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Binjomah AZ, Alnimr AM, Zareah SM, Alharbi SF, Alasmari KS, Aldosari KM, Alduealej IM. The diagnostic impact of implementing a molecular-based algorithm to standard mycobacterial screening at a reference laboratory with an intermediate prevalence for non-respiratory samples. Saudi J Biol Sci 2021; 28:4103-4108. [PMID: 34354388 PMCID: PMC8324989 DOI: 10.1016/j.sjbs.2021.05.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/29/2021] [Accepted: 05/30/2021] [Indexed: 11/17/2022] Open
Abstract
Rapid, reliable results can be given by molecular, direct detection and identification of the Mycobacterium tuberculosis (MTB/Mtb) complex from clinical samples. The Xpert MTB/RIF assay is an assay that has been availablefor more than a decade for identification of Mycobacterium tuberculosis and resistance to rifampicin. However, there is minimal evidence on its clinical usefulness in paucibacillary, non-respiratory samples. The Xpert MTB/RIF assay clinical utility index, its diagnostic characteristics and the number required to diagnose 2935 non-respiratory specimens submitted for routine mycobacterial work-up in a reference laboratory in an intermediate prevalence setting per specimen form were evaluated. The Xpert MTB/RIF assay showed a variable clinical utility index and number required to diagnose (NND) depending on the type of specimen, which was moderate in tissue biopsies (NND = 1.8) and excellent in pus and urine samples, compared to acid-fast microscopy and culture as a gold standard technique (NND = 1.1 and 1.2). Microscopy, on the other hand, consistently showed a weak to fair index of clinical usefulness in all specimen forms, with in NND of 2.3-12.5. The NND for detecting tuberculous infection in the cerebrospinal fluid by the Xpert MTB/RIF assay was noted to be 1.2, with a moderate clinical utility index of 0.8. The evidence presented indicates that the overall appropriate diagnostic utility of the Xpert MTB/RIF assay is clinically successful in most non-respiratory samples. To check the cost-effectiveness and prognostic effect of integrating this completely automated molecular-based assay into the routine testing algorithm for non-respiratory mycobacterial specimens, further data must be collected.
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Affiliation(s)
- Abdulwahab Z. Binjomah
- Riyadh Regional Laboratory and Blood Bank, Mycobacteriology Reference Laboratory, Imam Abdulaziz Bin Mohammed Bin Saud Street, Ulaishah, 3485, Riyadh 12746, Saudi Arabia
- College of Medicine, Alfaisal University, Takhassusi Street, Riyadh 11533, Saudi Arabia
| | - Amani M. Alnimr
- Department of Microbiology, King Fahad Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, King Faisal Road, Dammam 34212, Saudi Arabia
| | - Suzan M. Zareah
- Riyadh Regional Laboratory and Blood Bank, Mycobacteriology Reference Laboratory, Imam Abdulaziz Bin Mohammed Bin Saud Street, Ulaishah, 3485, Riyadh 12746, Saudi Arabia
| | - Shafi F. Alharbi
- Riyadh Regional Laboratory and Blood Bank, Mycobacteriology Reference Laboratory, Imam Abdulaziz Bin Mohammed Bin Saud Street, Ulaishah, 3485, Riyadh 12746, Saudi Arabia
| | - Khalid S. Alasmari
- Riyadh Regional Laboratory and Blood Bank, Mycobacteriology Reference Laboratory, Imam Abdulaziz Bin Mohammed Bin Saud Street, Ulaishah, 3485, Riyadh 12746, Saudi Arabia
| | - Kamel M. Aldosari
- Riyadh Regional Laboratory and Blood Bank, Mycobacteriology Reference Laboratory, Imam Abdulaziz Bin Mohammed Bin Saud Street, Ulaishah, 3485, Riyadh 12746, Saudi Arabia
| | - Ibrahim M. Alduealej
- Riyadh Regional Laboratory and Blood Bank, Mycobacteriology Reference Laboratory, Imam Abdulaziz Bin Mohammed Bin Saud Street, Ulaishah, 3485, Riyadh 12746, Saudi Arabia
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Yuen CM, Puma D, Millones AK, Galea JT, Tzelios C, Calderon RI, Brooks MB, Jimenez J, Contreras C, Nichols TC, Nicholson T, Lecca L, Becerra MC, Keshavjee S. Identifying barriers and facilitators to implementation of community-based tuberculosis active case finding with mobile X-ray units in Lima, Peru: a RE-AIM evaluation. BMJ Open 2021; 11:e050314. [PMID: 34234000 PMCID: PMC8264873 DOI: 10.1136/bmjopen-2021-050314] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Identify barriers and facilitators to integrating community tuberculosis screening with mobile X-ray units into a health system. METHODS Reach, effectiveness, adoption, implementation and maintenance evaluation. SETTING 3-district region of Lima, Peru. PARTICIPANTS 63 899 people attended the mobile units from 7 February 2019 to 6 February 2020. INTERVENTIONS Participants were screened by chest radiography, which was scored for abnormality by computer-aided detection. People with abnormal X-rays were evaluated clinically and by GeneXpert MTB/RIF (Xpert) sputum testing. People diagnosed with tuberculosis at the mobile unit were accompanied to health facilities for treatment initiation. PRIMARY AND SECONDARY OUTCOME MEASURES Reach was defined as the percentage of the population of the three-district region that attended the mobile units. Effectiveness was defined as the change in tuberculosis case notifications over a historical baseline. Key implementation fidelity indicators were the percentages of people who had chest radiography performed, were evaluated clinically, had sputum samples collected, had valid Xpert results and initiated treatment. RESULTS The intervention reached 6% of the target population and was associated with an 11% (95% CI 6 to 16) increase in quarterly case notifications, adjusting for the increasing trend in notifications over the previous 3 years. Implementation indicators for screening, sputum collection and Xpert testing procedures all exceeded 85%. Only 82% of people diagnosed with tuberculosis at the mobile units received treatment; people with negative or trace Xpert results were less likely to receive treatment. Suboptimal treatment initiation was driven by health facility doctors' lack of familiarity with Xpert and lack of confidence in diagnoses made at the mobile unit. CONCLUSION Mobile X-ray units were a feasible and effective strategy to extend tuberculosis diagnostic services into communities and improve early case detection. Effective deployment however requires advance coordination among stakeholders and targeted provider training to ensure that people diagnosed with tuberculosis by new modalities receive prompt treatment.
