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Chen S, Wang C, Zou Y, Zong Z, Xue Y, Jia J, Dong L, Zhao L, Chen L, Liu L, Chen W, Huang H. Tuberculosis-targeted next-generation sequencing and machine learning: An ultrasensitive diagnostic strategy for paucibacillary pulmonary tuberculosis and tuberculous meningitis. Clin Chim Acta 2024; 553:117697. [PMID: 38145644 DOI: 10.1016/j.cca.2023.117697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/03/2023] [Accepted: 12/04/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND Existing diagnostic approaches for paucibacillary tuberculosis (TB) are limited by the low sensitivity of testing methods and difficulty in obtaining suitable samples. METHODS An ultrasensitive TB diagnostic strategy was established, integrating efficient and specific TB targeted next-generation sequencing and machine learning models, and validated in clinical cohorts to test plasma cfDNA, cerebrospinal fluid (CSF) DNA collected from tuberculous meningitis (TBM) and pediatric pulmonary TB (PPTB) patients. RESULTS In the detection of 227 samples, application of the specific thresholds of CSF DNA (AUC = 0.974) and plasma cfDNA (AUC = 0.908) yielded sensitivity of 97.01 % and the specificity of 95.65 % in CSF samples and sensitivity of 82.61 % and specificity of 86.36 % in plasma samples, respectively. In the analysis of 44 paired samples from TBM patients, our strategy had a high concordance of 90.91 % (40/44) in plasma cfDNA and CSF DNA with both sensitivity of 95.45 % (42/44). In the PPTB patient, the sensitivity of the TB diagnostic strategy yielded higher sensitivity on plasma specimen than Xpert assay on gastric lavage (28.57 % VS. 15.38 %). CONCLUSIONS Our TB diagnostic strategy provides greater detection sensitivity for paucibacillary TB, while plasma cfDNA as an easily collected specimen, could be an appropriate sample type for PTB and TBM diagnosis.
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Affiliation(s)
- Suting Chen
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China
| | - Congli Wang
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Yijun Zou
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Zhaojing Zong
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China; Department of Respiratory and Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi 563001, China
| | - Yi Xue
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China
| | - Junnan Jia
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China
| | - Lingling Dong
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China
| | - Liping Zhao
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China
| | - Lu Chen
- Beijing Macroµ-test Bio-Tech Co., Ltd., Beijing 101300, China
| | - Licheng Liu
- Beijing Macroµ-test Bio-Tech Co., Ltd., Beijing 101300, China
| | - Weijun Chen
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, China.
| | - Hairong Huang
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China.
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Katoch C, Peter DK, Marwah V, Kumar K, Bhati G. Prevalence of isoniazid resistance in cases of rifampicin resistance detected on GeneXpert MTB/RIF assay. Med J Armed Forces India 2023; 79:S1-S5. [PMID: 38144631 PMCID: PMC10746728 DOI: 10.1016/j.mjafi.2021.04.007] [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: 01/05/2020] [Accepted: 04/14/2021] [Indexed: 10/21/2022] Open
Abstract
Background The fight against tuberculosis in our country has taken a new shape with the inclusion of rapid nucleic acid amplification tests like GeneXpert MTB/RIF assay which rapidly detects Mycobacterium tuberculosis and rifampicin resistance. Rifampicin resistance detected on GeneXpert has been considered as a sine qua non for the presence of isoniazid resistance and hence classified as multidrug-resistant tuberculosis (MDR-TB). However treatment of rifampicin-resistant, isoniazid-monoresistance, and MDR-TB are different. Our study was done with the aim of identification of the prevalence of isoniazid resistance on culture, in cases which had rifampicin resistance on GeneXpert. Methods Pulmonary samples of patients of presumptive tuberculosis were subjected to GeneXpert testing and liquid MGIT (mycobacterium growth indicator tube) culture. On detection of rifampicin resistance on MTB/RIF assay, the patients were included in our study and cultures were followed-up for sensitivity to isoniazid. A total of 76 patients were included. Results 76 patients of rifampicin resistance on GeneXpert MTB/RIF assay were followed-up for the sensitivity of isoniazid on culture media. Out of the 76 cases, 62 (81.57%) were found to have isoniazid resistance. Out of the 14 patients, the cultures showed no growth in 6, and in the rest, isoniazid was found to be sensitive. Conclusion GeneXpert MTB/RIF assay is an excellent modality for the detection of M. tuberculosis and rifampicin resistance. The decision to exclude isoniazid from the treatment regimen in patients with rifampicin resistance should be made only after conducting further molecular/phenotypic tests.
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Affiliation(s)
- C.D.S. Katoch
- Director & CEO, All India Institute of Medical Sciences (AIIMS), Rajkot, Gujarat, India
| | - Deepu K. Peter
- Graded Specialist (Pulmonary Medicine), Critical Care & Sleep Medicine, Army Institute of Cardiothoracic Sciences (AICTS), Pune, India
| | - Vikas Marwah
- Senior Advisor & Professor (Pulmonary Medicine), Critical Care & Sleep Medicine, Army Institute of Cardiothoracic Sciences (AICTS), Pune, India
| | - Kunal Kumar
- Graded Specialist (Pulmonary Medicine), Critical Care & Sleep Medicine, Military Hospital Namkum, Ranchi, India
| | - Gaurav Bhati
- Graded Specialist (Pulmonary Medicine), Critical Care & Sleep Medicine, Army Institute of Cardiothoracic Sciences (AICTS), Pune, India
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Abuzerr S, Zinszer K. Computer-aided diagnostic accuracy of pulmonary tuberculosis on chest radiography among lower respiratory tract symptoms patients. Front Public Health 2023; 11:1254658. [PMID: 37965525 PMCID: PMC10641698 DOI: 10.3389/fpubh.2023.1254658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/09/2023] [Indexed: 11/16/2023] Open
Abstract
Even though the Gaza Strip is a low pulmonary tuberculosis (TB) burden region, it is well-known that TB is primarily a socioeconomic problem associated with overcrowding, poor hygiene, a lack of fresh water, and limited access to healthcare, which is the typical case in the Gaza Strip. Therefore, this study aimed at assessing the accuracy of the automatic software computer-aided detection for tuberculosis (CAD4TB) in diagnosing pulmonary TB on chest radiography and compare the CAD4TB software reading with the results of geneXpert. Using a census sampling method, the study was conducted in radiology departments in the Gaza Strip hospitals between 1 December 2022 and 31 March 2023. A digital X-ray, printer, and online X-ray system backed by CAD4TBv6 software were used to screen patients with lower respiratory tract symptoms. GeneXpert analysis was performed for all patients having a score > 40. A total of 1,237 patients presenting with lower respiratory tract symptoms participated in this current study. Chest X-ray readings showed that 7.8% (n = 96) were presumptive for TB. The CAD4TBv6 scores showed that 11.8% (n = 146) of recruited patients were presumptive for TB. GeneXpert testing on sputum samples showed that 6.2% (n = 77) of those with a score > 40 on CAD4TB were positive for pulmonary TB. Significant differences were found in chest X-ray readings, CAD4TBv6 scores, and GeneXpert results among sociodemographic and health status variables (P-value < 0.05). The study showed that the incidence rate of TB in the Gaza Strip is 3.5 per 100,000 population in the Gaza strip. The sensitivity of the CAD4TBv6 score and the symptomatic review for tuberculosis with a threshold score of >40 is 80.2%, and the specificity is 94.0%. The positive Likelihood Ratio is 13.3%, Negative Likelihood Ratio is 0.2 with 7.8% prevalence. Positive Predictive Value is 52.7%, Negative Predictive Value is 98.3%, and accuracy is 92.9%. In a resource-limited country with a high burden of neglected disease, combining chest X-ray readings by CAD4TB and symptomatology is extremely valuable for screening a population at risk. CAD4TB is noticeably more efficient than other methods for TB screening and early diagnosis in people who would otherwise go undetected.
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Affiliation(s)
- Samer Abuzerr
- Department of Medical Sciences, University College of Science and Technology, Gaza, Palestine
| | - Kate Zinszer
- School of Public Health, Department of Social and Preventive Medicine, University of Montreal, Montréal, QC, Canada
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Tjale MA, Ombinda-Lemboumba S, Maphanga C, Mthunzi-Kufa P. TB diagnostic insights, progress made on point of care diagnostics and bioinformatics as an additional tool for improvement. Indian J Tuberc 2023; 70:468-474. [PMID: 37968053 DOI: 10.1016/j.ijtb.2023.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/19/2022] [Accepted: 03/31/2023] [Indexed: 11/17/2023]
Abstract
Despite major efforts made to control tuberculosis disease (TB), this disease continues to present a major global health challenge and drug resistance is continuously growing. TB is caused by Mycobacterium tuberculosis and spreads exclusively via human-to-human contact transmission. Therefore, early detection and diagnosis for proper treatment with active TB have a great impact on public health. Regardless, most people in developing countries with TB or TB-associated symptoms do not have access to an adequate initial diagnosis. Available bacteriologic-based techniques are either inefficient or may require a longer turnaround time from the laboratory. Contemporarily, non-bacteriologic based methods have both questionable sensitivity and specificity and while others cannot distinguish between active and latent TB. Thus, additional efforts have been made to find accurate diagnostic tests for TB. Herein, we review the available methods used for TB diagnosis, and in addition, we explore point of care (POC) diagnostics as an alternative way to develop TB diagnostic tests and further evaluate whether bioinformatics can be used as an additional screening tool for identification of possible TB biomarkers for the development of POC TB diagnostics, which is part of our research focus.
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Affiliation(s)
- Mabotse A Tjale
- Biophotonics, National Laser Centre, Council for Scientific and Industrial Research, P/O Box 395, Meiring Naudé Road Brummeria, Pretoria, South Africa.
| | - Saturnin Ombinda-Lemboumba
- Biophotonics, National Laser Centre, Council for Scientific and Industrial Research, P/O Box 395, Meiring Naudé Road Brummeria, Pretoria, South Africa
| | - Charles Maphanga
- Biophotonics, National Laser Centre, Council for Scientific and Industrial Research, P/O Box 395, Meiring Naudé Road Brummeria, Pretoria, South Africa; College of Agriculture, Engineering and Science, School of Chemistry and Physics, University of KwaZulu-Natal, Pietermaritzburg Campus, King Edward Avenue, Pietermaritzburg, South Africa
| | - Patience Mthunzi-Kufa
- Biophotonics, National Laser Centre, Council for Scientific and Industrial Research, P/O Box 395, Meiring Naudé Road Brummeria, Pretoria, South Africa; College of Agriculture, Engineering and Science, School of Chemistry and Physics, University of KwaZulu-Natal, Pietermaritzburg Campus, King Edward Avenue, Pietermaritzburg, South Africa
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Kitenge MK, Fatti G, Eshun-Wilson I, Aluko O, Nyasulu P. Prevalence and trends of advanced HIV disease among antiretroviral therapy-naïve and antiretroviral therapy-experienced patients in South Africa between 2010-2021: a systematic review and meta-analysis. BMC Infect Dis 2023; 23:549. [PMID: 37608300 PMCID: PMC10464046 DOI: 10.1186/s12879-023-08521-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 08/08/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Despite the significant progress made in South Africa in getting millions of individuals living with HIV into care, many patients still present or re-enter care with Advanced HIV Disease (AHD). We aimed to estimate the prevalence of AHD among ART-naive and ART-experienced patients in South Africa using studies published between January 2010 and May 2022. METHODS We searched for relevant data on PubMed, CINAHL, Scopus and other sources, with a geographical filters limited to South Africa, up to May 31, 2022. Two reviewers conducted all screening, eligibility assessment, data extraction, and critical appraisal. We synthesized the data using the inverse-variance heterogeneity model and Freeman-Tukey transformation. We assessed heterogeneity using the I2 statistic and publication bias using the Egger and Begg's test. RESULTS We identified 2,496 records, of which 53 met the eligibility criteria, involving 11,545,460 individuals. The pooled prevalence of AHD among ART-naive and ART-experienced patients was 43.45% (95% CI 40.1-46.8%, n = 53 studies) and 58.6% (95% CI 55.7 to 61.5%, n = 2) respectively. The time trend analysis showed a decline of 2% in the prevalence of AHD among ART-naive patients per year. However, given the high heterogeneity between studies, the pooled prevalence should be interpreted with caution. CONCLUSION Despite HIV's evolution to a chronic disease, our findings show that the burden of AHD remains high among both ART-naive and ART-experienced patients in South Africa. This emphasizes the importance of regular measurement of CD4 cell count as an essential component of HIV care. In addition, providing innovative adherence support and interventions to retain ART patients in effective care is a crucial priority for those on ART.
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Affiliation(s)
- Marcel K Kitenge
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
- Tuberculosis and HIV investigative Network (THINK), Durban, Kwazulu-Natal, South Africa.
| | - Geoffrey Fatti
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Kheth'Impilo AIDS Free Living, Cape Town, South Africa
| | - Ingrid Eshun-Wilson
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Omololu Aluko
- Faculty of Health Sciences, School of Medical Sciences, Department of Biostatistics, University of the Free State, Bloemfontein, South Africa
| | - Peter Nyasulu
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Kumar M, Kumar G, Kumar R, Muni S, Choubey S, Kumar S, Kumari N. A Comparative Analysis of Microscopy, Culture, and the Xpert Mycobacterium tuberculosis/Rifampicin Assay in Diagnosing Pulmonary Tuberculosis in Human Immunodeficiency-Positive Individuals. Cureus 2023; 15:e42962. [PMID: 37667708 PMCID: PMC10475316 DOI: 10.7759/cureus.42962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2023] [Indexed: 09/06/2023] Open
Abstract
INTRODUCTION Individuals with human immunodeficiency virus (HIV) infection have an increased likelihood of developing tuberculosis (TB). The primary objective of this study was to compare the diagnostic accuracy of microscopy, culture, and the Xpert Mycobacterium tuberculosis/Rifampicin (MTB/RIF) assay in the diagnosis of pulmonary TB in sputum samples of HIV-infected patients. The secondary objectives were to evaluate the sensitivity and specificity of these three methods along with a comparison of diagnostic approaches for detecting drug-resistant strains. MATERIAL AND METHODS This prospective, laboratory-based study was done in the Microbiology Department of IGIMS, Patna. The study included sputum samples of 102 individuals who were HIV-positive and exhibited symptoms indicative of tuberculosis. RESULTS Out of 102 individuals suspected of having tuberculosis, 18 tested positive for M. tuberculosis. Male individuals between the ages of 31 and 40 were more affected by both HIV and tuberculosis, and in most of these cases, their CD4 cell count was below 200 cells/µl. Among the 102 sputum samples collected, 18% (18 samples) were found to be positive using the Mycobacterium Growth Indicator Tube (MGIT) 960 liquid culture method. Two samples were contaminated, and 14.7% (15 cases) tested positive using the cartridge-based nucleic acid amplification test (CBNAAT) method. Additionally, 3.92% (four samples) were positive using the ZN staining method. CONCLUSION The study found that Xpert MTB/RIF outperformed other methods in identifying resistance to RIF, showed better agreement with gene sequencing results for RIF resistance, and had higher accuracy in detecting tuberculosis cases, including both smear-positive and smear-negative cases.
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Affiliation(s)
- Manish Kumar
- Microbiology, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Gudesh Kumar
- Microbiology, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Rakesh Kumar
- Microbiology, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Sweta Muni
- Microbiology, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Satyadeo Choubey
- Pulmonary Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Shailesh Kumar
- Microbiology, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Namrata Kumari
- Microbiology, Indira Gandhi Institute of Medical Sciences, Patna, IND
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Calvet-Seral J, Crespo-Yuste E, Mathys V, Rodriguez-Villalobos H, Ceyssens PJ, Martin A, Gonzalo-Asensio J. Targeted Chromosomal Barcoding Establishes Direct Genotype-Phenotype Associations for Antibiotic Resistance in Mycobacterium abscessus. Microbiol Spectr 2023; 11:e0534422. [PMID: 36988496 PMCID: PMC10269753 DOI: 10.1128/spectrum.05344-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 03/04/2023] [Indexed: 03/30/2023] Open
Abstract
A bedaquiline-resistant Mycobacterium abscessus isolate was sequenced, and a candidate mutation in the atpE gene was identified as responsible for the antibiotic resistance phenotype. To establish a direct genotype-phenotype relationship of this mutation which results in a Asp-to-Ala change at position 29 (D29A), we developed a recombineering-based method consisting of the specific replacement of the desired mutation in the bacterial chromosome. As surrogate bacteria, we used two M. abscessus bedaquiline-susceptible strains: ATCC 19977 and the SL541 clinical isolate. The allelic exchange substrates used in recombineering carried either the sole D29A mutation or a genetic barcode of silent mutations in codons flanking the D29A mutation. After selection of bedaquiline-resistant M. abscessus colonies transformed with both substrates, we obtained equivalent numbers of recombinants. These resistant colonies were analyzed by allele-specific PCR and Sanger sequencing, and we demonstrated that the presence of the genetic barcode was linked to the targeted incorporation of the desired mutation in its chromosomal location. All recombinants displayed the same MIC to bedaquiline as the original isolate, from which the D29A mutation was identified. Finally, to demonstrate the broad applicability of this method, we confirmed the association of bedaquiline resistance with the atpE A64P mutation in analysis performed in independent M. abscessus strains and by independent researchers. IMPORTANCE Antimicrobial resistance (AMR) threatens the effective prevention and treatment of an ever-increasing range of infections caused by microorganisms. On the other hand, infections caused by Mycobacterium abscessus affect people with chronic lung diseases, and their incidence has grown alarmingly in recent years. Further, these bacteria are known to easily develop AMR to the few therapeutic options available, making their treatment long-lasting and challenging. The recent introduction of new antibiotics against M. abscessus, such as bedaquiline, makes us anticipate a future when a plethora of antibiotic-resistant strains will be isolated and sequenced. However, in the era of whole-genome sequencing, one of the challenges is to unequivocally assign a biological function to each identified polymorphism. Thus, in this study, we developed a fast, robust, and reliable method to assign genotype-phenotype associations for putative antibiotic-resistant polymorphisms in M. abscessus.
