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Basile FW, Sweeney S, Singh MP, Bijker EM, Cohen T, Menzies NA, Vassall A, Indravudh P. Uncertainty in tuberculosis clinical decision-making: An umbrella review with systematic methods and thematic analysis. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003429. [PMID: 39042611 PMCID: PMC11265660 DOI: 10.1371/journal.pgph.0003429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 06/12/2024] [Indexed: 07/25/2024]
Abstract
Tuberculosis is a major infectious disease worldwide, but currently available diagnostics have suboptimal accuracy, particularly in patients unable to expectorate, and are often unavailable at the point-of-care in resource-limited settings. Test/treatment decision are, therefore, often made on clinical grounds. We hypothesized that contextual factors beyond disease probability may influence clinical decisions about when to test and when to treat for tuberculosis. This umbrella review aimed to identify such factors, and to develop a framework for uncertainty in tuberculosis clinical decision-making. Systematic reviews were searched in seven databases (MEDLINE, CINAHL Complete, Embase, Scopus, Cochrane, PROSPERO, Epistemonikos) using predetermined search criteria. Findings were classified as barriers and facilitators for testing or treatment decisions, and thematically analysed based on a multi-level model of uncertainty in health care. We included 27 reviews. Study designs and primary aims were heterogeneous, with seven meta-analyses and three qualitative evidence syntheses. Facilitators for decisions to test included providers' advanced professional qualification and confidence in tests results, availability of automated diagnostics with quick turnaround times. Common barriers for requesting a diagnostic test included: poor provider tuberculosis knowledge, fear of acquiring tuberculosis through respiratory sampling, scarcity of healthcare resources, and complexity of specimen collection. Facilitators for empiric treatment included patients' young age, severe sickness, and test inaccessibility. Main barriers to treatment included communication obstacles, providers' high confidence in negative test results (irrespective of negative predictive value). Multiple sources of uncertainty were identified at the patient, provider, diagnostic test, and healthcare system levels. Complex determinants of uncertainty influenced decision-making. This could result in delayed or missed diagnosis and treatment opportunities. It is important to understand the variability associated with patient-provider clinical encounters and healthcare settings, clinicians' attitudes, and experiences, as well as diagnostic test characteristics, to improve clinical practices, and allow an impactful introduction of novel diagnostics.
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Affiliation(s)
- Francesca Wanda Basile
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sedona Sweeney
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Maninder Pal Singh
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Else Margreet Bijker
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- Department of Paediatrics, Maastricht University Medical Centre, MosaKids Children’s Hospital, Maastricht, the Netherlands
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Nicolas A. Menzies
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
- Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Pitchaya Indravudh
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Li Z. The Value of GeneXpert MTB/RIF for Detection in Tuberculosis: A Bibliometrics-Based Analysis and Review. JOURNAL OF ANALYTICAL METHODS IN CHEMISTRY 2022; 2022:2915018. [PMID: 36284547 PMCID: PMC9588380 DOI: 10.1155/2022/2915018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 09/26/2022] [Accepted: 10/01/2022] [Indexed: 06/16/2023]
Abstract
With the continuous development of medical science and technology, especially with the advent of the era of precision diagnosis and treatment, molecular biology detection technology is widely valued and applied as an aid to early diagnosis of tuberculosis. The GeneXpert Mycobacterium tuberculosis Branching (MTB) technology is a suite of semi-nested real-time fluorescent quantitative PCR in vitro diagnostic technologies developed by Cepheid Inc. It targets the rifampicin resistance gene, rpoB, and can detect both MTB and resistance to rifampicin within 2 h. This review analyzed the papers related to GeneXpert using bibliometric software CiteSpace and Bibliometrix. A total of 151 articles were analyzed, spanning from 2011 to 2021. This bibliometrics-based review summarizes the history of the development of GeneXpert in tuberculosis diagnosis and its current status. Contributions of different countries to the topic, journal analysis, key paper analysis, and clustering of keywords were used to analyze this topic.