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Affiliation(s)
- Courtney M Yuen
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Jerome T Galea
- School of Social Work, University of South Florida, Tampa, Florida, USA
- College of Public Health, University of South Florida, Tampa, Florida, USA
| | | | - Roger I Calderon
- Socios En Salud Sucursal Peru, Lima, Peru
- Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Meredith B Brooks
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Tim C Nichols
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Tom Nicholson
- Center for International Development, Duke University Sanford School of Public Policy, Durham, North Carolina, USA
- Advance Access & Delivery, Durham, North Carolina, USA
| | | | - Mercedes C Becerra
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Center for Global Health Delivery, Harvard Medical School, Boston, Massachusetts, USA
| | - Salmaan Keshavjee
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Center for Global Health Delivery, Harvard Medical School, Boston, Massachusetts, USA
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Maitre T, Ok V, Morel F, Bonnet I, Sougakoff W, Robert J, Trosini V, Caumes E, Aubry A, Veziris N. Sampling strategy for bacteriological diagnosis of intrathoracic tuberculosis. Respir Med Res 2021; 79:100825. [PMID: 33971432 DOI: 10.1016/j.resmer.2021.100825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pulmonary tuberculosis (TB) is the most frequent site of TB and the one leading its spread worldwide. Multiple specimens are commonly collected for TB diagnosis including those requiring invasive procedures. This study aimed to review the sampling strategy for the microbiological diagnosis of pulmonary TB. METHODS A retrospective analysis of collected samples from September 1st 2014 to May 1st 2016 in the Bacteriology laboratory of Pitié-Salpêtrière Hospital (Paris, France) was performed. All the samples collected in patients aged over 18 years for the bacteriological diagnosis of pulmonary TB were included. RESULTS A total of 6267 samples were collected in 2187 patients. One hundred and twenty-six patients (6%) had a culture confirmed pulmonary TB. Among them, multiple sputum collections were sufficient for TB diagnosis in 63.5%, gastric lavages permitted to avoid bronchoscopy in only 7.1%, and bronchoscopy was necessary in 29.4%. The culture positivity of sputa (8.6%) was higher than that of bronchial aspirations (3.1%), bronchiolo-alveolar lavages (BAL) (2.3%) or gastric lavages (4.8%) (P<0.001). From its 70.0% theoretical PPV value, the 46.1% selection in bronchial aspirations allocated to molecular test increased PPV up to 88.9%. CONCLUSIONS Based on our data, we suggest to collect sputum consistently. If smear negative a bronchoscopy should be performed and molecular diagnosis be performed on a subset of bronchial aspirations based on expertise of the bronchoscopist.
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Affiliation(s)
- T Maitre
- Laboratoire de bactériologie-hygiène, centre national de référence des mycobactéries et de la résistance des mycobactéries aux antituberculeux, groupe hospitalier, Sorbonne Université, Site Pitié-Salpêtrière, AP-HP, Paris, France; Inserm U1135, Sorbonne université, centre d'immunologie et des maladies infectieuses (CIMI-Paris), Paris, France.