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Affiliation(s)
- Juan Calvet-Seral
- Grupo de Genética de Micobacterias, Departamento de Microbiología, Facultad de Medicina, Universidad de Zaragoza IIS-Aragón, Zaragoza, Spain
- CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Estefanía Crespo-Yuste
- Grupo de Genética de Micobacterias, Departamento de Microbiología, Facultad de Medicina, Universidad de Zaragoza IIS-Aragón, Zaragoza, Spain
- CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Vanessa Mathys
- Unit of Human Bacterial Diseases, Sciensano, Brussels, Belgium
| | - Hector Rodriguez-Villalobos
- Cliniques Universitaires Saint-Luc, Microbiology Department, Université Catholique de Louvain, Brussels, Belgium
| | | | - Anandi Martin
- Institute of Experimental and Clinical Research, Université Catholique de Louvain, Woluwe-Saint-Lambert, Belgium
- Syngulon, Seraing, Belgium
| | - Jesús Gonzalo-Asensio
- Grupo de Genética de Micobacterias, Departamento de Microbiología, Facultad de Medicina, Universidad de Zaragoza IIS-Aragón, Zaragoza, Spain
- CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Biocomputación y Física de Sistemas Complejos, Zaragoza, Spain
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Martin-Higuera MC, Rivas G, Rolo M, Muñoz-Gallego I, Lopez-Roa P. Xpert MTB/RIF Ultra CT value provides a rapid measure of sputum bacillary burden and predicts smear status in patients with pulmonary tuberculosis. Sci Rep 2023; 13:1591. [PMID: 36709214 PMCID: PMC9884223 DOI: 10.1038/s41598-023-28869-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 01/25/2023] [Indexed: 01/30/2023] Open
Abstract
Traditionally, smear microscopy has been used to estimate bacillary burden in order to assess infectiousness in tuberculosis (TB) patients. Since Xpert MTB assays might replace smear microscopy as the first-line diagnostic test for pulmonary tuberculosis, an alternative measure of bacillary load that correlates with smear positivity is needed. This study assessed the correlation between CT (with and without normalization), smear status, culture time-to-positivity (TTP), and clinical factors in patients with Xpert ultra positive sputum during a four-year period. A cut-off CT value for smear positivity was also estimated. 204 samples were included. Strong correlation between both Xpert Ultra CT values (raw and normalized) and smear status was obtained (r = 0.78 and - 0.79, respectively). The association between Raw-CT and TTP was weaker than normalized-CT (N-CT) and TTP (r = 0.50 and r = - 0.70, respectively). A Raw-CT cut-off value of 21.4 was identified with 85.7% (95% CI 65.4-95) sensitivity and 92.9% (95% CI 84.3-96.9) specificity. A N-CT cut-off value of 5.2 yielded a sensitivity of 94.3% (95% CI 86.2-97.8) and specificity of 85.7% (95% CI 65.4-95). Our study demonstrates that Xpert Ultra CT value correlates well with other measures of bacillary load such as smear status or TTP. The correlation with TTP is stronger when the CT value is normalized using the internal control. The proposed N-CT cut-off value of 5.2 shows a better sensitivity than the Raw-CT when predicting smear positive status.
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Affiliation(s)
- M C Martin-Higuera
- Department of Clinical Microbiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - G Rivas
- Department of Clinical Microbiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - M Rolo
- Department of Clinical Microbiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - I Muñoz-Gallego
- Department of Clinical Microbiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Paula Lopez-Roa
- Department of Clinical Microbiology, Hospital Universitario 12 de Octubre, Madrid, Spain.
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Mukoka M, Twabi HH, Msefula C, Semphere R, Ndhlovu G, Lipenga T, Sikwese TD, Malisita K, Choko A, Corbett EL, MacPherson P, Nliwasa M. Utility of Xpert MTB/RIF Ultra and digital chest radiography for the diagnosis and treatment of TB in people living with HIV: a randomised controlled trial (XACT-TB). Trans R Soc Trop Med Hyg 2023; 117:28-37. [PMID: 35963826 PMCID: PMC9808509 DOI: 10.1093/trstmh/trac079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/09/2022] [Accepted: 07/27/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND TB is a leading cause of morbidity among HIV positive individuals. Accurate algorithms are needed to achieve early TB diagnosis and treatment. We investigated the use of Xpert MTB/RIF Ultra in combination with chest radiography for TB diagnosis in ambulatory HIV positive individuals. METHODS This was a randomised controlled trial with a 2-by-2 factorial design. Outpatient HIV clinic attendees with cough were randomised to four arms: Arm 1-Standard Xpert/no chest radiography (CXR); Arm 2-Standard Xpert/CXR; Arm 3-Xpert Ultra/no CXR; and Arm 4-Xpert Ultra/CXR. Participants were followed up at days 28 and 56 to assess for TB treatment initiation. RESULTS We randomised 640 participants. Bacteriologically confirmed TB treatment initiation at day 28 were: Arm 1 (8.4% [14/162]), Arm 2 (6.9% [11/159]), Arm 3 (8.2% [13/159]) and Arm 4 (5.6% [9/160]) and between Xpert Ultra group (Arms 3 and 4) (6.9% [22/319]) vs Standard Xpert group (Arms 1 and 2) (7.8% [25/321]), risk ratio 0.89 (95% CI 0.51 to 1.54). By day 56, there were also similar all-TB treatment initiations in the x-ray group (Arms 2 and 4) (16.0% [51/319]) compared with the no x-ray group (Arms 1 and 3) (13.1% [42/321]), risk ratio 1.22 (95% CI 0.84 to 1.78); however, the contribution of clinically diagnosed treatment initiations were higher in x-ray groups (50.9% vs 19.0%). CONCLUSIONS Xpert Ultra performed similarly to Xpert MTB/RIF. X-rays are useful for TB screening but further research should investigate how to mitigate false-positive treatment initiations.
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Affiliation(s)
- Madalo Mukoka
- Pathology Department, Helse Nord TB Initiative, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi
- Public Health Group, Malawi–Liverpool–Wellcome Trust Clinical Research Programme, P.O. Box 30096, Blantyre, Malawi
| | - Hussein H Twabi
- Pathology Department, Helse Nord TB Initiative, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi
- Public Health Group, Malawi–Liverpool–Wellcome Trust Clinical Research Programme, P.O. Box 30096, Blantyre, Malawi
| | - Chisomo Msefula
- Pathology Department, Helse Nord TB Initiative, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi
| | - Robina Semphere
- Pathology Department, Helse Nord TB Initiative, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi
- Public Health Group, Malawi–Liverpool–Wellcome Trust Clinical Research Programme, P.O. Box 30096, Blantyre, Malawi
| | - Gabriel Ndhlovu
- Pathology Department, Helse Nord TB Initiative, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi
- Public Health Group, Malawi–Liverpool–Wellcome Trust Clinical Research Programme, P.O. Box 30096, Blantyre, Malawi
| | - Trancizeo Lipenga
- Pathology Department, Helse Nord TB Initiative, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi
| | - Tionge Daston Sikwese
- Pathology Department, Helse Nord TB Initiative, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi
| | - Kenneth Malisita
- Lighthouse Umodzi centre, Queen Elizabeth Central Hospital, P.O. Box 95, Blantyre, Malawi
| | - Augustine Choko
- Public Health Group, Malawi–Liverpool–Wellcome Trust Clinical Research Programme, P.O. Box 30096, Blantyre, Malawi
| | - Elizabeth L Corbett
- Public Health Group, Malawi–Liverpool–Wellcome Trust Clinical Research Programme, P.O. Box 30096, Blantyre, Malawi
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Peter MacPherson
- Public Health Group, Malawi–Liverpool–Wellcome Trust Clinical Research Programme, P.O. Box 30096, Blantyre, Malawi
- Department of Public Health and Policy, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Marriott Nliwasa
- Pathology Department, Helse Nord TB Initiative, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi
- Public Health Group, Malawi–Liverpool–Wellcome Trust Clinical Research Programme, P.O. Box 30096, Blantyre, Malawi
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10
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Caruso CR, Yang Z. Molecular diagnostics of infectious disease: Detection and characterization of microbial agents in cytology samples. Diagn Cytopathol 2023; 51:68-82. [PMID: 36263664 DOI: 10.1002/dc.25064] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/30/2022] [Accepted: 10/10/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cytology samples are widely used to diagnose various infectious diseases by detection and identification of causative infectious agents, including bacteria, fungi, and viruses. The role of cytopathology in infectious disease has expanded tremendously in the past decades with the advances in molecular techniques. Molecular diagnostic methods, compared to conventional methods, have shown improved patient outcome, reduction in cost, and shortened hospital stay times. The aim of this article is to review molecular testing in cytology samples for diagnosis of infectious diseases. METHODS The literature search for molecular testing in common cytology samples for diagnosis of infectious diseases was performed. The findings of the studies were summarized. The common cytology samples included in this article were gynecologic specimens, cerebrospinal fluid, bronchoalveolar lavage, and urine samples. CONCLUSIONS There are a number of molecular diagnostic tests that are available to be used in common cytology samples to detect infectious agents. Each test has its own advantages and limitations. It is our hope that upon reading this review article, the readers will have better understanding of molecular diagnostic testing of infectious diseases utilizing commonly sampled cytology specimens in daily practice.
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Affiliation(s)
- Carla R Caruso
- Department of Pathology and Anatomic Sciences, University of Missouri, Columbia, Missouri, USA
| | - Zhongbo Yang
- Department of Pathology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
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11
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Jayasooriya S, Dimambro-Denson F, Beecroft C, Balen J, Awokola B, Mitchell C, Kampmann B, Campbell F, Dodd P, Mortimer K. Patients with presumed tuberculosis in sub-Saharan Africa that are not diagnosed with tuberculosis: a systematic review and meta-analysis. Thorax 2023; 78:50-60. [PMID: 35074900 PMCID: PMC9763185 DOI: 10.1136/thoraxjnl-2021-217663] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 12/07/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Many patients in sub-Saharan Africa whom a diagnosis of tuberculosis is considered are subsequently not diagnosed with tuberculosis. The proportion of patients this represents, and their alternative diagnoses, have not previously been systematically reviewed. METHODS We searched four databases from inception to 27 April 2020, without language restrictions. We included all adult pulmonary tuberculosis diagnostic studies from sub-Saharan Africa, excluding case series and inpatient studies. We extracted the proportion of patients with presumed tuberculosis subsequently not diagnosed with tuberculosis and any alternative diagnoses received. We conducted a random effects meta-analysis to obtain pooled estimates stratified by passive and active case finding. RESULTS Our search identified 1799 studies, of which 18 studies (2002-2019) with 14 527 participants from 10 African countries were included. The proportion of patients with presumed tuberculosis subsequently not diagnosed with tuberculosis was 48.5% (95% CI 39.0 to 58.0) in passive and 92.8% (95% CI 85.0 to 96.7) in active case-finding studies. This proportion increased with declining numbers of clinically diagnosed tuberculosis cases. A history of tuberculosis was documented in 55% of studies, with just five out of 18 reporting any alternative diagnoses. DISCUSSION Nearly half of all patients with presumed tuberculosis in sub-Saharan Africa do not have a final diagnosis of active tuberculosis. This proportion may be higher when active case-finding strategies are used. Little is known about the healthcare needs of these patients. Research is required to better characterise these patient populations and plan health system solutions that meet their needs. PROSPERO REGISTRATION NUMBER CRD42018100004.
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Affiliation(s)
| | | | - Claire Beecroft
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Julie Balen
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Babatunde Awokola
- Vaccines and Immunity Theme, Medical Research Council The Gambia, Banjul, Gambia
| | - Caroline Mitchell
- Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, UK
| | - Beate Kampmann
- Vaccines and Immunity Theme, Medical Research Council The Gambia, Banjul, Gambia
- Paediatric Infection & Immunity, London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, UK
| | - Fiona Campbell
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Pete Dodd
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Kevin Mortimer
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Deparment of Respiratory Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
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12
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Wang C, Sun L, Li Q, Lu H. Xpert MTB/RIF Ultra in the auxiliary diagnosis of tuberculosis among people living with human immunodeficiency virus. Drug Discov Ther 2022; 16:305-308. [PMID: 36529510 DOI: 10.5582/ddt.2022.01082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Clinical diagnosis of tuberculosis (TB) in people living with the human immunodeficiency virus (HIV) poses a challenge. The Xpert MTB/RIF Ultra (Ultra) has displayed greater sensitivity at diagnosing tuberculosis and rifampicin resistance compared to the Xpert MTB/RIF (Xpert). However, whether Ultra is able to facilitate an auxiliary diagnosis of TB in patients with an HIV-TB co-infection remains unclear. Accordingly, the current study evaluated the use of Ultra in patients with an HIV-TB co-infection by summarizing relevant studies. The sensitivity and specificity of Ultra and Xpert at diagnosing patients with an HIV-TB co-infection have been summarized and compared. The performance of Ultra in diagnosing extrapulmonary tuberculosis was also summarized. Although a large-cohort, multi-center study needs to be conducted to assess Ultra's ability to detect TB in AIDS patients in the future, the current evidence supports the use of Ultra for the assessment of patients with an HIV-TB co-infection.
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Affiliation(s)
- Cheng Wang
- National Clinical Research Centre for Infectious Diseases, The Third People's Hospital of Shenzhen and The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China.,School of Public Health, Bengbu Medical College, Bengbu, Anhui, China
| | - Liqin Sun
- National Clinical Research Centre for Infectious Diseases, The Third People's Hospital of Shenzhen and The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Qian Li
- National Clinical Research Centre for Infectious Diseases, The Third People's Hospital of Shenzhen and The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Hongzhou Lu
- National Clinical Research Centre for Infectious Diseases, The Third People's Hospital of Shenzhen and The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
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13
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Algorithms for Screening for Active Tuberculosis among Individuals with Latent Tuberculosis Infection in a Rural Community in China. Microbiol Spectr 2022; 10:e0296722. [PMID: 36445141 PMCID: PMC9769587 DOI: 10.1128/spectrum.02967-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Screening for active tuberculosis (TB) among individuals with latent tuberculosis infection (LTBI) is important for the initiation and evaluation of TB preventive treatment. The performances of different tools and their combinations had rarely been studied in community-level screening among individuals with LTBI in China. This study aimed to explore appropriate algorithms for screening for active TB among individuals with LTBI in rural China. Three sputum samples were collected from each participant for smear microscopy, culture, and an Xpert MTB/RIF assay. Chest digital radiography and TB symptoms were investigated as well. The performances of different testing algorithms were compared with that of sputum culture as the gold standard. Overall, 1,564 study participants with LTBI were investigated, with a final diagnosis of 20 TB cases by sputum culture. Compared with other tests, the Xpert MTB/RIF assay detected 80.00% (95% confidence interval [CI], 58.40% to 91.93%) of culture-positive cases, with the highest sensitivity. When tests were combined using "or," "and," or "step" algorithms, the highest sensitivity reached 90.00% (95% CI, 69.90% to 97.21%) for the combination of the Xpert MTB/RIF assay and chest radiography, but the positive predictive value (PPV) decreased to 22.22% (95% CI, 14.54% to 32.41%). The Xpert MTB/RIF assay alone showed the best agreement with sputum culture, with a kappa value of 0.840. Pathogen molecular detection alone showed good performance compared to the other algorithms, for ruling out active TB in general LTBI, but the high cost might be a challenge for scaling it up. Identifying those with a high risk for progression to TB more precisely and establishing a cost-effective screening algorithm deserve further exploration. IMPORTANCE Enhancing community-wide active case screening in target LTBI populations is important for achieving the early treatment of active TB, and ruling active TB out is a prerequisite for initiating preventive treatment. The current study evaluated the performances of multiple tests and their combinations in screening for active TB among individuals with LTBI at the community level. Compared with the classical "TB symptoms and chest radiography" algorithm, the application of Xpert MTB/RIF improved the sensitivity from 45% to 80%. When the Xpert MTB/RIF assay was combined with chest radiography, the sensitivity was further improved to 90.00%, which achieved the World Health Organization (WHO) target product profiles. However, the algorithm requires caution as the PPV decreased from 88.89% for Xpert MTB/RIF alone to 22.22% for the combination. Xpert MTB/RIF alone offered remarkable sensitivity without compromising the PPV but would have major resource implications. Thus, identifying target populations for LTBI treatment more precisely and developing cost-effective and high-throughput screening tools and algorithms deserve further efforts.