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Affiliation(s)
- Zhiyi Li
- Laboratory Medicine, Nanan Hospital, Nanan, Quanzhou 362300, Fujian, China
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Pongpeeradech N, Kasetchareo Y, Chuchottaworn C, Lawpoolsri S, Silachamroon U, Kaewkungwal J. Evaluation of the use of GeneXpert MTB/RIF in a zone with high burden of tuberculosis in Thailand. PLoS One 2022; 17:e0271130. [PMID: 35895742 PMCID: PMC9328536 DOI: 10.1371/journal.pone.0271130] [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: 01/17/2022] [Accepted: 06/23/2022] [Indexed: 11/18/2022] Open
Abstract
GeneXpert MTB/RIF is a reliable molecular diagnostic tool capable of detecting Mycobacterium tuberculosis (MTB) and identifying genetic determinants of rifampicin (RIF) resistance. This study aimed to assess physicians’ diagnostic decision-making processes for TB based on GeneXpert MTB/RIF results and how this affected the initiation of multidrug resistance (MDR) treatment. This study employed a mixed method: data were collected retrospectively from the medical records of TB patients and in-depth interviews were conducted with healthcare workers in areas with a high TB burden in Thailand. A total of 2,030 complete TB records from 2 patient groups were reviewed, including 1443 suspected cases with negative smear results and 587 with high risk of MDR-TB. GeneXpert MTB/RIF was routinely used to assist the physicians in their decision-making for the diagnosis of pulmonary tuberculosis (PTB) and the initiation of MDR-TB treatment. The physicians used it as a “rule-in test” for all patients with negative chest X-rays (CXR) and smear results, to ensure timely treatment. Approximately one-fourth of the patients with negative CXR/smear and GeneXpert MTB/RIF results were diagnosed with PTB by the physicians, who based their decisions on other evidence, such as clinical symptoms, and did not use GeneXpert MTB/RIF as a “rule-out test.” GeneXpert MTB/RIF proved effective in early detection within a day, thereby radically shortening the time required to initiate second-line drug treatment. Despite its high sensitivity for detecting PTB and MDR-TB, GeneXpert MTB/RIF had contradictory results (false positive and/or false negative) for 21.8% of cases among patients with negative smear results and 41.1% of cases among patients with high risk of MDR-TB. Therefore, physicians still used the results of other conventional tests in their decision-making process. It is recommended that GeneXpert MTB/RIF should be established at all points of care and be used as the initial test for PTB and MDR-TB diagnosis.
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Affiliation(s)
- Nathakorn Pongpeeradech
- Faculty of Tropical Medicine, Department of Tropical Hygiene, Mahidol University, Bangkok, Thailand
| | - Yuthichai Kasetchareo
- Division of AIDS Tuberculosis and Sexual transmitted diseases, Department of Health, Nonthaburi, Thailand
- Thonburi Health Center, Bangkok, Thailand
| | - Charoen Chuchottaworn
- Central Chest Institute of Thailand (CCIT), Ministry of Public Health, Nonthaburi, Thailand
| | - Saranath Lawpoolsri
- Faculty of Tropical Medicine, Department of Tropical Hygiene, Mahidol University, Bangkok, Thailand
- Faculty of Tropical Medicine, Center of Excellence for Biomedical and Public Health Informatics (BIOPHICS), Mahidol University, Bangkok, Thailand
| | - Udomsak Silachamroon
- Faculty of Tropical Medicine, Department of Clinical Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Jaranit Kaewkungwal
- Faculty of Tropical Medicine, Department of Tropical Hygiene, Mahidol University, Bangkok, Thailand
- Faculty of Tropical Medicine, Center of Excellence for Biomedical and Public Health Informatics (BIOPHICS), Mahidol University, Bangkok, Thailand
- * E-mail:
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Feng JY, Lin CJ, Wang JY, Chien ST, Lin CB, Huang WC, Lee CH, Shu CC, Yu MC, Lee JJ, Chiang CY. Nucleic acid amplification tests reduce delayed diagnosis and misdiagnosis of pulmonary tuberculosis. Sci Rep 2022; 12:12064. [PMID: 35835940 PMCID: PMC9283405 DOI: 10.1038/s41598-022-16319-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 07/08/2022] [Indexed: 11/25/2022] Open