| | - V Ok
- Laboratoire de bactériologie-hygiène, centre national de référence des mycobactéries et de la résistance des mycobactéries aux antituberculeux, groupe hospitalier, Sorbonne Université, Site Pitié-Salpêtrière, AP-HP, Paris, France; Inserm U1135, Sorbonne université, centre d'immunologie et des maladies infectieuses (CIMI-Paris), Paris, France
| | - F Morel
- Laboratoire de bactériologie-hygiène, centre national de référence des mycobactéries et de la résistance des mycobactéries aux antituberculeux, groupe hospitalier, Sorbonne Université, Site Pitié-Salpêtrière, AP-HP, Paris, France; Inserm U1135, Sorbonne université, centre d'immunologie et des maladies infectieuses (CIMI-Paris), Paris, France
| | - I Bonnet
- Laboratoire de bactériologie-hygiène, centre national de référence des mycobactéries et de la résistance des mycobactéries aux antituberculeux, groupe hospitalier, Sorbonne Université, Site Pitié-Salpêtrière, AP-HP, Paris, France; Inserm U1135, Sorbonne université, centre d'immunologie et des maladies infectieuses (CIMI-Paris), Paris, France
| | - W Sougakoff
- Laboratoire de bactériologie-hygiène, centre national de référence des mycobactéries et de la résistance des mycobactéries aux antituberculeux, groupe hospitalier, Sorbonne Université, Site Pitié-Salpêtrière, AP-HP, Paris, France; Inserm U1135, Sorbonne université, centre d'immunologie et des maladies infectieuses (CIMI-Paris), Paris, France
| | - J Robert
- Laboratoire de bactériologie-hygiène, centre national de référence des mycobactéries et de la résistance des mycobactéries aux antituberculeux, groupe hospitalier, Sorbonne Université, Site Pitié-Salpêtrière, AP-HP, Paris, France; Inserm U1135, Sorbonne université, centre d'immunologie et des maladies infectieuses (CIMI-Paris), Paris, France
| | - V Trosini
- Service de pneumologie, médecine intensive et réanimation, département R3S, groupe hospitalier, Sorbonne université, Site Pitié-Salpêtrière, AP-HP, Paris, France
| | - E Caumes
- Service de maladies infectieuses et tropicales, groupe hospitalier, Sorbonne université, Site Pitié Salpêtrière, AP-HP, Paris, France
| | - A Aubry
- Laboratoire de bactériologie-hygiène, centre national de référence des mycobactéries et de la résistance des mycobactéries aux antituberculeux, groupe hospitalier, Sorbonne Université, Site Pitié-Salpêtrière, AP-HP, Paris, France; Inserm U1135, Sorbonne université, centre d'immunologie et des maladies infectieuses (CIMI-Paris), Paris, France
| | - N Veziris
- Laboratoire de bactériologie-hygiène, centre national de référence des mycobactéries et de la résistance des mycobactéries aux antituberculeux, groupe hospitalier, Sorbonne Université, Site Pitié-Salpêtrière, AP-HP, Paris, France; Inserm U1135, Sorbonne université, centre d'immunologie et des maladies infectieuses (CIMI-Paris), Paris, France; Département de bactériologie, groupe hospitalier, Sorbonne université, site Saint-Antoine, AP-HP, Paris, France
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Mollel E, Lekule I, Lynen L, Decroo T. Effect of reliance on Xpert MTB/RIF on time to treatment and multidrug-resistant tuberculosis treatment outcomes in Tanzania: a retrospective cohort study. Int Health 2020; 11:520-527. [PMID: 30806660 DOI: 10.1093/inthealth/ihz005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 12/21/2018] [Accepted: 01/21/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND During 2009-2013, Xpert MTB/RIF testing was decentralized in Tanzania. Standardized treatment of multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB) was centralized at the Kibong'oto Infectious Diseases Hospital. Initially, Xpert MTB/RIF results were confirmed and complemented with phenotypic drug susceptibility testing before MDR-TB treatment was started. Since 2013, the decision to start MDR-TB treatment in patients with RR-TB relied on Xpert MTB/RIF results. METHODS A retrospective cohort study of predictors of unsuccessful treatment outcomes (including death, lost to follow-up and treatment failure) was carried out. RESULTS During the study period, 201 patients started MDR-TB treatment. The number of patients starting MDR-TB treatment increased over time. Out of 201 patients, 48 (23.9%) had an unsuccessful treatment outcome. The median time between sample collection and MDR-TB treatment initiation was reduced from 155 d (IQR 40-228) in the 2009-2012 period to 26 d (IQR 13-64) in 2013. Patients who started MDR-TB treatment in 2013 were more likely (adjusted OR 2.3; 95% CI 1.1-4.7; p=0.02) to have an unsuccessful treatment outcome. CONCLUSIONS Xpert MTB/RIF testing increased enrolment on MDR-TB treatment. Reliance on Xpert MTB/RIF results to start MDR-TB treatment reduced time to treatment. However, treatment outcomes did not improve.
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Affiliation(s)
- Edson Mollel
- Kibong'oto Infectious Diseases Hospital, Ministry of Health, Tanzania
| | - Isack Lekule
- Kibong'oto Infectious Diseases Hospital, Ministry of Health, Tanzania
| | - Lutgarde Lynen
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Tanzania
| | - Tom Decroo
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Tanzania.,Research Foundation Flanders, Brussels, Belgium
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Urogenital tuberculosis - epidemiology, pathogenesis and clinical features. Nat Rev Urol 2019; 16:573-598. [PMID: 31548730 DOI: 10.1038/s41585-019-0228-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2019] [Indexed: 02/07/2023]
Abstract
Tuberculosis (TB) is the most common cause of death from infectious disease worldwide. A substantial proportion of patients presenting with extrapulmonary TB have urogenital TB (UG-TB), which can easily be overlooked owing to non-specific symptoms, chronic and cryptic protean clinical manifestations, and lack of clinician awareness of the possibility of TB. Delay in diagnosis results in disease progression, irreversible tissue and organ damage and chronic renal failure. UG-TB can manifest with acute or chronic inflammation of the urinary or genital tract, abdominal pain, abdominal mass, obstructive uropathy, infertility, menstrual irregularities and abnormal renal function tests. Advanced UG-TB can cause renal scarring, distortion of renal calyces and pelvic, ureteric strictures, stenosis, urinary outflow tract obstruction, hydroureter, hydronephrosis, renal failure and reduced bladder capacity. The specific diagnosis of UG-TB is achieved by culturing Mycobacterium tuberculosis from an appropriate clinical sample or by DNA identification. Imaging can aid in localizing site, extent and effect of the disease, obtaining tissue samples for diagnosis, planning medical or surgical management, and monitoring response to treatment. Drug-sensitive TB requires 6-9 months of WHO-recommended standard treatment regimens. Drug-resistant TB requires 12-24 months of therapy with toxic drugs with close monitoring. Surgical intervention as an adjunct to medical drug treatment is required in certain circumstances. Current challenges in UG-TB management include making an early diagnosis, raising clinical awareness, developing rapid and sensitive TB diagnostics tests, and improving treatment outcomes.