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14
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Kay AW, Ness T, Verkuijl SE, Viney K, Brands A, Masini T, González Fernández L, Eisenhut M, Detjen AK, Mandalakas AM, Steingart KR, Takwoingi Y. Xpert MTB/RIF Ultra assay for tuberculosis disease and rifampicin resistance in children. Cochrane Database Syst Rev 2022; 9:CD013359. [PMID: 36065889 PMCID: PMC9446385 DOI: 10.1002/14651858.cd013359.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Every year, an estimated one million children and young adolescents become ill with tuberculosis, and around 226,000 of those children die. Xpert MTB/RIF Ultra (Xpert Ultra) is a molecular World Health Organization (WHO)-recommended rapid diagnostic test that simultaneously detects Mycobacterium tuberculosis complex and rifampicin resistance. We previously published a Cochrane Review 'Xpert MTB/RIF and Xpert MTB/RIF Ultra assays for tuberculosis disease and rifampicin resistance in children'. The current review updates evidence on the diagnostic accuracy of Xpert Ultra in children presumed to have tuberculosis disease. Parts of this review update informed the 2022 WHO updated guidance on management of tuberculosis in children and adolescents. OBJECTIVES To assess the diagnostic accuracy of Xpert Ultra for detecting: pulmonary tuberculosis, tuberculous meningitis, lymph node tuberculosis, and rifampicin resistance, in children with presumed tuberculosis. Secondary objectives To investigate potential sources of heterogeneity in accuracy estimates. For detection of tuberculosis, we considered age, comorbidity (HIV, severe pneumonia, and severe malnutrition), and specimen type as potential sources. To summarize the frequency of Xpert Ultra trace results. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, three other databases, and three trial registers without language restrictions to 9 March 2021. SELECTION CRITERIA Cross-sectional and cohort studies and randomized trials that evaluated Xpert Ultra in HIV-positive and HIV-negative children under 15 years of age. We included ongoing studies that helped us address the review objectives. We included studies evaluating sputum, gastric, stool, or nasopharyngeal specimens (pulmonary tuberculosis), cerebrospinal fluid (tuberculous meningitis), and fine needle aspirate or surgical biopsy tissue (lymph node tuberculosis). For detecting tuberculosis, reference standards were microbiological (culture) or composite reference standard; for stool, we also included Xpert Ultra performed on a routine respiratory specimen. For detecting rifampicin resistance, reference standards were drug susceptibility testing or MTBDRplus. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and, using QUADAS-2, assessed methodological quality judging risk of bias separately for each target condition and reference standard. For each target condition, we used the bivariate model to estimate summary sensitivity and specificity with 95% confidence intervals (CIs). We stratified all analyses by type of reference standard. We summarized the frequency of Xpert Ultra trace results; trace represents detection of a very low quantity of Mycobacterium tuberculosis DNA. We assessed certainty of evidence using GRADE. MAIN RESULTS We identified 14 studies (11 new studies since the previous review). For detection of pulmonary tuberculosis, 335 data sets (25,937 participants) were available for analysis. We did not identify any studies that evaluated Xpert Ultra accuracy for tuberculous meningitis or lymph node tuberculosis. Three studies evaluated Xpert Ultra for detection of rifampicin resistance. Ten studies (71%) took place in countries with a high tuberculosis burden based on WHO classification. Overall, risk of bias was low. Detection of pulmonary tuberculosis Sputum, 5 studies Xpert Ultra summary sensitivity verified by culture was 75.3% (95% CI 64.3 to 83.8; 127 participants; high-certainty evidence), and specificity was 97.1% (95% CI 94.7 to 98.5; 1054 participants; high-certainty evidence). Gastric aspirate, 7 studies Xpert Ultra summary sensitivity verified by culture was 70.4% (95% CI 53.9 to 82.9; 120 participants; moderate-certainty evidence), and specificity was 94.1% (95% CI 84.8 to 97.8; 870 participants; moderate-certainty evidence). Stool, 6 studies Xpert Ultra summary sensitivity verified by culture was 56.1% (95% CI 39.1 to 71.7; 200 participants; moderate-certainty evidence), and specificity was 98.0% (95% CI 93.3 to 99.4; 1232 participants; high certainty-evidence). Nasopharyngeal aspirate, 4 studies Xpert Ultra summary sensitivity verified by culture was 43.7% (95% CI 26.7 to 62.2; 46 participants; very low-certainty evidence), and specificity was 97.5% (95% CI 93.6 to 99.0; 489 participants; high-certainty evidence). Xpert Ultra sensitivity was lower against a composite than a culture reference standard for all specimen types other than nasopharyngeal aspirate, while specificity was similar against both reference standards. Interpretation of results In theory, for a population of 1000 children: • where 100 have pulmonary tuberculosis in sputum (by culture): - 101 would be Xpert Ultra-positive, and of these, 26 (26%) would not have pulmonary tuberculosis (false positive); and - 899 would be Xpert Ultra-negative, and of these, 25 (3%) would have tuberculosis (false negative). • where 100 have pulmonary tuberculosis in gastric aspirate (by culture): - 123 would be Xpert Ultra-positive, and of these, 53 (43%) would not have pulmonary tuberculosis (false positive); and - 877 would be Xpert Ultra-negative, and of these, 30 (3%) would have tuberculosis (false negative). • where 100 have pulmonary tuberculosis in stool (by culture): - 74 would be Xpert Ultra-positive, and of these, 18 (24%) would not have pulmonary tuberculosis (false positive); and - 926 would be Xpert Ultra-negative, and of these, 44 (5%) would have tuberculosis (false negative). • where 100 have pulmonary tuberculosis in nasopharyngeal aspirate (by culture): - 66 would be Xpert Ultra-positive, and of these, 22 (33%) would not have pulmonary tuberculosis (false positive); and - 934 would be Xpert Ultra-negative, and of these, 56 (6%) would have tuberculosis (false negative). Detection of rifampicin resistance Xpert Ultra sensitivity was 100% (3 studies, 3 participants; very low-certainty evidence), and specificity range was 97% to 100% (3 studies, 128 participants; low-certainty evidence). Trace results Xpert Ultra trace results, regarded as positive in children by WHO standards, were common. Xpert Ultra specificity remained high in children, despite the frequency of trace results. AUTHORS' CONCLUSIONS We found Xpert Ultra sensitivity to vary by specimen type, with sputum having the highest sensitivity, followed by gastric aspirate and stool. Nasopharyngeal aspirate had the lowest sensitivity. Xpert Ultra specificity was high against both microbiological and composite reference standards. However, the evidence base is still limited, and findings may be imprecise and vary by study setting. Although we found Xpert Ultra accurate for detection of rifampicin resistance, results were based on a very small number of studies that included only three children with rifampicin resistance. Therefore, findings should be interpreted with caution. Our findings provide support for the use of Xpert Ultra as an initial rapid molecular diagnostic in children being evaluated for tuberculosis.
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Affiliation(s)
- Alexander W Kay
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Tara Ness
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | | - Kerri Viney
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Annemieke Brands
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Tiziana Masini
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Lucia González Fernández
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Michael Eisenhut
- Paediatric Department, Luton & Dunstable University Hospital NHS Foundation Trust, Luton, UK
| | | | - Anna M Mandalakas
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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15
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Bian Y, Deng M, Zhang Q, Hou G. Global trends of research on tuberculous pleurisy over the past 15 years: A bibliometric analysis. Front Cell Infect Microbiol 2022; 12:937811. [PMID: 36111237 PMCID: PMC9468418 DOI: 10.3389/fcimb.2022.937811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/28/2022] [Indexed: 11/17/2022] Open
Abstract
Tuberculous pleurisy (TP) is a common type of extrapulmonary tuberculosis (EPTB). With the development of research and changes in TP patient characteristics, an increasing number of studies have revealed the prevalence, risk factors, and novel diagnosis techniques. Thus, this bibliometric analysis was performed to identify global scientific output characteristics and research hotspots and frontiers for TP over the past 15 years. We searched the Web of Science Core Collection (WoSCC) Science Citation Index Expanded (SCI-expanded) for literature published between 2007 and 2021 and recorded their information. The Bibliometrix software package was used for bibliometric indicator analysis, and VOSviewer was used to visualize the trends of and hotspots in TP research. A total of 1,464 original articles were reviewed, and the results indicated that the annual number of publications (Np) focusing on TP has increased over the past 15 years. China had the largest number of papers and the highest H-index, and the United States ranked first for number of citations (Nc). EGYPTIAN KNOWLEDGE BANK and PLOS ONE were the most prolific unit and journal, respectively. The use of the Xpert assay and immune-related biomarker detection to diagnose TP appears to be a recent research hotspot. This bibliometric study demonstrated that the number of publications related to TP have tended to increase. China is a major producer, and the United States is an influential country in this field. Research in the past 15 years has been predominantly clinical research. The diagnosis of TP was the focus of research, and the exploration of novel diagnostic techniques, verification of diagnostic markers, and combination of diagnostic methods have been recent research hotspots. Immune-related biomarkers should be given more attention in the field of TP diagnosis.
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Affiliation(s)
- Yiding Bian
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Mingming Deng
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Qin Zhang
- Department of Pulmonary and Critical Care Medicine, First Hospital of China Medical University, Shenyang, China
| | - Gang Hou
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
- *Correspondence: Gang Hou,
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16
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Yusoof KA, García JI, Schami A, Garcia-Vilanova A, Kelley HV, Wang SH, Rendon A, Restrepo BI, Yotebieng M, Torrelles JB. Tuberculosis Phenotypic and Genotypic Drug Susceptibility Testing and Immunodiagnostics: A Review. Front Immunol 2022; 13:870768. [PMID: 35874762 PMCID: PMC9301132 DOI: 10.3389/fimmu.2022.870768] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/06/2022] [Indexed: 12/24/2022] Open
Abstract
Tuberculosis (TB), considered an ancient disease, is still killing one person every 21 seconds. Diagnosis of Mycobacterium tuberculosis (M.tb) still has many challenges, especially in low and middle-income countries with high burden disease rates. Over the last two decades, the amount of drug-resistant (DR)-TB cases has been increasing, from mono-resistant (mainly for isoniazid or rifampicin resistance) to extremely drug resistant TB. DR-TB is problematic to diagnose and treat, and thus, needs more resources to manage it. Together with+ TB clinical symptoms, phenotypic and genotypic diagnosis of TB includes a series of tests that can be used on different specimens to determine if a person has TB, as well as if the M.tb strain+ causing the disease is drug susceptible or resistant. Here, we review and discuss advantages and disadvantages of phenotypic vs. genotypic drug susceptibility testing for DR-TB, advances in TB immunodiagnostics, and propose a call to improve deployable and low-cost TB diagnostic tests to control the DR-TB burden, especially in light of the increase of the global burden of bacterial antimicrobial resistance, and the potentially long term impact of the coronavirus disease 2019 (COVID-19) disruption on TB programs.
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Affiliation(s)
- Kizil A. Yusoof
- Graduate School of Biomedical Sciences, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Juan Ignacio García
- Population Health Program, Tuberculosis Group, Texas Biomedical Research Institute, San Antonio, TX, United States
- *Correspondence: Juan Ignacio García, ; Blanca I. Restrepo, ; Marcel Yotebieng, ; Jordi B. Torrelles,
| | - Alyssa Schami
- Graduate School of Biomedical Sciences, University of Texas Health San Antonio, San Antonio, TX, United States
- Population Health Program, Tuberculosis Group, Texas Biomedical Research Institute, San Antonio, TX, United States
| | - Andreu Garcia-Vilanova
- Population Health Program, Tuberculosis Group, Texas Biomedical Research Institute, San Antonio, TX, United States
| | - Holden V. Kelley
- Population Health Program, Tuberculosis Group, Texas Biomedical Research Institute, San Antonio, TX, United States
| | - Shu-Hua Wang
- Department of Internal Medicine, Division of Infectious Diseases, College of Medicine and Global One Health Initiative, The Ohio State University, Columbus, OH, United States
| | - Adrian Rendon
- Centro de Investigación, Prevención y Tratamiento de Infecciones Respiratorias (CIPTIR), Hospital Universitario de Monterrey Universidad Autónoma de Nuevo León (UANL), Monterrey, Mexico
| | - Blanca I. Restrepo
- School of Public Health, University of Texas Health Science Center at Houston, Brownsville, TX, United States
- School of Medicine, South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Edinburg, TX, United States
- *Correspondence: Juan Ignacio García, ; Blanca I. Restrepo, ; Marcel Yotebieng, ; Jordi B. Torrelles,
| | - Marcel Yotebieng
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, New York City, NY, United States
- *Correspondence: Juan Ignacio García, ; Blanca I. Restrepo, ; Marcel Yotebieng, ; Jordi B. Torrelles,
| | - Jordi B. Torrelles
- Graduate School of Biomedical Sciences, University of Texas Health San Antonio, San Antonio, TX, United States
- Population Health Program, Tuberculosis Group, Texas Biomedical Research Institute, San Antonio, TX, United States
- *Correspondence: Juan Ignacio García, ; Blanca I. Restrepo, ; Marcel Yotebieng, ; Jordi B. Torrelles,
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17
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Joaquim L, Faria A, Loureiro H, Matafome P. Benefits, mechanisms, and risks of intermittent fasting in metabolic syndrome and type 2 diabetes. J Physiol Biochem 2022; 78:295-305. [PMID: 34985730 DOI: 10.1007/s13105-021-00839-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 08/18/2021] [Indexed: 10/19/2022]
Abstract
One of the emergent nutritional strategies for improving multiple features of cardiometabolic diseases is the practice of intermittent fasting (IF), which consists of alternating periods of eating and fasting. IF can reduce circulating glucose and insulin levels, fat mass, and the risk of developing age-related pathologies. IF appears to upregulate evolution-conserved adaptive cellular responses, such as stress-response pathways, autophagy, and mitochondrial function. IF was also observed to modulate the circadian rhythms of hormones like insulin or leptin, among others, which levels change in conditions of food abundance and deficit. However, some contradictory results regarding the duration of the interventions and the anterior metabolic status of the participants suggest that more and longer studies are needed in order to draw conclusions. This review summarizes the current knowledge regarding the role of IF in the modulation of mechanisms involved in type 2 diabetes, as well as the risks.
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Affiliation(s)
- Lisandra Joaquim
- Instituto Politécnico de Coimbra, Coimbra Health School (ESTeSC), Coimbra, Portugal
| | - Ana Faria
- Instituto Politécnico de Coimbra, Coimbra Health School (ESTeSC), Coimbra, Portugal
| | - Helena Loureiro
- Instituto Politécnico de Coimbra, Coimbra Health School (ESTeSC), Coimbra, Portugal
| | - Paulo Matafome
- Instituto Politécnico de Coimbra, Coimbra Health School (ESTeSC), Coimbra, Portugal.
- Institute of Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Subunit 1, 1st floor, Azinhaga de Santa Comba, Celas, 3000-354, Coimbra, Portugal.
- Centre for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, Coimbra, Portugal.
- Clinical Academic Center, Coimbra, Portugal.
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18
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Kumar R, Muni S, Gupta A, Pankaj D, Kumar S, Kumari N. Evaluation of gene-xpert in paediatric tuberculous meningitis cases: A hospital-based study. ADVANCES IN HUMAN BIOLOGY 2022. [DOI: 10.4103/aihb.aihb_69_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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19
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de Faria MGBF, Andrade RLDP, Camillo AJG, Leite KFDS, Saita NM, Bollela VR, de Rezende CEM, Monroe AA. Effectiveness of GeneXpert® in the diagnosis of tuberculosis in people living with HIV/AIDS. Rev Saude Publica 2021; 55:89. [PMID: 34932706 PMCID: PMC8664060 DOI: 10.11606/s1518-8787.2021055003125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 02/19/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To identify and synthesize the scientific knowledge produced regarding the effectiveness of the GeneXpert test in the diagnosis of pulmonary tuberculosis (TB) in people living with HIV/AIDS. METHODS Integrative literature review, which was searched on Embase, Scopus, PubMed, Cinahl, Academic Search Premier, Socindex, and LILACS platforms, in December 2019. The studies surveyed went through two stages of selection: reading of titles and abstracts by two reviewers independently; using the Rayyan platform and reading. Nineteen primary studies in English, Portuguese, and Spanish that answered the study's guiding question were included: How effective is the GeneXpert test in the diagnosis of pulmonary TB in people living with HIV/AIDS? RESULTS The use of GeneXpert substantially increased the detection of TB cases among the population co-infected with HIV/AIDS, with sensitivity ranging from 68% to 100%, superior to sputum smear microscopy. Specificity ranged from 91.7% to 100%; the positive predictive value from 79.2% to 96.1%; and the negative predictive value from 84.6% to 99.3%. These values were considered similar to sputum smear microscopy by most studies. We also compared these results with different ways of performing culture and other molecular tests, being considered inferior only to the Xpert Ultra. CONCLUSION It is possible to affirm that places with a high incidence of HIV/AIDS would benefit from the implementation of the GeneXpert test, entailing effectiveness in diagnosing pulmonary TB in this population when compared to sputum smear microscopy, a widely used test for detection of cases.
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Affiliation(s)
- Mariana Gaspar Botelho Funari de Faria
- Universidade de São PauloEscola de Enfermagem de Ribeirão PretoPrograma de Pós-Graduação em Saúde PúblicaRibeirão PretoSPBrasilUniversidade de São Paulo. Escola de Enfermagem de Ribeirão Preto. Programa de Pós-Graduação em Saúde Pública. Ribeirão Preto, SP, Brasil
| | - Rubia Laine de Paula Andrade
- Universidade de São PauloEscola de Enfermagem de Ribeirão PretoDepartamento Materno-Infantil e Saúde PúblicaRibeirão PretoSPBrasilUniversidade de São Paulo. Escola de Enfermagem de Ribeirão Preto. Departamento Materno-Infantil e Saúde Pública. Ribeirão Preto, SP, Brasil
| | - Ana Julia Gonçalves Camillo
- Universidade de São PauloEscola de Enfermagem de Ribeirão PretoPrograma de Pós-Graduação em Saúde PúblicaRibeirão PretoSPBrasilUniversidade de São Paulo. Escola de Enfermagem de Ribeirão Preto. Programa de Pós-Graduação em Saúde Pública. Ribeirão Preto, SP, Brasil
| | - Karina Fonseca de Souza Leite
- Universidade de São PauloEscola de Enfermagem de Ribeirão PretoPrograma de Pós-Graduação em Saúde PúblicaRibeirão PretoSPBrasilUniversidade de São Paulo. Escola de Enfermagem de Ribeirão Preto. Programa de Pós-Graduação em Saúde Pública. Ribeirão Preto, SP, Brasil
| | - Nanci Michele Saita
- Universidade de São PauloEscola de Enfermagem de Ribeirão PretoPrograma de Pós-Graduação em Saúde PúblicaRibeirão PretoSPBrasilUniversidade de São Paulo. Escola de Enfermagem de Ribeirão Preto. Programa de Pós-Graduação em Saúde Pública. Ribeirão Preto, SP, Brasil
| | - Valdes Roberto Bollela
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoDepartamento de Clínica MédicaRibeirão PretoSPBrasilUniversidade de São Paulo. Faculdade de Medicina de Ribeirão Preto. Departamento de Clínica Médica e Divisão de Moléstias Infecciosas. Ribeirão Preto, SP, Brasil
| | - Carlos Eduardo Menezes de Rezende
- Universidade de São PauloEscola de Enfermagem de Ribeirão PretoPrograma de Pós-Graduação em Saúde PúblicaRibeirão PretoSPBrasilUniversidade de São Paulo. Escola de Enfermagem de Ribeirão Preto. Programa de Pós-Graduação em Saúde Pública. Ribeirão Preto, SP, Brasil
- Ministério da SaúdeAgência Nacional de Saúde SuplementarRio de JaneiroRJBrasilMinistério da Saúde. Agência Nacional de Saúde Suplementar. Rio de Janeiro, RJ, Brasil
| | - Aline Aparecida Monroe
- Universidade de São PauloEscola de Enfermagem de Ribeirão PretoDepartamento Materno-Infantil e Saúde PúblicaRibeirão PretoSPBrasilUniversidade de São Paulo. Escola de Enfermagem de Ribeirão Preto. Departamento Materno-Infantil e Saúde Pública. Ribeirão Preto, SP, Brasil
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20
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GeneXpert on patients with human immunodeficiency virus and smear-negative pulmonary tuberculosis. PLoS One 2021; 16:e0253961. [PMID: 34228759 PMCID: PMC8259960 DOI: 10.1371/journal.pone.0253961] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 06/17/2021] [Indexed: 11/25/2022] Open
Abstract
Objectives Vietnam is a high-prevalence country for tuberculosis (TB). Xpert MTB/RIF is a novel PCR-based diagnostic test that is substantially more sensitive for detecting M. tuberculosis than traditional smear-based techniques. However, locally-derived evidence of Xpert MTB/RIF in HIV-infected people is limited. This study evaluates the performance of the Xpert MTB/RIF in HIV-infected patients with smear-negative pulmonary TB (SNTB). Methods This was a cross-sectional study in 3 hospitals. The performance of Xpert MTB/RIF was compared with the reference standard of liquid culture and phenotypic drug-susceptibility testing for rifampicin (RIF) resistance. Results Out of 123 patients, the median age was 37.0 (IQR: 32.0–41.0) and 81.3% were male. The area under the receiver operating characteristic curve, sensitivity (Se) and specificity (Sp) of Xpert MTB/RIF for pulmonary TB diagnosis were 0.72 (95% confidence interval [CI]: 0.63–0.81), 66.7% (95%CI: 54.8–77.1) and 77.1% (95%CI: 62.7–88.0), respectively, while Se and Sp of Xpert MTB/RIF in detecting RIF resistance were 50.0 (11.8–88.2) and 86.4% (95%CI: 72.7–94.8). Conclusion The performance of Xpert MTB/RIF in HIV-infected patients with SNTB for the diagnosis of TB and RIF-resistance was low. Further studies are required to evaluate the results of Xpert MTB/RIF assay in HIV-infected patients with SNTB and the role of Xpert repetition on the same specimens.
