to support effective implementation. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12879-026-12642-x.