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Dutta A, Pattanaik S, Choudhury R, Nanda P, Sahu S, Panigrahi R, Padhi BK, Sahoo KC, Mishra PR, Panigrahi P, Lekharu D, Stevens RH. Impact of involvement of non-formal health providers on TB case notification among migrant slum-dwelling populations in Odisha, India. PLoS One 2018; 13:e0196067. [PMID: 29791449 PMCID: PMC5965830 DOI: 10.1371/journal.pone.0196067] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 04/05/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Migrant labourers living in the slums of urban and industrial patches across India make up a key sub-population so far controlling Tuberculosis (TB) in the country is concerned. This is because many TB patients from these communities- remain under reached by the Revised National Tuberculosis Control Programme (RNTCP) of India. This marginalized community usually seeks early-stage healthcare from "friendly neighbourhood" non-formal health providers (NFHPs). Because, RNTCP has limited capacity to involve the NFHPs, an implementation research project was conceived, whereby an external partner would engage with the NFHPs to enable them to identify early TB symptomatics from this key sub-population who would be then tested using Xpert MTB/RIF technology. Diagnosed TB cases among them would be referred promptly to RNTCP for treatment. This paper aimed to describe the project and its impact. METHODS Adopting a quasi-experimental before-after design, four RNTCP units from two major urban-industrial areas of Odisha were selected for intervention, which spanned five quarters and covered 151,400 people, of which 30% were slum-dwelling migrants. Two similar units comprised the control population. The hypothesis was, reaching the under reached in the intervention area through NFHPs would increase TB notification from these traditionally under-notifying units. RNTCP notification data during intervention was compared with pre-intervention era, adjusted for contemporaneous changes in control population. RESULTS The project detected 488 Xpert+ TB cases, of whom 466 were administered RNTCP treatment. This translated into notification of additional 198 new bacteriologically positive cases to RNTCP, a 30% notification surge, after adjustment for 2% decline in control. This meant an average quarterly increase in notification of 41.20(20.08, 62.31; p<0.001) cases. The increase was immediate, evident from the rise in level in the time series analysis by 50.42(10.28, 90.55; p = 0.02) cases. CONCLUSION Engagement with NFHPs contributed to an increase in TB notification to RNTCP from key under reached, slum-dwelling migrant populations.
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Affiliation(s)
- Ambarish Dutta
- Asian Institute of Public Health, Bhubaneswar, India
- * E-mail:
| | | | | | - Pritish Nanda
- Asian Institute of Public Health, Bhubaneswar, India
| | | | | | | | | | - P. R. Mishra
- Asian Institute of Public Health, Bhubaneswar, India
| | - Pinaki Panigrahi
- University of Nebraska Medical Centre, Omaha, Nebraska, United States of America
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Seki M, Kim CK, Hayakawa S, Mitarai S. Recent advances in tuberculosis diagnostics in resource-limited settings. Eur J Clin Microbiol Infect Dis 2018; 37:1405-1410. [DOI: 10.1007/s10096-018-3258-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 04/10/2018] [Indexed: 10/17/2022]
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Pathmanathan I, Date A, Coggin WL, Nkengasong J, Piatek AS, Alexander H. Rolling Out Xpert ® MTB/RIF for TB Detection in HIV-Infected Populations:An Opportunity for Systems Strengthening. Afr J Lab Med 2017; 6. [PMID: 28785533 PMCID: PMC5523912 DOI: 10.4102/ajlm.v6i2.460] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background To eliminate preventable deaths, disease and suffering due to tuberculosis, improved diagnostic capacity is critical. The Cepheid Xpert MTB/RIF® assay is recommended by the World Health Organization as the initial diagnostic test for people with suspected HIV-associated tuberculosis. However, despite high expectations, its scale-up in real-world settings has faced challenges, often due to the systems that support it. Opportunities for System Strengthening In this commentary, we discuss needs and opportunities for systems strengthening to support widespread scale-up of Xpert MTB/RIF as they relate to each step within the tuberculosis diagnostic cascade, from finding presumptive patients, to collecting, transporting and testing sputum specimens, to reporting and receiving results, to initiating and monitoring treatment and, ultimately, to ensuring successful and timely treatment and cure. Investments in evidence-based interventions at each step along the cascade and within the system as a whole will augment not only the utility of Xpert MTB/RIF, but also the successful implementation of future diagnostic tests. Conclusion Xpert MTB/RIF will only improve patient outcomes if optimally implemented within the context of strong tuberculosis programmes and systems. Roll-out of this technology to people living with HIV and others in resource-limited settings offers the opportunity to leverage current tuberculosis and HIV laboratory, diagnostic and programmatic investments, while also addressing challenges and strengthening coordination between laboratory systems, laboratory-programme interfaces, and tuberculosis-HIV programme interfaces. If successful, the benefits of this tool could extend beyond progress toward global End TB Strategy goals, to improve system-wide capacity for global disease detection and control.