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21
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Sun L, Yang Z, Yang F, Wang Z, Li H, Wang H, Sun T. Diagnosis of Mycobacterium tuberculosis Septic Shock in Patients With Anti-synthetase Syndrome Based on Next-Generation Sequencing: A Case Report and Literature Review. Front Med (Lausanne) 2021; 8:675041. [PMID: 34277657 PMCID: PMC8281055 DOI: 10.3389/fmed.2021.675041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/03/2021] [Indexed: 12/27/2022] Open
Abstract
A 51-year-old woman was transferred to the intensive care unit with such symptoms as fever, swollen left knee joint, pain and hypotension. After preliminary evaluation, she was diagnosed as suffering acute suppurative arthritis and septic shock. Then, she was rescued and prescribed to receive treatment with broad-spectrum antibiotics. However, there was no source of infection identified except for the knee joint. The bacterial and fungal cultures of blood samples and articular effusion were shown to be negative, while the results obtained from the next-generation sequencing of blood and articular effusion revealed that Mycobacterium tuberculosis was positive. The patient was then put on five combinations of anti-tuberculosis therapeutic treatment. Nevertheless, despite the active anti-tuberculosis treatment put in place, her general condition still deteriorated progressively. As the level of her bilirubin continued to rise, further treatment was affected, which prompted the change made to the anti-tuberculosis treatment program. Her clinical condition continued to deteriorate, which led to the development of unstable vital signs and the multiple organ dysfunction syndrome. In spite of our best efforts to save her life, the patient still ended up with death.
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Affiliation(s)
- Limin Sun
- General Intensive Care Unit, Zhengzhou Key Laboratory of Sepsis, Henan Key Laboratory of Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ziyue Yang
- General Intensive Care Unit, Zhengzhou Key Laboratory of Sepsis, Henan Key Laboratory of Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fei Yang
- General Intensive Care Unit, Zhengzhou Key Laboratory of Sepsis, Henan Key Laboratory of Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhenhua Wang
- General Intensive Care Unit, Zhengzhou Key Laboratory of Sepsis, Henan Key Laboratory of Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongqiang Li
- General Intensive Care Unit, Zhengzhou Key Laboratory of Sepsis, Henan Key Laboratory of Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Huifen Wang
- Department of Infectious Diseases, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Gene Hospital of Henan Province, Precision Medicine Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tongwen Sun
- General Intensive Care Unit, Zhengzhou Key Laboratory of Sepsis, Henan Key Laboratory of Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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22
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Krishnan S, Queiroz ATL, Gupta A, Gupte N, Bisson GP, Kumwenda J, Naidoo K, Mohapi L, Mave V, Mngqibisa R, Lama JR, Hosseinipour MC, Andrade BB, Karakousis PC. Integrative Multi-Omics Reveals Serum Markers of Tuberculosis in Advanced HIV. Front Immunol 2021; 12:676980. [PMID: 34168648 PMCID: PMC8217878 DOI: 10.3389/fimmu.2021.676980] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 05/13/2021] [Indexed: 11/13/2022] Open
Abstract
Tuberculosis (TB) accounts for disproportionate morbidity and mortality among persons living with HIV (PLWH). Conventional methods of TB diagnosis, including smear microscopy and Xpert MTB/RIF, have lower sensitivity in PLWH. Novel high-throughput approaches, such as miRNAomics and metabolomics, may advance our ability to recognize subclinical and difficult-to-diagnose TB, especially in very advanced HIV. We conducted a case-control study leveraging REMEMBER, a multi-country, open-label randomized controlled trial comparing 4-drug empiric standard TB treatment with isoniazid preventive therapy in PLWH initiating antiretroviral therapy (ART) with CD4 cell counts <50 cells/μL. Twenty-three cases of incident TB were site-matched with 32 controls to identify microRNAs (miRNAs), metabolites, and cytokines/chemokines, associated with the development of newly diagnosed TB in PLWH. Differentially expressed miRNA analysis revealed 11 altered miRNAs with a fold change higher than 1.4 or lower than -1.4 in cases relative to controls (p<0.05). Our analysis revealed no differentially abundant metabolites between cases and controls. We found higher TNFα and IP-10/CXCL10 in cases (p=0.011, p=0.0005), and higher MDC/CCL22 in controls (p=0.0072). A decision-tree algorithm identified gamma-glutamylthreonine and hsa-miR-215-5p as the optimal variables to classify incident TB cases (AUC 0.965; 95% CI 0.925-1.000). hsa-miR-215-5p, which targets genes in the TGF-β signaling pathway, was downregulated in cases. Gamma-glutamylthreonine, a breakdown product of protein catabolism, was less abundant in cases. To our knowledge, this is one of the first uses of a multi-omics approach to identify incident TB in severely immunosuppressed PLWH.
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Affiliation(s)
- Sonya Krishnan
- Center for Clinical Global Health Education and Center for Tuberculosis Research, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Artur T. L. Queiroz
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
| | - Amita Gupta
- Center for Clinical Global Health Education and Center for Tuberculosis Research, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Nikhil Gupte
- Center for Clinical Global Health Education and Center for Tuberculosis Research, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Gregory P. Bisson
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | | | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- South African Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Lerato Mohapi
- Soweto ACTG CRS, Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Rosie Mngqibisa
- Durban International Clinical Research Site, Enhancing Care Foundation, Durban, South Africa
| | | | - Mina C. Hosseinipour
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States
| | - Bruno B. Andrade
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Curso de Medicina, Faculdade de Tecnologia e Ciências (FTC), Salvador, Brazil
- Curso de Medicina, Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, Brazil
| | - Petros C. Karakousis
- Center for Clinical Global Health Education and Center for Tuberculosis Research, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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23
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Foster N, Cunnama L, McCarthy K, Ramma L, Siapka M, Sinanovic E, Churchyard G, Fielding K, Grant AD, Cleary S. Strengthening health systems to improve the value of tuberculosis diagnostics in South Africa: A cost and cost-effectiveness analysis. PLoS One 2021; 16:e0251547. [PMID: 33989317 PMCID: PMC8121360 DOI: 10.1371/journal.pone.0251547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 04/28/2021] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND In South Africa, replacing smear microscopy with Xpert-MTB/RIF (Xpert) for tuberculosis diagnosis did not reduce mortality and was cost-neutral. The unchanged mortality has been attributed to suboptimal Xpert implementation. We developed a mathematical model to explore how complementary investments may improve cost-effectiveness of the tuberculosis diagnostic algorithm. METHODS Complementary investments in the tuberculosis diagnostic pathway were compared to the status quo. Investment scenarios following an initial Xpert test included actions to reduce pre-treatment loss-to-follow-up; supporting same-day clinical diagnosis of tuberculosis after a negative result; and improving access to further tuberculosis diagnostic tests following a negative result. We estimated costs, deaths and disability-adjusted-life-years (DALYs) averted from provider and societal perspectives. Sensitivity analyses explored the mediating influence of behavioural, disease- and organisational characteristics on investment effectiveness. FINDINGS Among a cohort of symptomatic patients tested for tuberculosis, with an estimated active tuberculosis prevalence of 13%, reducing pre-treatment loss-to-follow-up from ~20% to ~0% led to a 4% (uncertainty interval [UI] 3; 4%) reduction in mortality compared to the Xpert scenario. Improving access to further tuberculosis diagnostic tests from ~4% to 90% among those with an initial negative Xpert result reduced overall mortality by 28% (UI 27; 28) at $39.70/ DALY averted. Effectiveness of investment scenarios to improve access to further diagnostic tests was dependent on a high return rate for follow-up visits. INTERPRETATION Investing in direct and indirect costs to support the TB diagnostic pathway is potentially highly cost-effective.
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Affiliation(s)
- Nicola Foster
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Health Research, Lancaster University, Lancaster, United Kingdom
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Lucy Cunnama
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kerrigan McCarthy
- Division of Public Health, Surveillance and Response, National Institute for Communicable Disease of the National Health Laboratory Service, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lebogang Ramma
- Department of Health and Rehabilitation Sciences, University of Cape Town, Cape Town, South Africa
| | - Mariana Siapka
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Edina Sinanovic
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Gavin Churchyard
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Aurum Institute, Johannesburg, South Africa
| | - Katherine Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alison D. Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Susan Cleary
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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24
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Haraka F, Kakolwa M, Schumacher SG, Nathavitharana RR, Denkinger CM, Gagneux S, Reither K, Ross A. Impact of the diagnostic test Xpert MTB/RIF on patient outcomes for tuberculosis. Cochrane Database Syst Rev 2021; 5:CD012972. [PMID: 34097769 PMCID: PMC8208889 DOI: 10.1002/14651858.cd012972.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The World Health Organization (WHO) recommends Xpert MTB/RIF in place of smear microscopy to diagnose tuberculosis (TB), and many countries have adopted it into their diagnostic algorithms. However, it is not clear whether the greater accuracy of the test translates into improved health outcomes. OBJECTIVES To assess the impact of Xpert MTB/RIF on patient outcomes in people being investigated for tuberculosis. SEARCH METHODS We searched the following databases, without language restriction, from 2007 to 24 July 2020: Cochrane Infectious Disease Group (CIDG) Specialized Register; CENTRAL; MEDLINE OVID; Embase OVID; CINAHL EBSCO; LILACS BIREME; Science Citation Index Expanded (Web of Science), Social Sciences citation index (Web of Science), and Conference Proceedings Citation Index - Social Science & Humanities (Web of Science). We also searched the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and the Pan African Clinical Trials Registry for ongoing trials. SELECTION CRITERIA We included individual- and cluster-randomized trials, and before-after studies, in participants being investigated for tuberculosis. We analysed the randomized and non-randomized studies separately. DATA COLLECTION AND ANALYSIS: For each study, two review authors independently extracted data, using a piloted data extraction tool. We assessed the risk of bias using Cochrane and Effective Practice and Organisation of Care (EPOC) tools. We used random effects meta-analysis to allow for heterogeneity between studies in setting and design. The certainty of the evidence in the randomized trials was assessed by GRADE. MAIN RESULTS We included 12 studies: eight were randomized controlled trials (RCTs), and four were before-and-after studies. Most included RCTs had a low risk of bias in most domains of the Cochrane 'Risk of bias' tool. There was inconclusive evidence of an effect of Xpert MTB/RIF on all-cause mortality, both overall (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.75 to 1.05; 5 RCTs, 9932 participants, moderate-certainty evidence), and restricted to studies with six-month follow-up (RR 0.98, 95% CI 0.78 to 1.22; 3 RCTs, 8143 participants; moderate-certainty evidence). There was probably a reduction in mortality in participants known to be infected with HIV (odds ratio (OR) 0.80, 95% CI 0.67 to 0.96; 5 RCTs, 5855 participants; moderate-certainty evidence). It is uncertain whether Xpert MTB/RIF has no or a modest effect on the proportion of participants starting tuberculosis treatment who had a successful treatment outcome (OR) 1.10, 95% CI 0.96 to 1.26; 3RCTs, 4802 participants; moderate-certainty evidence). There was also inconclusive evidence of an effect on the proportion of participants who were treated for tuberculosis (RR 1.10, 95% CI 0.98 to 1.23; 5 RCTs, 8793 participants; moderate-certainty evidence). The proportion of participants treated for tuberculosis who had bacteriological confirmation was probably higher in the Xpert MTB/RIF group (RR 1.44, 95% CI 1.29 to 1.61; 6 RCTs, 2068 participants; moderate-certainty evidence). The proportion of participants with bacteriological confirmation who were lost to follow-up pre-treatment was probably reduced (RR 0.59, 95% CI 0.41 to 0.85; 3 RCTs, 1217 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS We were unable to confidently rule in or rule out the effect on all-cause mortality of using Xpert MTB/RIF rather than smear microscopy. Xpert MTB/RIF probably reduces mortality among participants known to be infected with HIV. We are uncertain whether Xpert MTB/RIF has a modest effect or not on the proportion treated or, among those treated, on the proportion with a successful outcome. It probably does not have a substantial effect on these outcomes. Xpert MTB/RIF probably increases both the proportion of treated participants who had bacteriological confirmation, and the proportion with a laboratory-confirmed diagnosis who were treated. These findings may inform decisions about uptake alongside evidence on cost-effectiveness and implementation.
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Affiliation(s)
- Frederick Haraka
- Elizabeth Glaser Pediatric AIDS Foundation, Dar es Salaam, Tanzania
- Ifakara Health Institute, Bagamoyo, Tanzania
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | | | | | - Ruvandhi R Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Claudia M Denkinger
- FIND, Geneva, Switzerland
- Division of Tropical Medicine, Centre for Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Sebastien Gagneux
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Klaus Reither
- Ifakara Health Institute, Bagamoyo, Tanzania
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Amanda Ross
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
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25
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Kumar NP, Hissar S, Thiruvengadam K, Banurekha VV, Suresh N, Shankar J, S E, N S G, S K, J G, M A A, Baskaran D, Tripathy S, Swaminathan S, Babu S. Discovery and Validation of a Three-Cytokine Plasma Signature as a Biomarker for Diagnosis of Pediatric Tuberculosis. Front Immunol 2021; 12:653898. [PMID: 33936077 PMCID: PMC8085486 DOI: 10.3389/fimmu.2021.653898] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/22/2021] [Indexed: 11/23/2022] Open
Abstract
Pediatric TB poses challenge in diagnosis due to the paucibacillary nature of the disease. We conducted a prospective diagnostic study to identify immune biomarkers of pediatric TB and controls (discovery cohort) and obtained a separate “validation” cohort of confirmed cases of pediatric TB and controls. Multiplex ELISA was performed to examine the plasma levels of cytokines. Discovery and validation cohorts revealed that baseline plasma levels of IFNγ, TNFα, IL-2, and IL-17A were significantly higher in active TB (confirmed TB and unconfirmed TB) in comparison to unlikely TB children. Receiver operating characteristics (ROC) curve analysis revealed that IFNγ, IL-2, TNFα, and IL-17A (in the discovery cohort) and TNFα and IL-17A (in the validation cohort) could act as biomarkers distinguishing confirmed or unconfirmed TB from unlikely TB with the sensitivity and specificity of more than 90%. In the discovery cohort, cytokines levels were significantly diminished following anti-tuberculosis treatment. In both the cohorts, combiROC models offered 100% sensitivity and 98% to 100% specificity for a three-cytokine signature of TNFα, IL-2, and IL-17A, which can distinguish confirmed or unconfirmed TB children from unlikely TB. Thus, a baseline cytokine signature of TNFα, IL-2, and IL-17A could serve as an accurate biomarker for the diagnosis of pediatric tuberculosis.