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Affiliation(s)
- Ishani Pathmanathan
- Division of Global HIV and TB, U.S. Centers for Disease Control & Prevention, Atlanta, USA.,Epidemic Intelligence Service, U.S. Centers for Disease Control & Prevention, Atlanta, USA
| | - Anand Date
- Division of Global HIV and TB, U.S. Centers for Disease Control & Prevention, Atlanta, USA
| | - William L Coggin
- Division of Global HIV and TB, U.S. Centers for Disease Control & Prevention, Atlanta, USA
| | - John Nkengasong
- Division of Global HIV and TB, U.S. Centers for Disease Control & Prevention, Atlanta, USA
| | - Amy S Piatek
- Global Health Bureau, United States Agency for International Development, Washington DC, USA
| | - Heather Alexander
- Division of Global HIV and TB, U.S. Centers for Disease Control & Prevention, Atlanta, USA
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Somily AM, Barry MA, Habib HA, Alotaibi FE, Al-Zamil FA, Khan MA, Sarwar MS, Bakhash ND, Alrabiaah AA, Shakoor ZA, Senok AC. Evaluation of GeneXpert MTB/RIF for detection of Mycobacterium tuberculosis complex and rpo B gene in respiratory and non-respiratory clinical specimens at a tertiary care teaching hospital in Saudi Arabia. Saudi Med J 2016; 37:1404-1407. [PMID: 27874159 PMCID: PMC5303782 DOI: 10.15537/smj.2016.12.15506] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 08/31/2016] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES To assess the performance of Xpert MTB/RIF, an automated molecular test for Mycobacterium tuberculosis (MTB) and resistance to rifampin (RIF), against smear microscopy and culture method for diagnosis of MTB infection. Methods: This is a retrospective analysis of 103 respiratory and 137 non-respiratory patient specimens suspected of tuberculosis at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia performed between April 2014 and March 2015. Each sample underwent smear microscopy, mycobacterial culture, and GeneXpert MTB/RIF test. Results: Fifteen out of 103 respiratory samples were smear and culture positive, whereas 9 out of 137 non-respiratory samples were smear positive. Out of 9 smear positive specimens, 8 were also culture positive. All 15 culture positive respiratory samples were detected by Xpert MTB/RIF (sensitivity and positive predictive value [PPV]=100%). Similarly, all 8 culture positive non-respiratory specimens were identified by Xpert MTB/RIF (sensitivity 100%; PPV 88.8%). The Xpert MTB/RIF detected only one false positive result in 88 smear negative respiratory specimens (specificity 98.9%; negative predictive value [NPV]= 100%). All 125 smear negative non-respiratory specimens tested negative by culture and Xpert MTB/RIF (sensitivity, specificity, PPV, NPV= 100%). Conclusion: The performance of Xpert MTB/RIF was comparable to the gold standard culture method for identification of MTB in both respiratory and non-respiratory clinical specimens.
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Affiliation(s)
- Ali M Somily
- Department of Pathology/Microbiology, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia. E-mail.
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Gupta-Wright A, Fielding KL, van Oosterhout JJ, Wilson DK, Corbett EL, Flach C, Reddy KP, Walensky RP, Peters JA, Alufandika-Moyo M, Lawn SD. Rapid urine-based screening for tuberculosis to reduce AIDS-related mortality in hospitalized patients in Africa (the STAMP trial): study protocol for a randomised controlled trial. BMC Infect Dis 2016; 16:501. [PMID: 27659507 PMCID: PMC5034586 DOI: 10.1186/s12879-016-1837-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 09/16/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND HIV-associated tuberculosis (TB) co-infection remains an enormous burden to international public health. Post-mortem studies have highlighted the high proportion of HIV-positive adults admitted to hospital with TB. Determine TB-LAM and Xpert MTB/RIF assays can substantially increase diagnostic yield of TB within one day of hospital admission. However, it remains unclear if this approach can impact clinical outcomes. The STAMP trial aims to test the hypothesis that the implementation a urine-based screening strategy for TB can reduce all cause-mortality among HIV-positive patients admitted to hospital when compared to current, sputum-based screening. METHODS The trial is a pragmatic, individually randomised, multi-country (Malawi and South Africa) clinical trial with two study arms (1:1 recruitment). Unselected HIV-positive patients admitted to medical wards, irrespective of presentation, meeting the inclusion criteria and giving consent will be randomized to screening for TB using either: (i) 'standard of care'- testing of sputum using the Xpert MTB/RIF assay (Xpert) or (ii) 'intervention'- testing of sputum using Xpert and testing of urine using (a) Determine TB-LAM lateral-flow assay and (b) Xpert following concentration of urine by centrifugation. Patients will be excluded if they have received TB treatment in the previous 12 months, if they have received isoniazid preventive therapy in the last 6 months, if they are aged <18 years or they live outside the pre-specified geographical area. Results will be provided to the responsible medical team as soon as available to inform decisions regarding TB treatment. Both the study and routine medical team will be masked to study arm allocation. 1300 patients will be enrolled per arm (equal numbers at the two trial sites). The primary endpoint is all-cause mortality at 56 days. An economic analysis will be conducted to project long-term outcomes for shorter-term trial data, including cost-effectiveness. DISCUSSION This pragmatic trial assesses an intervention to reduce the high mortality caused by HIV-associated TB, which could feasibly be scaled up in high-burden settings if shown to be efficacious and cost-effective. We discuss the challenges of designing a trial to assess the impact on mortality of laboratory-based TB screening interventions given frequent initiation of empirical treatment and a failure of several previous clinical trials to demonstrate an impact on clinical outcomes. We also elaborate on the practical and ethical issues of 'testing a test' in general. TRIAL REGISTRATION ISRCTN Registry ( ISRCTN71603869 ) prospectively registered 08 May 2015; the South African National Controlled Trials Registry (DOH-27-1015-5185) prospectively registered October 2015.