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Affiliation(s)
- Nathella Pavan Kumar
- National Institutes of Health, National Institute for Research in Tuberculosis, International Center for Excellence in Research, Chennai, India.,Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Syed Hissar
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Kannan Thiruvengadam
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Velayuthum V Banurekha
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - N Suresh
- Department of Pediatrics, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Janani Shankar
- Department of Pediatrics, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Elilarasi S
- Department of Pediatrics, Institute of Child Health and Hospital for Children, Chennai, India
| | - Gomathi N S
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Kalpana S
- Department of Pediatrics, Institute of Child Health and Hospital for Children, Chennai, India
| | - Ganesh J
- Department of Pediatrics, Government Stanley Medical College and Hospital, Chennai, India
| | - Aravind M A
- Department of Pediatrics, Government Stanley Medical College and Hospital, Chennai, India
| | - Dhanaraj Baskaran
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Srikanth Tripathy
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Soumya Swaminathan
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India.,Public Health Division, World Health Organization, Geneva, Switzerland
| | - Subash Babu
- National Institutes of Health, National Institute for Research in Tuberculosis, International Center for Excellence in Research, Chennai, India.,Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institute of Health, Bethesda, MD, United States
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26
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Peng J, Song J, Wang F, Zuo P, Lu Y, Liu W, Tian L, Chen Z, Zhu Y, Wang X, Shen N, Wang X, Wu S, Yu Q, Vallance BA, Jacobson K, Sun Z, Yu HB. Harnessing Big Data to Optimize an Algorithm for Rapid Diagnosis of Pulmonary Tuberculosis in a Real-World Setting. Front Cell Infect Microbiol 2021; 11:650163. [PMID: 33816355 PMCID: PMC8012509 DOI: 10.3389/fcimb.2021.650163] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/01/2021] [Indexed: 11/13/2022] Open
Abstract
Background The prompt diagnosis of pulmonary tuberculosis (PTB) remains a challenge in clinical practice. The present study aimed to optimize an algorithm for rapid diagnosis of PTB in a real-world setting. Methods 28,171 adult inpatients suspected of having PTB in China were retrospectively analyzed. Bronchoalveolar lavage fluid (BALF) and/or sputum were used for acid-fast bacilli (AFB) smear, Xpert MTB/RIF (Xpert), and culture. A positive mycobacterial culture was used as the reference standard. Peripheral blood mononuclear cells (PBMC) were used for T-SPOT.TB. We analyzed specimen types' effect on these assays' performance, determined the number of smears for diagnosing PTB, and evaluated the ability of these assays performed alone, or in combination, to diagnose PTB and nontuberculous mycobacteria (NTM) infections. Results Sputum and BALF showed moderate to substantial consistency when they were used for AFB smear or Xpert, with a higher positive detection rate by BALF. 3-4 smears had a higher sensitivity than 1-2 smears. Moreover, simultaneous combination of AFB and Xpert correctly identified 44/51 of AFB+/Xpert+ and 6/7 of AFB+/Xpert- cases as PTB and NTM, respectively. Lastly, when combined with AFB/Xpert sequentially, T-SPOT showed limited roles in patients that were either AFB+ or Xpert+. However, T-SPOTMDC (manufacturer-defined cut-off) showed a high negative predicative value (99.1%) and suboptimal sensitivity (74.4%), and TBAg/PHA (ratio of Mycobacterium tuberculosis-specific antigens to phytohaemagglutinin spot-forming cells, which is a modified method calculating T-SPOT.TB assay results) ≥0.3 demonstrated a high specificity (95.7%) and a relatively low sensitivity (16.3%) in AFB-/Xpert- patients. Conclusions Concurrently performing AFB smear (at least 3 smears) and Xpert on sputum and/or BALF could aid in rapid diagnosis of PTB and NTM infections in a real-world high-burden setting. If available, BALF is preferred for both AFB smear and Xpert. Expanding this algorithm, PBMC T-SPOTMDC and TBAg/PHA ratios have a supplementary role for PTB diagnosis in AFB-/Xpert- patients (moderately ruling out PTB and ruling in PTB, respectively). Our findings may also inform policy makers' decisions regarding prevention and control of TB in a high burden setting.
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Affiliation(s)
- Jing Peng
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Juan Song
- Department of Gastroenterology & Endocrinology, Wuhan No. 9 Hospital, Wuhan, China
| | - Feng Wang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Peng Zuo
- Department of Respiratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanjun Lu
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Weiyong Liu
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lei Tian
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhongju Chen
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yaowu Zhu
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiong Wang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Na Shen
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xu Wang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shiji Wu
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qin Yu
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bruce A Vallance
- Department of Pediatrics, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Kevan Jacobson
- Department of Pediatrics, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Ziyong Sun
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hong Bing Yu
- Department of Pediatrics, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
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Ravimohan S, Auld SC, Maenetje P, Ratsela N, Mlotshwa M, Ncube I, Smith JP, Vangu MDT, Sebe M, Kossenkov A, Weissman D, Wallis RS, Churchyard G, Kornfeld H, Bisson GP. Lung Injury on Antiretroviral Therapy in Adults With Human Immunodeficiency Virus/Tuberculosis. Clin Infect Dis 2021; 70:1845-1854. [PMID: 31242296 DOI: 10.1093/cid/ciz560] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 06/24/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Immune restoration on antiretroviral therapy (ART) can drive inflammation in people living with human immunodeficiency virus (HIV) who have pulmonary tuberculosis (TB), but its effects on the lungs have not been assessed. We evaluated associations between pulmonary inflammation, recovery of pathogen-specific CD4 T-cell function, and lung injury prior to and after ART initiation in adults with HIV and pulmonary TB. METHODS This was a prospective cohort study in South Africa, following adults with HIV and pulmonary TB prior to and up to 48 weeks after ART initiation. Pulmonary-specific inflammation was defined as total glycolytic activity (TGA) on [18]F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) at baseline and 4 weeks after ART initiation. Spirometry, respiratory symptom tests, and flow cytometry were performed at the same times to assess lung involvement and the frequency of mycobacteria-specific CD4 T-cells. In addition, we evaluated lung function longitudinally up to 48 weeks after ART initiation. RESULTS Greater lung TGA on FDG PET-CT was associated with worse lung function and respiratory symptoms prior to ART initiation, and nearly half of subjects experienced worsening lung inflammation and lung function at Week 4 of ART. Worsening Week 4 lung inflammation and pulmonary function were both associated with greater increases in pathogen-specific functional CD4 T-cell responses on ART, and early decreases in lung function were independently associated with persistently lower lung function months after TB treatment completion. CONCLUSIONS Increases in pulmonary inflammation and decreases in lung function are common on ART, relate to greater ART-mediated CD4 T-cell restoration, and are associated with the persistent impairment of lung function in individuals with HIV/TB.
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Affiliation(s)
- Shruthi Ravimohan
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Sara C Auld
- Emory University Rollins School of Public Health and School of Medicine, Atlanta, Georgia
| | | | | | | | | | - Jonathan P Smith
- Emory University Rollins School of Public Health and School of Medicine, Atlanta, Georgia
| | - Mboyo-Di-Tamba Vangu
- Nuclear Medicine, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, South Africa
| | | | | | - Drew Weissman
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | | | - Gavin Churchyard
- The Aurum Institute, Johannesburg.,Advancing Care and Treatment for Tuberculosis/Human Immuondeficiency Virus, A Collaborating Centre of The South African Medical Research Council.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Hardy Kornfeld
- Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Gregory P Bisson
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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28
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Du Bruyn E, Ruzive S, Lindestam Arlehamn CS, Sette A, Sher A, Barber DL, Wilkinson RJ, Riou C. Mycobacterium tuberculosis-specific CD4 T cells expressing CD153 inversely associate with bacterial load and disease severity in human tuberculosis. Mucosal Immunol 2021; 14:491-499. [PMID: 32678272 PMCID: PMC7855386 DOI: 10.1038/s41385-020-0322-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/20/2020] [Accepted: 06/22/2020] [Indexed: 02/04/2023]
Abstract
Recent data from mice and non-human primate models of tuberculosis suggested that CD153, a TNF super family member, plays an important role in Mycobacterium tuberculosis (Mtb) control. However, this molecule has not been comprehensively evaluated in humans. Here, we show that the proportion of Mtb-specific CD4 T cells expressing CD153 was significantly reduced in active TB patients compared to latently infected persons. Importantly, the CD153+ Mtb-specific CD4 response inversely correlated with lung bacterial load, inferred by Xpert cycle threshold, irrespective of HIV status. Antitubercular treatment partially restored CD153 expression on Mtb-specific CD4 T cells. This is the first report of a subset of Mtb-specific CD4 T cells showing strong negative correlation with bacterial burden. Building on substantial evidence from animal models implicating CD153 as a mediator of host protection, our findings suggest it may play a similar role in humans and its measurement may be useful to evaluate TB vaccine efficacy.
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Affiliation(s)
- Elsa Du Bruyn
- grid.7836.a0000 0004 1937 1151Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, Cape Town, 7925 South Africa
| | - Sheena Ruzive
- grid.7836.a0000 0004 1937 1151Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, Cape Town, 7925 South Africa
| | | | - Alessandro Sette
- grid.185006.a0000 0004 0461 3162Division of Vaccine Discovery, La Jolla Institute for Immunology, La Jolla, CA USA ,grid.266100.30000 0001 2107 4242Department of Medicine, University of California San Diego, La Jolla, CA USA
| | - Alan Sher
- grid.419681.30000 0001 2164 9667Immunobiology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD USA
| | - Daniel L. Barber
- grid.419681.30000 0001 2164 9667T Lymphocyte Biology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD USA
| | - Robert J. Wilkinson
- grid.7836.a0000 0004 1937 1151Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, Cape Town, 7925 South Africa ,grid.7445.20000 0001 2113 8111Department of Infectious Diseases, Imperial College London, London, W2 1PG UK ,grid.7836.a0000 0004 1937 1151Department of Medicine, University of Cape Town, Observatory, Cape Town, 7925 South Africa ,grid.451388.30000 0004 1795 1830The Francis Crick Institute, London, NW1 1AT UK
| | - Catherine Riou
- grid.7836.a0000 0004 1937 1151Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, Cape Town, 7925 South Africa ,grid.7836.a0000 0004 1937 1151Division of Medical Virology, Department of Pathology, University of Cape Town, Cape Town, South Africa
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Kasozi S, Kirirabwa NS, Kimuli D, Luwaga H, Kizito E, Turyahabwe S, Lukoye D, Byaruhanga R, Chen L, Suarez P. Addressing the drug-resistant tuberculosis challenge through implementing a mixed model of care in Uganda. PLoS One 2020; 15:e0244451. [PMID: 33373997 PMCID: PMC7772013 DOI: 10.1371/journal.pone.0244451] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 12/09/2020] [Indexed: 12/02/2022] Open
Abstract
Worldwide, Drug-resistant Tuberculosis (DR-TB) remains a big problem; the diagnostic capacity has superseded the clinical management capacity thereby causing ethical challenges. In Sub-Saharan Africa, treatment is either inadequate or lacking and some diagnosed patients are on treatment waiting lists. In Uganda, various health system challenges impeded scale-up of DR-TB care in 2012; only three treatment initiation facilities existed, with only 41 of the estimated 1010 RR-TB/MDR-TB cases enrolled on treatment yet 300 were on the waiting list and there was no DR-TB treatment scale-up plan. To scale up care, the National TB and leprosy Program (NTLP) with partners rolled out a DR-TB mixed model of care. In this paper, we share achievements and outcomes resulting from the implementation of this mixed Model of DR-TB care. Routine NTLP DR-TB program data on treatment initiation site, number of patients enrolled, their demographic characteristics, patient category, disease classification (based on disease site and human immunodeficiency virus (HIV) status), on co-trimoxazole preventive therapy (CPT) and antiretroviral therapy (ART) statuses, culture results, smear results and treatment outcomes (6, 12, and 24 months) from 2012 to 2017 RR-TB/MDR-TB cohorts were collected from all the 15 DR-TB treatment initiation sites and descriptive analysis was done using STATA version 14.2. We presented outcomes as the number of patient backlog cleared, DR-TB initiation sites, RR-TB/DR-TB cumulative patients enrolled, percentage of co-infected patients on the six, twelve interim and 24 months treatment outcomes as per the Uganda NTLP 2016 Programmatic Management of drug-resistant Tuberculosis (PMDT) guidelines (NTLP, 2016). Over the period 2013–2015, the RR-TB/MDR-TB Treatment success rate (TSR) was sustained between 70.1% and 74.1%, a performance that is well above the global TSR average rate of 50%. Additionally, the cure rate increased from 48.8% to 66.8% (P = 0.03). The Uganda DR-TB mixed model of care coupled with early application of continuous improvement approaches, enhanced cohort reviews and use of multi-disciplinary teams allowed for rapid DR-TB program expansion, rapid clearance of patient backlog, attainment of high cumulative enrollment and high treatment success rates. Sustainability of these achievements is needed to further reduce the DR-TB burden in the country. We highly recommend this mixed model of care in settings with similar challenges.
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Affiliation(s)
- Samuel Kasozi
- TRACK TB Project, Management Sciences for Health, Kampala, Uganda
| | | | - Derrick Kimuli
- TRACK TB Project, Management Sciences for Health, Kampala, Uganda
- * E-mail:
| | - Henry Luwaga
- TRACK TB Project, Management Sciences for Health, Kampala, Uganda
| | - Enock Kizito
- TRACK TB Project, Management Sciences for Health, Kampala, Uganda
| | - Stavia Turyahabwe
- National Tuberculosis and Leprosy Program, Ministry of Health, Kampala, Uganda
| | - Deus Lukoye
- TRACK TB Project, Management Sciences for Health, Kampala, Uganda
| | | | - Lisa Chen
- Curry International Tuberculosis Center (UCSF/CITC), University of California, San Francisco, San Francisco, California, United States of America
| | - Pedro Suarez
- Management Sciences for Health, Arlington, Virginia, United States of America
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30
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Li Y, He D, Che Y, Zhao X. Monokine induced by gamma interferon for detecting pulmonary tuberculosis: A diagnostic meta-analysis. Medicine (Baltimore) 2020; 99:e23302. [PMID: 33217864 PMCID: PMC7676613 DOI: 10.1097/md.0000000000023302] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUNDS Pulmonary tuberculosis (PTB) is an oldest-known and most formidable disease. The standard microbiology culture is time-wasting. Monokine induced by gamma interferon (MIG) has been reported as a new biomarker to auxiliarily detect PTB. In our study, we used meta-analysis to assess the diagnostic value of MIG for PTB. METHODS PubMed, Embase, Web of Science, and Cochrane Library were searched for relative records up to April 2, 2020. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, area under the curve, and summary receiver operating characteristic curve were estimated. RESULTS Eight studies including 1487 participants were included. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of MIG for detecting PTB were 84%, 84%, 5.19, and 0.19, respectively. The diagnostic odds ratio and area under the curve were 27.88 and 0.90, respectively, indicating a good diagnostic ability of MIG. Meta-regression analysis showed that human immunodeficiency virus status might be a source of heterogeneity (P = .02). CONCLUSIONS Our results showed that MIG had a good diagnostic value for PTB.
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31
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Chien JY, Lin CK, Yu CJ, Hsueh PR. Usefulness of Xpert MTB/RIF Ultra to Rapidly Diagnose Sputum Smear-Negative Pulmonary Tuberculosis Using Bronchial Washing Fluid. Front Microbiol 2020; 11:588963. [PMID: 33072058 PMCID: PMC7536285 DOI: 10.3389/fmicb.2020.588963] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/01/2020] [Indexed: 11/13/2022] Open
Abstract
This study evaluated the performance of the Xpert MTB/RIF Ultra assay (Xpert Ultra) to detect smear-negative pulmonary tuberculosis (PTB). Xpert Ultra assay was prospectively performed using bronchial washing fluid (BWF) in comparison to COBAS TaqMan MTB (COBAS) assay and mycobacterial culture. Of the 165 enrolled participants, 27 (16.4%) had PTB based on composite reference standard and 16 (9.7%) had culture-confirmed PTB. By the composite reference standard of PTB, the sensitivity of Xpert Ultra (63.0, 95% confidence interval, CI, 42.4–80.6%) was higher than the COBAS assay (25.9%, P = 0.006), BWF-culture (33.3%, P = 0.029) and sputum-culture (37.0%, P = 0.057). Meanwhile, the specificity of Xpert Ultra was 99.3% which was slightly lower than the 100.0% specificity of the COBAS assay (P = 1.000) and cultures (P = 1.000). Against the reference standard of culture-confirmed PTB, Xpert Ultra also had a higher sensitivity (62.5, 95% CI, 35.4–84.8%) than the COBAS assay (31.3%, P = 0.077) and was similar to BWF-culture (56.3%, P = 0.719) and sputum-culture (62.5%, P = 1.000). However, one subject with previously treated old PTB had a false-positive result on the Xpert Ultra assay. This prospective study showed Xpert Ultra assay using BWF had better sensitivity than COBAS assay and mycobacterial cultures but could represent a false positive in patients with inactive old PTB.
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Affiliation(s)
- Jung-Yien Chien
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ching-Kai Lin
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Po-Ren Hsueh
- Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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32
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Tang Y, Yu J, Yang G, Li L, Cheng J, Wang H, Liu G, Pan Z, Yu X, Li W. Probe A shown in the GeneXpert MTB/RIF assay during the detection of Mycobacterium intracellular infections. Diagn Microbiol Infect Dis 2020; 99:115243. [PMID: 33130506 DOI: 10.1016/j.diagmicrobio.2020.115243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/08/2020] [Accepted: 10/11/2020] [Indexed: 11/19/2022]
Abstract
Mycobacterium tuberculosis (MTB) is commonly diagnosed via the GeneXpert MTB/RIF assay. The cycle threshold (Ct) value of probe A from this assay produced a fluorescence signal upon Mycobacterium intracellulare detection. No other nontuberculous mycobacteria (NTM) exhibited positive probe signals. Using a confirmed mycobacterial culture as a standard, probe A of the assay exhibited 84% sensitivity (95% confidence interval [CI]: 71%-97%) and 50% specificity (95% CI: 37%-63%) for clinical samples. For M. intracellulare strains, probe A exhibited 90% sensitivity (95% CI: 80%-100%) and 50% specificity (95% CI: 37%-63%). The identity of the amino acid sequence and 81-bp core region of rpoB from MTB and NTM suggested that the highly conserved property might be associated with a mismatch between the probes and the chromosomal DNA target. Probe A yielded a positive signal upon M. intracellulare detection; thus, probe A may help diagnose M. intracellular infections.
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Affiliation(s)
- Yuanyuan Tang
- School of Public Health, Weifang Medical University, Weifang, Shandong, PR China; Weifang No.2 People's Hospital, Weifang, Shandong, PR China
| | - Jing Yu
- Shandong University of Traditional Chinese Medicine Affiliated Hospital, Jinan, Shandong, PR China
| | - Guoru Yang
- Weifang No.2 People's Hospital, Weifang, Shandong, PR China
| | - Lanhua Li
- School of Public Health, Weifang Medical University, Weifang, Shandong, PR China
| | - Juan Cheng
- Weifang No.2 People's Hospital, Weifang, Shandong, PR China
| | - Haizhi Wang
- Weifang No.2 People's Hospital, Weifang, Shandong, PR China
| | - Guangfu Liu
- Weifang No.2 People's Hospital, Weifang, Shandong, PR China
| | - Zhaobao Pan
- Weifang No.2 People's Hospital, Weifang, Shandong, PR China
| | - Xiaoli Yu
- School of Public Health, Weifang Medical University, Weifang, Shandong, PR China.
| | - Wanwei Li
- School of Public Health, Weifang Medical University, Weifang, Shandong, PR China
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Performance of Xpert MTB/RIF Ultra assay on respiratory and extra-respiratory samples in a high-resource setting with a low tuberculosis prevalence. Diagn Microbiol Infect Dis 2020; 99:115235. [PMID: 33130504 DOI: 10.1016/j.diagmicrobio.2020.115235] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/01/2020] [Accepted: 10/02/2020] [Indexed: 11/22/2022]
Abstract
The Xpert MTB/RIF assay is a molecular assay that has improved the detection of tuberculosis and rifampicin resistance. However, its sensitivity is limited in patients with paucibacillary disease. Xpert MTB/RIF Ultra has been developed to resolve this limitation. We compared the performance of Xpert Ultra with that of culture for detection of Mycobacterium tuberculosis and rifampicin resistance. We reviewed laboratory records for 848 respiratory and 419 extrarespiratory samples that were processed between April 2018 and October 2019. The sensitivity, specificity, negative predictive value, and positive predictive value of Xpert Ultra were 94.8%, 98%, 98.8%, and 91.3% for respiratory samples and 83.8%, 96.9%, 98.4% and 72.1% for nonrespiratory ones. We found 26 culture-negative/Ultra-positive samples. Most of them have low bacillary burden and more than half belonged to patients with history of tuberculosis. Xpert Ultra demonstrates excellent diagnostic accuracy for tuberculosis detection, including paucibacillary specimens. In patients with history of tuberculosis, PCR results should be interpreted carefully.