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Affiliation(s)
- Ankur Gupta-Wright
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK.
- Malawi-Liverpool-Wellcome Trust Clinical Research Program, University of Malawi College of Medicine, Blantyre, Malawi.
| | - Katherine L Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
- University of the Witwatersrand, Johannesburg, South Africa
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Douglas K Wilson
- Department of Internal Medicine, Edendale Hospital, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Elizabeth L Corbett
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Program, University of Malawi College of Medicine, Blantyre, Malawi
| | - Clare Flach
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Krishna P Reddy
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard University Center for AIDS Research, Harvard Medical School, Boston, MA, USA
| | - Rochelle P Walensky
- Divisions of General Medicine and Infectious Disease, Massachusetts General Hospital, Boston, MA, USA
- The Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard University Center for AIDS Research, Harvard Medical School, Boston, MA, USA
| | - Jurgens A Peters
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Stephen D Lawn
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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11
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Schito M, Migliori GB, Fletcher HA, McNerney R, Centis R, D'Ambrosio L, Bates M, Kibiki G, Kapata N, Corrah T, Bomanji J, Vilaplana C, Johnson D, Mwaba P, Maeurer M, Zumla A. Perspectives on Advances in Tuberculosis Diagnostics, Drugs, and Vaccines. Clin Infect Dis 2016; 61Suppl 3:S102-18. [PMID: 26409271 DOI: 10.1093/cid/civ609] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Despite concerted efforts over the past 2 decades at developing new diagnostics, drugs, and vaccines with expanding pipelines, tuberculosis remains a global emergency. Several novel diagnostic technologies show promise of better point-of-care rapid tests for tuberculosis including nucleic acid-based amplification tests, imaging, and breath analysis of volatile organic compounds. Advances in new and repurposed drugs for use in multidrug-resistant (MDR) or extensively drug-resistant (XDR) tuberculosis have focused on development of several new drug regimens and their evaluation in clinical trials and now influence World Health Organization guidelines. Since the failure of the MVA85A vaccine 2 years ago, there have been no new tuberculosis vaccine candidates entering clinical testing. The current status quo of the lengthy treatment duration and poor treatment outcomes associated with MDR/XDR tuberculosis and with comorbidity of tuberculosis with human immunodeficiency virus and noncommunicable diseases is unacceptable. New innovations and political and funder commitment for early rapid diagnosis, shortening duration of therapy, improving treatment outcomes, and prevention are urgently required.
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Affiliation(s)
- Marco Schito
- Critical Path to TB Drug Regimens, Critical Path Institute, Tucson, Arizona
| | - Giovanni Battista Migliori
- World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy
| | - Helen A Fletcher
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine
| | | | - Rosella Centis
- World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy
| | - Lia D'Ambrosio
- World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy
| | - Matthew Bates
- University of Zambia-University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia
| | - Gibson Kibiki
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Nathan Kapata
- University of Zambia-University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia
| | - Tumena Corrah
- Department of Infectious Diseases and Tropical Medicine, Northwick Park Hospital
| | - Jamshed Bomanji
- Department of Nuclear Imaging, University College London Hospitals NHS Foundation Trust, United Kingdom
| | - Cris Vilaplana
- Unitat de Tuberculosi Experimental, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Ctra. de Can Ruti, Camí de les Escoles, Barcelona, Spain
| | - Daniel Johnson
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Peter Mwaba
- University of Zambia-University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia
| | - Markus Maeurer
- Therapeutic Immunology, Departments of Laboratory Medicine and Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden
| | - Alimuddin Zumla
- Division of Infection and Immunity, University College London and National Institute for Health Research Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, United Kingdom
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12
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McNerney R, Peeling RW. Regulatory In Vitro Diagnostics Landscape in Africa: Update on Regional Activities. Clin Infect Dis 2016; 61Suppl 3:S135-40. [PMID: 26409274 DOI: 10.1093/cid/civ553] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Improved diagnostic tests for tuberculosis case detection are urgently needed that are affordable, robust, and easy to use so that they can be implemented widely. The mandate of national regulatory authorities is to ensure the safety and effectiveness of diagnostics, protecting the population against unsafe products while expediting access to beneficial new devices. However, regulatory approval processes in the developing world are often complex, lengthy, and not transparent. Recent progress in building regulatory capacity using harmonized approaches will reduce duplication in clinical performance studies and manufacturing audits, facilitate information sharing through trust and mutual confidence building, and ultimately improve efficiency. These savings can be passed onto the consumers in the form of more affordable pricing and allowing new high-quality tests for tuberculosis to be introduced more quickly and without delay.