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Park M, Kon OM. Use of Xpert MTB/RIF and Xpert Ultra in extrapulmonary tuberculosis. Expert Rev Anti Infect Ther 2020; 19:65-77. [PMID: 32806986 DOI: 10.1080/14787210.2020.1810565] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Tuberculosis (TB) remains a major global health burden. There still remains a large gap between the notified and estimated incident cases. Extrapulmonary (EP) TB represents 15% of all TB cases and the diagnosis is more challenging due to the paucity of the organism. Smear microscopy is often insensitive and culture methods are prolonged. With the introduction of Xpert MTB/RIF and more recently Xpert Ultra, this has changed TB diagnostics by providing a rapid accessible platform to diagnose TB and identify rifampicin resistance within 2 h. AREAS COVERED The diagnostic accuracy and the clinical role of Xpert MTB/RIF and Xpert Ultra in the different forms of EPTB. EXPERT OPINION Whilst significant advances have been made in TB diagnostics, there is still a need to optimize the diagnostic yield of Xpert MTB/RIF and Xpert Ultra in EPTB samples. Research is needed to facilitate standardization and optimal preparation of samples as well as understanding the role of Xpert MTB/RIF and Xpert Ultra in different burden settings. Alongside the current GeneXpert platform, the launch of rapid second-line drug resistance polymerase chain reactions and whole genome sequencing may help tackle the global health burden with a more comprehensive diagnostic approach and appropriate treatment.
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Affiliation(s)
- Mirae Park
- Imperial College Healthcare NHS Trust, St Mary's Hospital , London, UK.,National Heart and Lung Institute, Imperial College London , London, UK
| | - Onn Min Kon
- Imperial College Healthcare NHS Trust, St Mary's Hospital , London, UK.,National Heart and Lung Institute, Imperial College London , London, UK
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Esmail A, Pooran A, Sabur NF, Fadul M, Brar MS, Oelofse S, Tomasicchio M, Dheda K. An Optimal Diagnostic Strategy for Tuberculosis in Hospitalized HIV-Infected Patients Using GeneXpert MTB/RIF and Alere Determine TB LAM Ag. J Clin Microbiol 2020; 58:e01032-20. [PMID: 32727831 PMCID: PMC7512177 DOI: 10.1128/jcm.01032-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 07/24/2020] [Indexed: 11/20/2022] Open
Abstract
The diagnosis of tuberculosis (TB) in HIV-infected patients is challenging. Both a urinary lipoarabinomannan (LAM) test (Alere TB LAM) and GeneXpert-MTB/RIF (Xpert) are useful for the diagnosis of TB. However, how to optimally integrate Xpert and LAM tests into clinical practice algorithms remain unclear. We performed a post hoc analysis of 561 HIV-infected sputum-expectorating patients (median CD4 count of 130 cells/ml) from a previously published randomized controlled trial evaluating the LAM test in hospitalized HIV-infected patients with suspected TB. We evaluated 5 different diagnostic strategies using sputum culture as a reference standard (Xpert alone, LAM alone, sequential Xpert followed by LAM and vice versa [LAM in Xpert-negative patients and Xpert in LAM-negative patients], and both tests concurrently [LAM + Xpert]). A cost-consequence analysis was performed. Strategy-specific sensitivity and specificity, using culture as a reference, were similar with the Xpert-only and sequential and concurrent strategies. However, when any positive TB-specific test was used as a reference, the incremental yield of LAM over Xpert was 29.6% (45/152) and that of Xpert over LAM was 75% (84/11). The incremental yield of LAM increased with decreasing CD4 count. The costs per TB case diagnosed were similar for the sequential and concurrent strategies ($1,617 to $1,626). In sputum-expectorating hospitalized patients with advanced HIV and access to both tests, concurrent testing with Xpert and LAM may be the best strategy for diagnosing TB. These data inform clinical practice in settings where TB and HIV are endemic.
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Affiliation(s)
- Aliasgar Esmail
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Anil Pooran
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Natasha F Sabur
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Department of Respirology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Mohammed Fadul
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Mantaj S Brar
- Division of General Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Suzette Oelofse
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Michele Tomasicchio
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Faculty of Infectious and Tropical Diseases, Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Chimbetete C, Shamu T, Roelens M, Bote S, Mudzviti T, Keiser O. Mortality trends and causes of death among HIV positive patients at Newlands Clinic in Harare, Zimbabwe. PLoS One 2020; 15:e0237904. [PMID: 32853215 PMCID: PMC7451579 DOI: 10.1371/journal.pone.0237904] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 08/05/2020] [Indexed: 12/30/2022] Open
Abstract
Background We report trends in mortality patterns and causes among HIV positive patients, who initiated antiretroviral therapy (ART), at an urban clinic in Harare, Zimbabwe. Methods A retrospective cohort study was conducted in which routinely collected data for patients enrolled and followed up between February 2004 and December 2017 were assessed. Patients follow up was from the day of the treatment initiation until exit by death, transfer out or loss to follow up. Two doctors categorized causes of death (COD) as tuberculosis (TB), communicable AIDS, non-communicable diseases (NCDs), malignancies, others and unknown. We used competing risk survival analysis, first to estimate all-causes and cause-specific mortality rates over time, and then to assess risk factors of different causes of death. Results A total of 4 868 patients were followed up for 27 527 person years (PY). Among the 506 patients who died, COD was unknown for 76 patients (15%) and common COD were TB (n = 71, 14%), Malignancies (n = 54, 10.7%) Meningitis (n = 39, 7.7%) and NCDs (n = 60, 11.9%). 49.4% of the deaths were within the first year of starting ART. Median age at death was 36 years (IQR:19–46). There was a near threefold increase in proportion of deaths due to NCDs and malignancies over the period of follow up. Low baseline CD4 cell count and WHO stages 3 & 4 were significant risk factors for all-cause mortality. Conclusions TB remains the leading cause of death among HIV infected people. Deaths due to NCDs and malignancies increased over time. ART facilities need to incorporate management of NCDs including cancer as part of comprehensive care of PLHIV to reduce mortality.
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Affiliation(s)
- Cleophas Chimbetete
- Newlands Clinic, Harare, Zimbabwe
- Institute of Global Health, University of Geneva, Geneva, Switzerland
- * E-mail:
| | | | - Maroussia Roelens
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | | | - Tinashe Mudzviti
- Newlands Clinic, Harare, Zimbabwe
- School of Pharmacy, University of Zimbabwe, Harare, Zimbabwe
| | - Olivia Keiser
- Institute of Global Health, University of Geneva, Geneva, Switzerland
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Kay AW, González Fernández L, Takwoingi Y, Eisenhut M, Detjen AK, Steingart KR, Mandalakas AM. Xpert MTB/RIF and Xpert MTB/RIF Ultra assays for active tuberculosis and rifampicin resistance in children. Cochrane Database Syst Rev 2020; 8:CD013359. [PMID: 32853411 PMCID: PMC8078611 DOI: 10.1002/14651858.cd013359.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Every year, at least one million children become ill with tuberculosis and around 200,000 children die. Xpert MTB/RIF and Xpert Ultra are World Health Organization (WHO)-recommended rapid molecular tests that simultaneously detect tuberculosis and rifampicin resistance in adults and children with signs and symptoms of tuberculosis, at lower health system levels. To inform updated WHO guidelines on molecular assays, we performed a systematic review on the diagnostic accuracy of these tests in children presumed to have active tuberculosis. OBJECTIVES Primary objectives • To determine the diagnostic accuracy of Xpert MTB/RIF and Xpert Ultra for (a) pulmonary tuberculosis in children presumed to have tuberculosis; (b) tuberculous meningitis in children presumed to have tuberculosis; (c) lymph node tuberculosis in children presumed to have tuberculosis; and (d) rifampicin resistance in children presumed to have tuberculosis - For tuberculosis detection, index tests were used as the initial test, replacing standard practice (i.e. smear microscopy or culture) - For detection of rifampicin resistance, index tests replaced culture-based drug susceptibility testing as the initial test Secondary objectives • To compare the accuracy of Xpert MTB/RIF and Xpert Ultra for each of the four target conditions • To investigate potential sources of heterogeneity in accuracy estimates - For tuberculosis detection, we considered age, disease severity, smear-test status, HIV status, clinical setting, specimen type, high tuberculosis burden, and high tuberculosis/HIV burden - For detection of rifampicin resistance, we considered multi-drug-resistant tuberculosis burden • To compare multiple Xpert MTB/RIF or Xpert Ultra results (repeated testing) with the initial Xpert MTB/RIF or Xpert Ultra result SEARCH METHODS: We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, Science Citation Index, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and the International Standard Randomized Controlled Trials Number (ISRCTN) Registry up to 29 April 2019, without language restrictions. SELECTION CRITERIA Randomized trials, cross-sectional trials, and cohort studies evaluating Xpert MTB/RIF or Xpert Ultra in HIV-positive and HIV-negative children younger than 15 years. Reference standards comprised culture or a composite reference standard for tuberculosis and drug susceptibility testing or MTBDRplus (molecular assay for detection of Mycobacterium tuberculosis and drug resistance) for rifampicin resistance. We included studies evaluating sputum, gastric aspirate, stool, nasopharyngeal or bronchial lavage specimens (pulmonary tuberculosis), cerebrospinal fluid (tuberculous meningitis), fine needle aspirates, or surgical biopsy tissue (lymph node tuberculosis). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality using the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2). For each target condition, we used the bivariate model to estimate pooled sensitivity and specificity with 95% confidence intervals (CIs). We stratified all analyses by type of reference standard. We assessed certainty of evidence using the GRADE approach. MAIN RESULTS For pulmonary tuberculosis, 299 data sets (68,544 participants) were available for analysis; for tuberculous meningitis, 10 data sets (423 participants) were available; for lymph node tuberculosis, 10 data sets (318 participants) were available; and for rifampicin resistance, 14 data sets (326 participants) were available. Thirty-nine studies (80%) took place in countries with high tuberculosis burden. Risk of bias was low except for the reference standard domain, for which risk of bias was unclear because many studies collected only one specimen for culture. Detection of pulmonary tuberculosis For sputum specimens, Xpert MTB/RIF pooled sensitivity (95% CI) and specificity (95% CI) verified by culture were 64.6% (55.3% to 72.9%) (23 studies, 493 participants; moderate-certainty evidence) and 99.0% (98.1% to 99.5%) (23 studies, 6119 participants; moderate-certainty evidence). For other specimen types (nasopharyngeal aspirate, 4 studies; gastric aspirate, 14 studies; stool, 11 studies), Xpert MTB/RIF pooled sensitivity ranged between 45.7% and 73.0%, and pooled specificity ranged between 98.1% and 99.6%. For sputum specimens, Xpert Ultra pooled sensitivity (95% CI) and specificity (95% CI) verified by culture were 72.8% (64.7% to 79.6%) (3 studies, 136 participants; low-certainty evidence) and 97.5% (95.8% to 98.5%) (3 studies, 551 participants; high-certainty evidence). For nasopharyngeal specimens, Xpert Ultra sensitivity (95% CI) and specificity (95% CI) were 45.7% (28.9% to 63.3%) and 97.5% (93.7% to 99.3%) (1 study, 195 participants). For all specimen types, Xpert MTB/RIF and Xpert Ultra sensitivity were lower against a composite reference standard than against culture. Detection of tuberculous meningitis For cerebrospinal fluid, Xpert MTB/RIF pooled sensitivity and specificity, verified by culture, were 54.0% (95% CI 27.8% to 78.2%) (6 studies, 28 participants; very low-certainty evidence) and 93.8% (95% CI 84.5% to 97.6%) (6 studies, 213 participants; low-certainty evidence). Detection of lymph node tuberculosis For lymph node aspirates or biopsies, Xpert MTB/RIF pooled sensitivity and specificity, verified by culture, were 90.4% (95% CI 55.7% to 98.6%) (6 studies, 68 participants; very low-certainty evidence) and 89.8% (95% CI 71.5% to 96.8%) (6 studies, 142 participants; low-certainty evidence). Detection of rifampicin resistance Xpert MTB/RIF pooled sensitivity and specificity were 90.0% (67.6% to 97.5%) (6 studies, 20 participants; low-certainty evidence) and 98.3% (87.7% to 99.8%) (6 studies, 203 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS We found Xpert MTB/RIF sensitivity to vary by specimen type, with gastric aspirate specimens having the highest sensitivity followed by sputum and stool, and nasopharyngeal specimens the lowest; specificity in all specimens was > 98%. Compared with Xpert MTB/RIF, Xpert Ultra sensitivity in sputum was higher and specificity slightly lower. Xpert MTB/RIF was accurate for detection of rifampicin resistance. Xpert MTB/RIF was sensitive for diagnosing lymph node tuberculosis. For children with presumed tuberculous meningitis, treatment decisions should be based on the entirety of clinical information and treatment should not be withheld based solely on an Xpert MTB/RIF result. The small numbers of studies and participants, particularly for Xpert Ultra, limits our confidence in the precision of these estimates.
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MESH Headings
- Adolescent
- Antibiotics, Antitubercular/therapeutic use
- Bias
- Child
- Feces/microbiology
- Gastrointestinal Contents/microbiology
- Humans
- Molecular Typing/methods
- Molecular Typing/standards
- Mycobacterium tuberculosis/drug effects
- Mycobacterium tuberculosis/isolation & purification
- Rifampin/therapeutic use
- Sensitivity and Specificity
- Sputum/microbiology
- Tuberculosis, Lymph Node/diagnosis
- Tuberculosis, Lymph Node/drug therapy
- Tuberculosis, Lymph Node/microbiology
- Tuberculosis, Meningeal/cerebrospinal fluid
- Tuberculosis, Meningeal/diagnosis
- Tuberculosis, Meningeal/drug therapy
- Tuberculosis, Meningeal/microbiology
- Tuberculosis, Multidrug-Resistant/diagnosis
- Tuberculosis, Multidrug-Resistant/drug therapy
- Tuberculosis, Multidrug-Resistant/microbiology
- Tuberculosis, Pulmonary/diagnosis
- Tuberculosis, Pulmonary/drug therapy
- Tuberculosis, Pulmonary/microbiology
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Affiliation(s)
- Alexander W Kay
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Michael Eisenhut
- Paediatric Department, Luton & Dunstable University Hospital NHS Foundation Trust, Luton, UK
| | | | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Anna M Mandalakas
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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Jiang J, Yang J, Shi Y, Jin Y, Tang S, Zhang N, Lu Y, Sun G. Head-to-head comparison of the diagnostic accuracy of Xpert MTB/RIF and Xpert MTB/RIF Ultra for tuberculosis: a meta-analysis. Infect Dis (Lond) 2020; 52:763-775. [PMID: 32619114 DOI: 10.1080/23744235.2020.1788222] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) diagnosis has significantly improved since the introduction of the automated molecular test Xpert MTB/RIF (Xpert) and the new version Xpert MTB/RIF Ultra (Ultra) that detect Mycobacterium tuberculosis. Due to the rapidly widespread use of Xpert and Ultra, we conducted a meta-analysis to compare the performances of Xpert and Ultra in diagnosing TB and discuss the advantages and limitations of these two tests. METHODS Web of Science, Medline (via PubMed), Embase (via OvidSP), the Cochrane Central Register of Controlled Trials and Google Scholar (up to April 2020) were searched for relevant studies. The diagnostic performance of Xpert and Ultra for TB was determined using a bivariate random-effects regression model. The sources of heterogeneity were explored via meta-regression and subgroup analyses. RESULTS Of 19 studies that examined a total of 5855 samples, the pooled sensitivity and specificity of Xpert in TB diagnosis were 0.69 (95% CI: 0.57-0.78) and 0.99 (95% CI: 0.98-0.99), respectively. However, the pooled sensitivity and specificity of Ultra in TB diagnosis were 0.84 (95% CI: 0.76-0.90) and 0.97 (95% CI: 0.96-0.98), respectively. Regardless of whether the comparisons were indirect or direct, Ultra was consistently found to be more sensitive, but with slightly lower specificity than Xpert in diagnosing TB. CONCLUSIONS Compared with Xpert, Ultra had higher sensitivity but slightly lower specificity for the diagnosis of TB disease. The excellent upgrade in sensitivity of the Ultra test was particularly relevant in subjects with paucibacillary TB including tuberculous pleurisy, tuberculous meningitis and paediatric TB.