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Affiliation(s)
- Ruth McNerney
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Rosanna W Peeling
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
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13
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Banerjee R, Starke JR. What tuberculosis can teach us about combating multidrug-resistant Gram negative bacilli. J Clin Tuberc Other Mycobact Dis 2016; 3:28-34. [PMID: 31723682 PMCID: PMC6850263 DOI: 10.1016/j.jctube.2016.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 03/15/2016] [Accepted: 03/18/2016] [Indexed: 12/03/2022] Open
Abstract
There are striking similarities between the dual pandemics of multidrug-resistant tuberculosis (MDR TB) and multidrug-resistant Gram negative bacilli (MDR GNB) despite fundamental differences in the pathogenesis and epidemiology of these pathogens. In this perspective, we highlight several strategies that have been used by the global TB community to address the MDR TB problem, including approaches to: encourage appropriate use of anti-TB medications, enhance appropriate utilization of molecular diagnostic testing, facilitate development of new antimicrobial agents, and strengthen surveillance systems and infection control practices. Understanding the successes and challenges of these strategies for MDR TB control will be instructive for efforts to curb emergence and spread of MDR GNB.
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Affiliation(s)
- Ritu Banerjee
- Division of Pediatric Infectious Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States
| | - Jeffrey R. Starke
- Section of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
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14
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Danquah CA, Maitra A, Gibbons S, Faull J, Bhakta S. HT-SPOTi: A Rapid Drug Susceptibility Test (DST) to Evaluate Antibiotic Resistance Profiles and Novel Chemicals for Anti-Infective Drug Discovery. ACTA ACUST UNITED AC 2016; 40:17.8.1-17.8.12. [PMID: 26855282 DOI: 10.1002/9780471729259.mc1708s40] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Antibiotic resistance is one of the major threats to global health and well-being. The past decade has seen an alarming rise in the evolution and spread of drug-resistant strains of pathogenic microbes. The emergence of extensively drug resistant (XDR) strains of Mycobacterium tuberculosis and antimicrobial resistance among the ESKAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumanii, Pseudomonas aeruginosa, and Enterobacter species) as well as fungal pathogens (such as certain species of Candida, Aspergillus, Cryptococcus, and Trichophyton) poses a significant 21st century scientific challenge. With an extremely limited arsenal of efficacious antibiotics, techniques that can (a) identify novel antimicrobials and (b) detect antimicrobial resistance are becoming increasingly important. In this article, we illustrate the HT-SPOTi, an assay that is principally based on the growth of an organism on agar medium containing a range of different concentrations of drugs or inhibitors. The simple methodology makes this assay ideal for evaluating novel antimicrobial compounds as well as profiling an organism's antibiotic resistance profile.
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Affiliation(s)
- Cynthia A Danquah
- Department of Biological Sciences, Institute of Structural and Molecular Biology, Birkbeck, University of London, London, United Kingdom.,Research Department of Pharmaceutical and Biological Chemistry, UCL School of Pharmacy, London, United Kingdom.,These authors contributed equally
| | - Arundhati Maitra
- Department of Biological Sciences, Institute of Structural and Molecular Biology, Birkbeck, University of London, London, United Kingdom.,These authors contributed equally
| | - Simon Gibbons
- Research Department of Pharmaceutical and Biological Chemistry, UCL School of Pharmacy, London, United Kingdom
| | - Jane Faull
- Department of Biological Sciences, Institute of Structural and Molecular Biology, Birkbeck, University of London, London, United Kingdom
| | - Sanjib Bhakta
- Department of Biological Sciences, Institute of Structural and Molecular Biology, Birkbeck, University of London, London, United Kingdom
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15
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Expanding the role of diagnostic and prognostic tools for infectious diseases in resource-poor settings. Nature 2015; 528:S50-2. [PMID: 26633765 DOI: 10.1038/nature16038] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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16
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Rabna P, Ramos J, Ponce G, Sanca L, Mané M, Armada A, Machado D, Vieira F, Gomes VF, Martins E, Colombatti R, Riccardi F, Perdigão J, Sotero J, Portugal I, Couto I, Atouguia J, Rodrigues A, Viveiros M. Direct Detection by the Xpert MTB/RIF Assay and Characterization of Multi and Poly Drug-Resistant Tuberculosis in Guinea-Bissau, West Africa. PLoS One 2015; 10:e0127536. [PMID: 26017968 PMCID: PMC4446334 DOI: 10.1371/journal.pone.0127536] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 04/16/2015] [Indexed: 11/18/2022] Open
Abstract
Background This study aimed to evaluate the usefulness of the Xpert MTB/RIF assay for the rapid direct detection of M. tuberculosis complex (MTBC) strains and rifampicin resistance associated mutations in a resource-limited setting such as Guinea-Bissau and its implications in the management of tuberculosis (TB) and drug resistant tuberculosis, complementing the scarce information on resistance and genotypic diversity of MTBC strains in this West African country. Methods and Results This cross-sectional prospective study included 100 consecutive TB patients with positive acid-fast smears at two months of anti-tuberculosis treatment or in a re-treatment situation, between May and December 2012. Resistance to rifampicin was detected using the GeneXpert system and the Xpert MTB/RIF assay. MTBC isolates obtained with the BACTEC MGIT 960 system were tested for susceptibility to first- and second-line anti-tuberculosis drugs. Overall, the prevalence of multidrug-resistant tuberculosis (MDR-TB) was found to be 9 cases. Of these, 67% (6 patients) of confirmed MDR-TB cases had no past history of TB treatment and 33% (3 patients) were previously treated cases. Extensively drug-resistant TB was not found. Molecular typing of the MDR-TB strains revealed recent transmission patterns of imported MDR strains. Conclusions The Xpert MTB/RIF assay was reliable for the detection of rifampicin resistant MTBC strains directly from sputum samples of patients undergoing first-line treatment for two months, being more trustworthy than the simple presence of acid-fast bacilli in the smear. Its implementation is technically simple, does not require specialized laboratory infrastructures and is suitable for resource-limited settings when a regular source of electricity and maintenance is available as well as financial and operation sustainability is guaranteed by the health authorities. A high prevalence of MDR-TB among patients at risk of MDR-TB after two months of first-line treatment was found, in support of the WHO recommendations for its use in the management of this risk group.
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Affiliation(s)
- Paulo Rabna
- Instituto Nacional de Saúde Pública/Projecto de Saúde de Bandim (INASA/PSB), Bissau, Guiné-Bissau
| | - Jorge Ramos
- Grupo de Micobactérias, Unidade de Microbiologia Médica, Global Health and Tropical Medicine (GHTM), Instituto de Higiene e Medicina Tropical, Universidade NOVA de Lisboa (IHMT, UNL), Lisboa, Portugal
| | - Gema Ponce
- Unidade de Clínica Tropical, Instituto de Higiene e Medicina Tropical de Lisboa/Universidade NOVA de Lisboa (IHMT/UNL), Lisboa, Portugal
| | - Lilica Sanca
- Instituto Nacional de Saúde Pública/Projecto de Saúde de Bandim (INASA/PSB), Bissau, Guiné-Bissau
| | - Morto Mané
- Instituto Nacional de Saúde Pública/Projecto de Saúde de Bandim (INASA/PSB), Bissau, Guiné-Bissau
| | - Ana Armada
- Grupo de Micobactérias, Unidade de Microbiologia Médica, Global Health and Tropical Medicine (GHTM), Instituto de Higiene e Medicina Tropical, Universidade NOVA de Lisboa (IHMT, UNL), Lisboa, Portugal
- Centro de Malária e Outras Doenças Tropicais (CMDT), Instituto de Higiene e Medicina Tropical de Lisboa/Universidade NOVA de Lisboa (IHMT/UNL), Lisboa, Portugal
| | - Diana Machado
- Grupo de Micobactérias, Unidade de Microbiologia Médica, Global Health and Tropical Medicine (GHTM), Instituto de Higiene e Medicina Tropical, Universidade NOVA de Lisboa (IHMT, UNL), Lisboa, Portugal
| | - Fina Vieira
- Hospital Raoul Follereau, Bissau, Guiné-Bissau
| | - Victor F. Gomes
- Ministério da Saúde/Programa Nacional de Luta contra a Tuberculose, Bissau, Guiné-Bissau
| | | | | | - Fabio Riccardi
- Aid, Health and Development-Onlus—Ahead-Onlus, Rome, Italy
| | - João Perdigão
- Centro de Patogénese Molecular, URIA, Faculdade de Farmácia, Universidade de Lisboa, Lisboa, Portugal
| | - Joana Sotero
- Centro de Patogénese Molecular, URIA, Faculdade de Farmácia, Universidade de Lisboa, Lisboa, Portugal
| | - Isabel Portugal
- Centro de Patogénese Molecular, URIA, Faculdade de Farmácia, Universidade de Lisboa, Lisboa, Portugal
| | - Isabel Couto
- Grupo de Micobactérias, Unidade de Microbiologia Médica, Global Health and Tropical Medicine (GHTM), Instituto de Higiene e Medicina Tropical, Universidade NOVA de Lisboa (IHMT, UNL), Lisboa, Portugal
| | - Jorge Atouguia
- Unidade de Clínica Tropical, Instituto de Higiene e Medicina Tropical de Lisboa/Universidade NOVA de Lisboa (IHMT/UNL), Lisboa, Portugal
- Centro de Malária e Outras Doenças Tropicais (CMDT), Instituto de Higiene e Medicina Tropical de Lisboa/Universidade NOVA de Lisboa (IHMT/UNL), Lisboa, Portugal
| | - Amabélia Rodrigues
- Instituto Nacional de Saúde Pública/Projecto de Saúde de Bandim (INASA/PSB), Bissau, Guiné-Bissau
| | - Miguel Viveiros
- Grupo de Micobactérias, Unidade de Microbiologia Médica, Global Health and Tropical Medicine (GHTM), Instituto de Higiene e Medicina Tropical, Universidade NOVA de Lisboa (IHMT, UNL), Lisboa, Portugal
- Centro de Malária e Outras Doenças Tropicais (CMDT), Instituto de Higiene e Medicina Tropical de Lisboa/Universidade NOVA de Lisboa (IHMT/UNL), Lisboa, Portugal
- * E-mail:
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17
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Respiratory tract infections in community and healthcare settings: epidemiological, diagnostic and management challenges. Curr Opin Pulm Med 2015; 21:209-11. [PMID: 25784249 DOI: 10.1097/mcp.0000000000000163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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