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Affiliation(s)
- Jianjun Jiang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jin Yang
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yining Shi
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yongmei Jin
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Sihui Tang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Na Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Youjin Lu
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Gengyun Sun
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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Sorsa A, Jerene D, Negash S, Habtamu A. Use of Xpert Contributes to Accurate Diagnosis, Timely Initiation, and Rational Use of Anti-TB Treatment Among Childhood Tuberculosis Cases in South Central Ethiopia. Pediatric Health Med Ther 2020; 11:153-160. [PMID: 32523391 PMCID: PMC7236239 DOI: 10.2147/phmt.s244154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 04/13/2020] [Indexed: 11/23/2022] Open
Abstract
Background Childhood tuberculosis (TB) was under-prioritized, and only 15% of childhood TB cases are microbiologically confirmed. Hence, most childhood TB diagnoses are made on a clinical basis and prone to over- or under-treatment. Xpert is a rapid method for the diagnosis of childhood TB with high sensitivity. Objective To assess the use of Xpert for accurate diagnosis, timely initiation, and rational use of anti-TB treatment among childhood TB. Methods In 2016, the hospital facilitated the installation of the Xpert machine. We reviewed data trends over four consecutive years; two years before the arrival of the machine and two years following the implementation of Xpert. Data were extracted retrospectively from electronically stored databases and medical records and entered to SPSS 21 for analysis. Results In the pre-intervention period (2014–2015), 404 cases of children presenting with symptoms or signs suggestive of TB (“presumptive TB”) were evaluated using AFB microscopy. A total of 254 (62.8%) TB diagnoses were made, of which 54 (21.3%) were confirmed by smear AFB while 200 (78.7%) were treated as smear-negative TB cases. The mean waiting time to start anti-TB treatment was 6.95 days [95% CI (3.71–10.90)]. During the intervention period (2016–2017), 371 children with presumptive TB were evaluated using Xpert. A total of 199 (53.6%) childhood TB cases were notified, of which 88 (44.2%) were Xpert positive and 111 (55.8%) were treated as Xpert-negative probable TB cases. The tendency to initiate anti-TB treatment for unconfirmed TB cases was reduced by a third. Compared with smear AFB, Xpert improved accuracy of diagnosing pediatric TB cases two-fold. The average waiting time to start anti-TB treatment was 1.33 days [95% CI (0.95–1.71)]. There was a significant reduction in the waiting time to start anti-TB treatment, with a mean time difference before and during intervention of 5.62 days [95% CI (1.68–9.56)]. Conclusion Xpert use was associated with a significant increase in the accuracy of identifying confirmed TB cases, reduced unnecessary anti-TB prescription, and shortened the time taken to start TB treatment.
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Affiliation(s)
- Abebe Sorsa
- Department of Pediatric and Child Health, Arsi University, College of Health Sciences, Asella, Ethiopia
| | - Degu Jerene
- Management Sciences for Health, USAID/Challenge TB Project, Addis Ababa, Ethiopia
| | - Solomon Negash
- Management Sciences for Health, USAID/Challenge TB Project, Addis Ababa, Ethiopia
| | - Ashenafi Habtamu
- Department of Pediatric and Child Health, Arsi University, College of Health Sciences, Asella, Ethiopia
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Wang F, Liu K, Peng J, Luo Y, Tang G, Lin Q, Hou H, Liu W, Wang J, Fang Z, Kuang H, Sun Z. Combination of Xpert MTB/RIF and TBAg/PHA Ratio for Prompt Diagnosis of Active Tuberculosis: A Two-Center Prospective Cohort Study. Front Med (Lausanne) 2020; 7:119. [PMID: 32351964 PMCID: PMC7174554 DOI: 10.3389/fmed.2020.00119] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 03/18/2020] [Indexed: 11/14/2022] Open
Abstract
The prompt diagnosis of active tuberculosis (ATB) is still a challenge in clinical practice, especially in TB-endemic countries. We prospectively enrolled consecutive patients with suspected pulmonary TB from two tertiary hospitals. Acid-fast staining (AFS), Xpert MTB/RIF (Xpert), Mycobacterium tuberculosis culture, and T-SPOT.TB were simultaneously performed. 226 ATB and 348 non-TB patients were diagnosed in Tongji hospital (test cohort), and 86 ATB and 110 non-TB patients were diagnosed in Guangzhou Chest Hospital (validation cohort). Using ATB as patient group and non-TB as control group, for diagnosis of ATB in Tongji Hospital, the sensitivity of AFS was 17.70% (95% CI: 13.08–23.44%). The sensitivity of Xpert and culture were 53.54% (95% CI: 46.81–60.14%) and 46.46% (95% CI: 39.86–53.19%), respectively. The sensitivity of T-SPOT.TB was 81.42% (95% CI: 75.60–86.14%), but the specificity was 71.55% (95% CI: 66.60–76.04%). Calculation of the ratio of TB-specific antigen to phytohaemagglutinin (TBAg/PHA) of T-SPOT.TB assay increased the specificity but with a loss of sensitivity. Combination of Xpert and culture slightly increased the sensitivity compared to using these methods separately. Combination of Xpert and TBAg/PHA ratio (defined as Xpert positive or TBAg/PHA ≥ 0.2) increased diagnostic accuracy, and the sensitivity and specificity of combination of them were 85.84% (95% CI: 80.45–89.98%) and 95.98% (95% CI: 93.36–97.59%), respectively. The diagnostic model was also established based on combination of Xpert and TBAg/PHA ratio. The area under the curve of the diagnostic model was 0.952 (95% CI: 0.932–0.973) for diagnosis of ATB, with a sensitivity of 88.05% (95% CI: 83.10–91.98%) and a specificity of 96.26% (95% CI: 93.70–98.00%) when a cutoff value of 0.44 was used in Wuhan cohort. The performance of combination of Xpert and TBAg/PHA ratio was similar in Guangzhou Chest Hospital. Our data suggest that combination of Xpert and TBAg/PHA ratio may be a good algorithm for prompt diagnosis of ATB in high endemic areas.
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Affiliation(s)
- Feng Wang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kui Liu
- Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Peng
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ying Luo
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guoxing Tang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qun Lin
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongyan Hou
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Weiyong Liu
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Wang
- Department of Prevention and Health Care, Jianghan University, Wuhan, China
| | - Zemin Fang
- Department of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Haobin Kuang
- Department of Tuberculosis, Guangzhou Chest Hospital, Guangzhou, China
| | - Ziyong Sun
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Esmail A, Tomasicchio M, Meldau R, Makambwa E, Dheda K. Comparison of Xpert MTB/RIF (G4) and Xpert Ultra, including trace readouts, for the diagnosis of pulmonary tuberculosis in a TB and HIV endemic setting. Int J Infect Dis 2020; 95:246-252. [PMID: 32247825 DOI: 10.1016/j.ijid.2020.03.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/05/2020] [Accepted: 03/08/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND There are limited data about Xpert-Ultra performance in different settings, in HIV-infected persons, in those with a history of previous TB, and with trace readouts. METHODS We evaluated the relative accuracy of Xpert-MTB/RIF and Xpert-Ultra in 272 selected but well-characterized archived sputum samples. Of these, 168 were culture-positive (64/168 smear-positive and 104/168 smear-negative), and 104 were culture-negative (102/104 from patients with previous TB and 2/104 from patients without a TB history). Assay-specific limit-of-detection (LOD) experiments were conducted using serial dilutions of Mycobacterium tuberculosis H37Rv. RESULTS Overall sensitivity (95%CI) in smear-negative culture-positive samples for Xpert-MTB/RIF and Xpert-Ultra were 71.2% (62.5-79.9) and 77% (68.9-85.1), respectively (and in HIV-infected persons: 63.5% (50-76.1) and 73.1% (61.1-85.2), respectively). The LOD for Xpert-Ultra was lower (9 versus 184 CFU/ml). There were a total of 9/272 (3.3%) Xpert Ultra trace readouts (6/104 [5.8%]) in smear-negative culture-positive persons, and 3/102 (3%) in culture-negative non-TB persons with a history of previous TB). CONCLUSIONS Xpert-Ultra had a lower LOD compared to Xpert-MTB/RIF. A small proportion of samples (<5%) from culture-negative patients but with a history of previous TB had a likely false-positive trace readout. These data inform the management of patients with suspected TB in endemic settings.
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Affiliation(s)
- Aliasgar Esmail
- Centre for Lung Infection and Immunity, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, UK
| | - Michele Tomasicchio
- Centre for Lung Infection and Immunity, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard Meldau
- Centre for Lung Infection and Immunity, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, UK
| | - Edson Makambwa
- Centre for Lung Infection and Immunity, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, UK
| | - Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa; Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, UK.
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Sánchez-Cabral O, Santillán-Díaz C, Flores-Bello ÁP, Herrera-Ortega MI, Sandoval-Gutiérrez JL, Santillán-Doherty P, Martínez-Mendoza D. GeneXpert ® MTB/RIF assay with transbronchial lung cryobiopsy for Mycobacterium tuberculosis diagnosis. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:351. [PMID: 32355795 PMCID: PMC7186622 DOI: 10.21037/atm.2020.02.100] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Early tuberculosis (TB) diagnostic is one of the critical steps to TB control. GeneXpert MTB/RIF has been widely proven for a prompt TB diagnosis. The use of GeneXpert MTB/RIF assay with transbronchial lung cryobiopsy samples may increase diagnostic accuracy. We aim to assess the diagnostic of TB with GeneXpert MTB/RIF assay with transbronchial lung cryobiopsy. Methods Patients with suspected diagnosis of TB and negative smear microscopies, with TB culture and GeneXpert MTB/RIF assay with transbronchial lung cryobiopsy were included in this cross-sectional study. Participants were enrolled from 2016 to 2018 at National Institute of Respiratory Diseases, Mexico. Results We included 54 patients (77.8% males) aged 30 to 65 years. The sensitivity of the GeneXpert MTB/RIF assay with transbronchial lung cryobiopsy was 81.3% (95% CI, 62.1-100%), with a specificity of 100% (95% CI, 100-100%) and a negative predictive value of 92.7% (95% CI, 84.7-100%). Twenty-two patients of the total population have HIV, the sensitivity of the test in these patients was 87.5% (95% CI, 64.6-100%). Also, 28 patients with a peripheral localized lesion which had a solid pattern were identified (51.9%). The sensitivity in patients with peripheral localized lesions was 88.9% (68.4-100%). Conclusions The GeneXpert MTB/RIF assay with transbronchial lung cryobiopsy test is as efficient as broncho alveolar lavage for TB diagnosis. Transbronchial lung cryobiopsy increases a major diagnostic opportunity when the nature of illness is malignant. Transbronchial lung cryobiopsy is efficient in HIV patients, especially in patients with peripheral localized lesion.
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Affiliation(s)
- Olivia Sánchez-Cabral
- Interventional Pulmonology Unit, National Institute of Respiratory Diseases "Ismael Cosío Villegas", Mexico City, Mexico
| | - Cira Santillán-Díaz
- Interventional Pulmonology Unit, National Institute of Respiratory Diseases "Ismael Cosío Villegas", Mexico City, Mexico
| | - Ángel Paul Flores-Bello
- Clinic of Tuberculosis and Pleural Diseases, National Institute of Respiratory Diseases "Ismael Cosío Villegas", Mexico City, Mexico
| | - Mildred Ivannia Herrera-Ortega
- Interventional Pulmonology Unit, National Institute of Respiratory Diseases "Ismael Cosío Villegas", Mexico City, Mexico
| | - José Luis Sandoval-Gutiérrez
- Auxiliary and Diagnostic Services, National Institute of Respiratory Diseases "Ismael Cosío Villegas", Mexico City, Mexico
| | - Patricio Santillán-Doherty
- Medical Direction, National Institute of Respiratory Diseases "Ismael Cosío Villegas", Mexico City, Mexico
| | - Dina Martínez-Mendoza
- Epidemiology Surveillance Unit, National Institute of Respiratory Diseases "Ismael Cosío Villegas", Mexico City, Mexico
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Lee HS, Kee SJ, Shin JH, Kwon YS, Chun S, Lee JH, Won EJ, Choi HJ, Kim SH, Shin MG, Shin JH, Suh SP. Xpert MTB/RIF Assay as a Substitute for Smear Microscopy in an Intermediate-Burden Setting. Am J Respir Crit Care Med 2020; 199:784-794. [PMID: 30252496 DOI: 10.1164/rccm.201804-0654oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
RATIONALE Use of Xpert MTB/RIF assay as a substitute for smear microscopy in routine clinical practice remains unexplored in an intermediate-tuberculosis-burden setting. OBJECTIVES To compare the diagnostic performance of Xpert and smear microscopy, based on sampling time and location, correlation of Xpert semiquantitative category with smear grade and time to culture positivity, and compliance of reporting time with defined standard time. METHODS Consecutive sputum samples collected from 2,952 suspected pulmonary tuberculosis patients over a 3-year period were tested by Xpert, smear microscopy, and liquid culture as part of routine diagnostics in South Korea. MEASUREMENTS AND MAIN RESULTS Based on the analysis of a single sputum specimen per patient, of 2,952 samples, 263 (8.9%) were culture-confirmed tuberculosis and 265 (9.0%) were nontuberculous mycobacteria. The overall sensitivity and specificity were 74.1% and 97.5% for Xpert versus 38.8% and 96.7% for smear microscopy, respectively (P < 0.0001; P > 0.05). Of 82 smear-positive nontuberculous mycobacteria, 81 (98.8%) were accurately excluded by Xpert. Sampling time and location significantly affected the performance of smear microscopy but not that of Xpert. Xpert semiquantitative category strongly correlated with smear grade (γGoodman-Kruskal = 0.982; P < 0.0001) and time to culture positivity (γGoodman-Kruskal = -0.962; P < 0.0001). Median reporting time and its compliance rate within 24 hours were 3.1 hours and 96.3% for Xpert versus 19.1 hours and 88.7% for smear microscopy, respectively (P < 0.0001; P < 0.05). CONCLUSIONS Xpert provides faster, more stable, and superior results compared with smear microscopy, in addition to its strong correlation with smear grade. Xpert might replace smear microscopy as the first-line diagnostic test for pulmonary tuberculosis in routine clinical practice in an intermediate-burden setting.
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Affiliation(s)
- Hyun-Seung Lee
- 1 Department of Laboratory Medicine, Chonbuk National University Hospital, Jeonju, Republic of Korea
| | | | | | - Yong-Soo Kwon
- 3 Department of Pulmonary and Critical Care Medicine, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
| | | | - Jun Hyung Lee
- 4 Department of Laboratory Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun, Republic of Korea; and
| | - Eun Jeong Won
- 2 Department of Laboratory Medicine and.,5 Department of Parasitology, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Hyun-Jung Choi
- 4 Department of Laboratory Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun, Republic of Korea; and
| | - Soo Hyun Kim
- 4 Department of Laboratory Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun, Republic of Korea; and
| | - Myung-Geun Shin
- 4 Department of Laboratory Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun, Republic of Korea; and
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Low diagnostic accuracy of Xpert MTB/RIF assay for extrapulmonary tuberculosis: A multicenter surveillance. Sci Rep 2019; 9:18515. [PMID: 31811239 PMCID: PMC6898377 DOI: 10.1038/s41598-019-55112-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 11/20/2019] [Indexed: 01/27/2023] Open
Abstract
Diagnostic accuracy of Xpert MTB/RIF assay for pulmonary tuberculosis (PTB) and extrapulmonary TB (EPTB) has not been investigated in Iran. This study was aimed to assess the diagnostic accuracy of Xpert MTB/RIF assay for both PTB and EPTB. A total of 2111 clinical samples (1218 pulmonary and 838 extra-pulmonary) were collected from 16 medical centers during the study period and were analyzed for detection of PTB and EPTB by both Xpert MTB/RIF assay and standard conventional methods (culture and direct smear microscopy). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of Xpert MTB/RIF assay for PTB were found to be 95.5%, 96.7%, 83.8%, and 99.1% respectively. For EPTB, the sensitivity, specificity, PPV and NPV of Xpert MTB/RIF assay counted for 76.5%, 95.9%, 62%, and 97.9% respectively. Xpert MTB/RIF assay found to be highly sensitive, specific and comparable to standard conventional methods for the diagnosis of PTB. However, the sensitivity and specificity of Xpert MTB/RIF for EPTB specimens were highly variable; thus, Xpert MTB/RIF cannot be recommended to replace standard conventional tests for diagnosis of EPTB.
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45
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Feliciano CS, Menon LJB, Anselmo LMP, Dippenaar A, Warren RM, Silva WA, Bollela VR. Xpert MTB/RIF performance to diagnose tuberculosis and rifampicin resistance in a reference centre in southern Brazil. ERJ Open Res 2019; 5:00043-2019. [PMID: 31404338 PMCID: PMC6680070 DOI: 10.1183/23120541.00043-2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 06/07/2019] [Indexed: 12/27/2022] Open
Abstract
Effective treatment of tuberculosis (TB) remains a serious public health problem in many countries, including Brazil, especially when considering drug-resistant disease. Xpert MTB/RIF has been implemented in many countries to reduce the time to TB diagnosis and to rapidly detect rifampicin resistance. The study aimed to describe and evaluate Xpert MTB/RIF performance in diagnosing pulmonary TB and rifampicin resistance in a tertiary healthcare facility in Brazil. A cross-sectional study was performed, which included all isolates of confirmed pulmonary TB patients from 2015 to 2018. Both Xpert MTB/RIF and GenoType MTBDRplus assays were performed to detect rifampicin and isoniazid resistance. In addition, isolates with detected resistance to rifampicin and/or isoniazid were analysed by phenotypic testing using MGIT-960 SIRE kit and whole-genome sequencing (WGS) using Illumina MiSeq Sequencing System. 2148 respiratory specimens tested with Xpert MTB/RIF were included: n=1556 sputum, n=348 bronchoalveolar lavage and n=244 gastric washing. The overall Xpert MTB/RIF sensitivity in sputum was 94% and the overall specificity was 98%. The negative predictive value in sputum of all the patients was 99% with a positive predictive value of 89%. The concordance between Xpert MTB/RIF and phenotypic susceptibility test was 94.1%, while its concordance with WGS was 78.9%. Xpert MTB/RIF is a rapid and accurate diagnostic strategy for pulmonary TB, which can contribute to improvement in TB control. However, detection of rifampicin resistance might be associated with false-positive results.
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Affiliation(s)
- Cinara Silva Feliciano
- Dept of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo (FMRP-USP), São Paulo, Brazil
| | - Lucas José Bazzo Menon
- Dept of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo (FMRP-USP), São Paulo, Brazil
| | - Livia Maria Pala Anselmo
- Dept of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo (FMRP-USP), São Paulo, Brazil
| | - Anzaan Dippenaar
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Robin Mark Warren
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Wilson Araújo Silva
- Center for Medical Genomics, Clinics Hospital at Ribeirão Preto Medical School, FMRP-USP, São Paulo, Brazil.,Dept of Genetics, Ribeirão Preto Medical School, FMRP-USP, São Paulo, Brazil
| | - Valdes Roberto Bollela
- Dept of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo (FMRP-USP), São Paulo, Brazil
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46
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Zong K, Luo C, Zhou H, Jiang Y, Li S. Xpert MTB/RIF assay for the diagnosis of rifampicin resistance in different regions: a meta-analysis. BMC Microbiol 2019; 19:177. [PMID: 31382894 PMCID: PMC6683411 DOI: 10.1186/s12866-019-1516-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 06/17/2019] [Indexed: 01/08/2023] Open
Abstract
Background To estimate the diagnostic accuracy of Xpert MTB/RIF for rifampicin resistance in different regions, a meta-analysis was carried out. Methods Several databases were searched for relevant studies up to March 3, 2019. A bivariate random-effects model was used to estimate the diagnostic accuracy. Results We identified 97 studies involving 26,037 samples for the diagnosis of rifampicin resistance. The pooled sensitivity, specificity and AUC of Xpert MTB/RIF for rifampicin resistance detection were 0.93 (95% CI 0.90–0.95), 0.98 (95% CI 0.96–0.98) and 0.99 (95% CI 0.97–0.99), respectively. For different regions, the pooled sensitivity were 0.94(95% CI 0.89–0.97) and 0.92 (95% CI 0.88–0.94), the pooled specificity were 0.98 (95% CI 0.94–1.00) and 0.98 (95% CI 0.96–0.99), and the AUC were 0.99 (95% CI 0.98–1.00) and 0.99 (95% CI 0.97–0.99) in high and middle/low income countries, respectively. The pooled sensitivity were 0.91 (95% CI 0.87–0.94) and 0.91 (95% CI 0.86–0.94), the pooled specificity were 0.98 (95% CI 0.96–0.99) and 0.98 (95% CI 0.96–0.99), and the AUC were 0.98 (95% CI 0.97–0.99) and 0.99 (95% CI 0.97–0.99) in high TB burden and middle/low prevalence countries, respectively. Conclusions The diagnostic accuracy of Xpert MTB/RIF for rifampicin resistance detection was excellent.
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Affiliation(s)
- Kaican Zong
- Department of Respiratory Medicine, The Seventh People's Hospital of Chongqing, Chongqing, People's Republic of China
| | - Chen Luo
- Department of Respiratory Medicine, The Seventh People's Hospital of Chongqing, Chongqing, People's Republic of China
| | - Hui Zhou
- Department of Respiratory Medicine, The Seventh People's Hospital of Chongqing, Chongqing, People's Republic of China
| | - Yangzhi Jiang
- Department of Respiratory Medicine, The Seventh People's Hospital of Chongqing, Chongqing, People's Republic of China
| | - Shiying Li
- Department of Infectious Disease, The Second Affiliated Hospital, Chongqing Medical University, 74# Linjiang Road, Chongqing, 400010, People's Republic of China.
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47
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Fakey Khan D, Suleman M, Baijnath P, Perumal R, Moodley V, Mhlane Z, Naidoo T, Ndung'u T, Wong EB. Multiple microbiologic tests for tuberculosis improve diagnostic yield of bronchoscopy in medically complex patients. AAS Open Res 2019; 2:25. [PMID: 32382702 PMCID: PMC7194149 DOI: 10.12688/aasopenres.12980.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2019] [Indexed: 01/09/2023] Open
Abstract
Background: Bronchoalveolar lavage (BAL) is indicated for medical evaluation of complex cases of lung disease. There is limited data on the performance of tuberculosis (TB) microbiologic tests on BAL in such patients, particularly in human immunodeficiency virus (HIV) and TB endemic areas. Methods: We evaluated the performance of Mycobacterium tuberculosis (Mtb) culture and up to two simultaneous Xpert MTB/RIF tests on BAL fluid against a consensus clinical diagnosis in 98 medically complex patients undergoing bronchoscopy over a two-year period in Durban, South Africa. Results: TB was the most frequently diagnosed lung disease, found in 19 of 98 participants (19%) and was microbiologically proven in 14 of these (74%); 9 (47%) were culture positive and 5 were positive on at least one Xpert MTB/RIF assay. Immunosuppression prevalence was high (26% HIV-infected, 29% on immunosuppressive therapy and 4% on chemotherapy). Xpert MTB/RIF had low sensitivity (45%) and high specificity (99%) when assessed against the consensus clinical diagnosis. Compared to TB culture, a single Xpert MTB/RIF increased the diagnostic yield by 11% and a second Xpert MTB/RIF by a further 16%. Conclusion: Although Xpert MTB/RIF had a low sensitivity, sending two tests improved the microbiologically-proven diagnostic yield of bronchoscopy from 47% to 74% compared to culture alone.
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Affiliation(s)
- Dilshaad Fakey Khan
- Department of Pulmonology, Inkosi Albert Luthuli Central Hospital, Durban, KZN, 4000, South Africa
| | - Moosa Suleman
- Department of Pulmonology, Inkosi Albert Luthuli Central Hospital, Durban, KZN, 4000, South Africa
| | - Prinita Baijnath
- Department of Pulmonology, Inkosi Albert Luthuli Central Hospital, Durban, KZN, 4000, South Africa
| | - Rubeshan Perumal
- Department of Pulmonology, Inkosi Albert Luthuli Central Hospital, Durban, KZN, 4000, South Africa
- Center for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Vedanthi Moodley
- Department of Pulmonology, Inkosi Albert Luthuli Central Hospital, Durban, KZN, 4000, South Africa
| | - Zoey Mhlane
- Africa Health Research Institute, Durban, South Africa
| | - Taryn Naidoo
- Africa Health Research Institute, Durban, South Africa
| | - Thumbi Ndung'u
- Africa Health Research Institute, Durban, South Africa
- Division of Infection and Immunity, University College London, London, UK
- HIV Pathogenesis programme, Doris Duke Medical Research Institute, Durban, South Africa
- Max Planck Institute for Infection Biology, Berlin, Germany
- The Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology, Massachusetts, USA
| | - Emily B. Wong
- Africa Health Research Institute, Durban, South Africa
- Division of Infection and Immunity, University College London, London, UK
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, USA
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48
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Horne DJ, Kohli M, Zifodya JS, Schiller I, Dendukuri N, Tollefson D, Schumacher SG, Ochodo EA, Pai M, Steingart KR. Xpert MTB/RIF and Xpert MTB/RIF Ultra for pulmonary tuberculosis and rifampicin resistance in adults. Cochrane Database Syst Rev 2019; 6:CD009593. [PMID: 31173647 PMCID: PMC6555588 DOI: 10.1002/14651858.cd009593.pub4] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Xpert MTB/RIF (Xpert MTB/RIF) and Xpert MTB/RIF Ultra (Xpert Ultra), the newest version, are the only World Health Organization (WHO)-recommended rapid tests that simultaneously detect tuberculosis and rifampicin resistance in persons with signs and symptoms of tuberculosis, at lower health system levels. A previous Cochrane Review found Xpert MTB/RIF sensitive and specific for tuberculosis (Steingart 2014). Since the previous review, new studies have been published. We performed a review update for an upcoming WHO policy review. OBJECTIVES To determine diagnostic accuracy of Xpert MTB/RIF and Xpert Ultra for tuberculosis in adults with presumptive pulmonary tuberculosis (PTB) and for rifampicin resistance in adults with presumptive rifampicin-resistant tuberculosis. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, Science Citation Index, Web of Science, Latin American Caribbean Health Sciences Literature, Scopus, the WHO International Clinical Trials Registry Platform, the International Standard Randomized Controlled Trial Number Registry, and ProQuest, to 11 October 2018, without language restriction. SELECTION CRITERIA Randomized trials, cross-sectional, and cohort studies using respiratory specimens that evaluated Xpert MTB/RIF, Xpert Ultra, or both against the reference standard, culture for tuberculosis and culture-based drug susceptibility testing or MTBDRplus for rifampicin resistance. DATA COLLECTION AND ANALYSIS Four review authors independently extracted data using a standardized form. When possible, we also extracted data by smear and HIV status. We assessed study quality using QUADAS-2 and performed meta-analyses to estimate pooled sensitivity and specificity separately for tuberculosis and rifampicin resistance. We investigated potential sources of heterogeneity. Most analyses used a bivariate random-effects model. For tuberculosis detection, we first estimated accuracy using all included studies and then only the subset of studies where participants were unselected, i.e. not selected based on prior microscopy testing. MAIN RESULTS We identified in total 95 studies (77 new studies since the previous review): 86 studies (42,091 participants) evaluated Xpert MTB/RIF for tuberculosis and 57 studies (8287 participants) for rifampicin resistance. One study compared Xpert MTB/RIF and Xpert Ultra on the same participant specimen.Tuberculosis detectionOf the total 86 studies, 45 took place in high tuberculosis burden and 50 in high TB/HIV burden countries. Most studies had low risk of bias.Xpert MTB/RIF pooled sensitivity and specificity (95% credible Interval (CrI)) were 85% (82% to 88%) and 98% (97% to 98%), (70 studies, 37,237 unselected participants; high-certainty evidence). We found similar accuracy when we included all studies.For a population of 1000 people where 100 have tuberculosis on culture, 103 would be Xpert MTB/RIF-positive and 18 (17%) would not have tuberculosis (false-positives); 897 would be Xpert MTB/RIF-negative and 15 (2%) would have tuberculosis (false-negatives).Xpert Ultra sensitivity (95% confidence interval (CI)) was 88% (85% to 91%) versus Xpert MTB/RIF 83% (79% to 86%); Xpert Ultra specificity was 96% (94% to 97%) versus Xpert MTB/RIF 98% (97% to 99%), (1 study, 1439 participants; moderate-certainty evidence).Xpert MTB/RIF pooled sensitivity was 98% (97% to 98%) in smear-positive and 67% (62% to 72%) in smear-negative, culture-positive participants, (45 studies). Xpert MTB/RIF pooled sensitivity was 88% (83% to 92%) in HIV-negative and 81% (75% to 86%) in HIV-positive participants; specificities were similar 98% (97% to 99%), (14 studies).Rifampicin resistance detectionXpert MTB/RIF pooled sensitivity and specificity (95% Crl) were 96% (94% to 97%) and 98% (98% to 99%), (48 studies, 8020 participants; high-certainty evidence).For a population of 1000 people where 100 have rifampicin-resistant tuberculosis, 114 would be positive for rifampicin-resistant tuberculosis and 18 (16%) would not have rifampicin resistance (false-positives); 886 would be would be negative for rifampicin-resistant tuberculosis and four (0.4%) would have rifampicin resistance (false-negatives).Xpert Ultra sensitivity (95% CI) was 95% (90% to 98%) versus Xpert MTB/RIF 95% (91% to 98%); Xpert Ultra specificity was 98% (97% to 99%) versus Xpert MTB/RIF 98% (96% to 99%), (1 study, 551 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS We found Xpert MTB/RIF to be sensitive and specific for diagnosing PTB and rifampicin resistance, consistent with findings reported previously. Xpert MTB/RIF was more sensitive for tuberculosis in smear-positive than smear-negative participants and HIV-negative than HIV-positive participants. Compared with Xpert MTB/RIF, Xpert Ultra had higher sensitivity and lower specificity for tuberculosis and similar sensitivity and specificity for rifampicin resistance (1 study). Xpert MTB/RIF and Xpert Ultra provide accurate results and can allow rapid initiation of treatment for multidrug-resistant tuberculosis.
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Affiliation(s)
- David J Horne
- University of WashingtonDepartment of Medicine, Division of Pulmonary and Critical Care Medicine, and Firland Northwest TB CenterSeattleUSA
| | - Mikashmi Kohli
- McGill UniversityDepartment of Epidemiology, Biostatistics and Occupational HealthMontrealCanada
| | - Jerry S Zifodya
- University of WashingtonPulmonary and Critical Care Medicine325 9th Avenue – Campus Box 359762SeattleUSA98104
| | - Ian Schiller
- McGill University Health Centre ‐ Research InstituteDivision of Clinical EpidemiologyMontrealCanada
| | - Nandini Dendukuri
- McGill University Health Centre ‐ Research InstituteDivision of Clinical EpidemiologyMontrealCanada
| | | | | | - Eleanor A Ochodo
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesPO Box 241Cape TownSouth Africa8000
| | - Madhukar Pai
- McGill UniversityDepartment of Epidemiology, Biostatistics and Occupational HealthMontrealCanada
| | - Karen R Steingart
- Department of Clinical Sciences, Liverpool School of Tropical MedicineHonorary Research FellowPembroke PlaceLiverpoolUK
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Najjingo I, Muttamba W, Kirenga BJ, Nalunjogi J, Bakesiima R, Olweny F, Lusiba P, Katamba A, Joloba M, Ssengooba W. Comparison of GeneXpert cycle threshold values with smear microscopy and culture as a measure of mycobacterial burden in five regional referral hospitals of Uganda- A cross-sectional study. PLoS One 2019; 14:e0216901. [PMID: 31091275 PMCID: PMC6519814 DOI: 10.1371/journal.pone.0216901] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 04/30/2019] [Indexed: 11/25/2022] Open
Abstract
Background Determining mycobacterial burden is important in assessing severity of disease, evaluating infectiousness and predicting patient treatment outcomes. Mycobacterial burden assessed by smear microscopy grade and time to culture positivity is clearly interpretable by most physicians. GeneXpert (Xpert) has been recommended by WHO as a first line tuberculosis (TB) diagnostic test as an alternative to smear microscopy. Xpert gives cycle threshold (Ct) values as a potential measure for mycobacterial burden. For physicians to clearly interpret Ct values as measures of mycobacterial burden, this study compared the Xpert quantification capabilities with those of smear microscopy and culture. The study also determined a linear relationship between Xpert Ct values and MGIT culture time to positivity (MGIT-TTP) and associated factors. A cut off Ct value which best predicts smear positivity was also determined using the Receiver Operator Curve analysis method. Results Excluding missing results and rifampicin resistant TB cases, a moderately strong correlation of 0.55 between Xpert Ct value and smear grade was obtained. A weak correlation of 0.37 was obtained between Xpert Ct values and MGIT time to positivity while that between Xpert Ct values and LJ culture was 0.34. The Xpert Ct values were found to increase by 2.57 for every unit increase in days to positive and HIV status was significantly associated with this relationship. A cut off Ct value of 23.62 was found to best predict smear positivity regardless of HIV status. Conclusion Our study findings show that GeneXpert Ct values are comparable to smear microscopy as a measure of M. tuberculosis burden and can be used to replace smear microscopy. However, given the low correlation between Xpert Ct value and culture positivity, Xpert Ct values cannot replace culture as a measure of M. tuberculosis burden among TB patients.
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Affiliation(s)
- Irene Najjingo
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda.,Lung Institute Makerere University, Kampala, Uganda
| | | | | | - Joanitah Nalunjogi
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Ritah Bakesiima
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Francis Olweny
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Pastan Lusiba
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Achilles Katamba
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Moses Joloba
- Department of Medical Microbiology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Willy Ssengooba
- Lung Institute Makerere University, Kampala, Uganda.,Department of Medical Microbiology, College of Health Sciences, Makerere University, Kampala, Uganda
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50
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Luo D, Wang L, Liu H, Li L, Liao Y, Yi X, Yan X, Wan K, Zeng Y. Ribokinase screened from T7 phage displayed Mycobacterium tuberculosis genomic DNA library had good potential for the serodiagnosis of tuberculosis. Appl Microbiol Biotechnol 2019; 103:5259-5267. [PMID: 31069485 DOI: 10.1007/s00253-019-09756-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/05/2019] [Accepted: 03/07/2019] [Indexed: 12/13/2022]
Abstract
Tuberculosis caused by Mycobacterium tuberculosis (M. tuberculosis) is the leading cause of death among infectious diseases in the worldwide. Lack of more sensitive and effective diagnostic reagents has increased the awareness of rapid diagnosis for tuberculosis. In this study, T7 phage displayed genomic DNA library of M. tuberculosis was constructed to screen the antigens that specially bind with TB-positive serum from the whole genome of M. tuberculosis and to improve the sensitivity and specificity of tuberculosis serological diagnosis. After three rounds of biopanning, results of DNA sequencing and BLAST analysis showed that 19 positive phages displayed four different proteins and the occurrence frequency of the phage which displayed ribokinase was the highest. The results of indirect ELISA and dot immunoblotting indicated that representative phages could specifically bind to tuberculosis-positive serum. The prokaryotic expression vector containing the DNA sequence of ribokinase gene was then constructed and the recombinant protein was expressed and purified to evaluate the serodiagnosis value of ribokinase. The reactivity of the recombinant ribokinase with different clinical serum was detected and the sensitivities and specificities in tuberculosis serodiagnosis were 90% and 86%, respectively by screening serum from tuberculosis patients (n = 90) and uninfected individuals (n = 90) based on ELISA. Therefore, this study demonstrated that ribokinase had good potential for the serodiagnosis of tuberculosis.
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Affiliation(s)
- Dan Luo
- Institute of Pathogenic Biology, Hengyang Medical College, Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, University of South China, Hengyang, 421001, People's Republic of China
| | - Li Wang
- Institute of Pathogenic Biology, Hengyang Medical College, Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, University of South China, Hengyang, 421001, People's Republic of China
| | - Haican Liu
- State Key Laboratory for Infectious Disease Prevention and Control/National Institute for communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 102206, People's Republic of China
| | - Lingling Li
- Institute of Pathogenic Biology, Hengyang Medical College, Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, University of South China, Hengyang, 421001, People's Republic of China
| | - Yating Liao
- Institute of Pathogenic Biology, Hengyang Medical College, Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, University of South China, Hengyang, 421001, People's Republic of China
| | - Xiaomei Yi
- Reproductive Medical Center, The Affiliated First Hospital, University of South China, Hengyang, 421001, People's Republic of China
| | - Xiaoliang Yan
- Institute of Pathogenic Biology, Hengyang Medical College, Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, University of South China, Hengyang, 421001, People's Republic of China
| | - Kanglin Wan
- State Key Laboratory for Infectious Disease Prevention and Control/National Institute for communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 102206, People's Republic of China.
| | - Yanhua Zeng
- Institute of Pathogenic Biology, Hengyang Medical College, Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, University of South China, Hengyang, 421001, People's Republic of China.
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