Abstract
The clinical impact of nucleic acid amplification (NAA) tests on reducing delayed diagnosis and misdiagnosis of pulmonary TB (PTB) has rarely been investigated. PTB patients were classified into a frontline NAA group, an add-on NAA group, and a no NAA group. The outcomes of interest were the proportion of PTB case died before anti-TB treatment, the interval between sputum examination and initiation of treatment, and misdiagnosis of PTB. A total of 2192 PTB patients were enrolled, including 282 with frontline NAA, 717 with add-on NAA, and 1193 with no NAA tests. Patients with NAA tests had a lower death rate before treatment initiation compared to those without NAA tests (1.6% vs. 4.4%, p < 0.001) in all cases. Patients with frontline NAA compared to those with add-on NAA and those without NAA, had a shorter interval between sputum examination and treatment initiation in all cases (3 days vs. 6 days (p < 0.001), vs 18 days (p < 0.001)), and less misdiagnosis in smear-positive cases (1.8% vs. 5.6% (p = 0.039), vs 6.5% (p = 0.026)). In conclusion, NAA tests help prevent death before treatment initiation. Frontline NAA tests perform better than add-on NAA and no NAA in avoiding treatment delay in all cases, and misdiagnosis of PTB in smear-positive cases.
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Affiliation(s)
- Jia-Yih Feng
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC.,Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Chou-Jui Lin
- Tao-Yuan General Hospital, Ministry of Health and Welfare, Tao-Yuan, Taiwan, ROC
| | - Jann-Yuan Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, ROC.,School of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan, ROC
| | - Shun-Tien Chien
- Chest Hospital, Ministry of Health and Welfare, Tainan, Taiwan, ROC
| | - Chih-Bin Lin
- Division of Chest Medicine, Department of Internal Medicine, Hualien Tzu Chi Hospital, Hualien, Taiwan, ROC.,School of Medicine, Tzu Chi University, Hualien, Taiwan, ROC
| | - Wei-Chang Huang
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan, ROC.,Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, ROC.,Department of Medical Technology, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan, ROC.,Master Program for Health Administration, Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan, ROC
| | - Chih-Hsin Lee
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan, ROC.,Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, 111 Hsin-Long Road, Section 3, Taipei 116, Taiwan, ROC
| | - Chin-Chung Shu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Ming-Chih Yu
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan, ROC.,Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, 111 Hsin-Long Road, Section 3, Taipei 116, Taiwan, ROC.,School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
| | - Jen-Jyh Lee
- Division of Chest Medicine, Department of Internal Medicine, Hualien Tzu Chi Hospital, Hualien, Taiwan, ROC
| | - Chen-Yuan Chiang
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan, ROC. .,Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, 111 Hsin-Long Road, Section 3, Taipei 116, Taiwan, ROC. .,International Union Against Tuberculosis and Lung Disease, Paris, France.
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Huang WC, Lin CB, Chien ST, Wang JY, Lin CJ, Feng JY, Lee CH, Shu CC, Yu MC, Lee JJ, Chiang CY. Performance of Nucleic Acid Amplification Tests in Patients with Presumptive Pulmonary Tuberculosis in Taiwan. Infect Dis Ther 2022; 11:871-885. [PMID: 35254635 PMCID: PMC8900096 DOI: 10.1007/s40121-022-00610-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 02/14/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Several nucleic acid amplification tests (NAATs) for detection of Mycobacterium tuberculosis (TB) complex (MTBC) are available in Taiwan; however, their performances may differ and have not been extensively evaluated. Therefore, we aimed to explore the accuracy of NAATs overall followed by comparison between platforms commonly used in Taiwan. METHODS This study enrolled presumptive pulmonary TB patients with NAATs throughout Taiwan. The diagnostic performance of smear microscopy and NAATs was assessed using sputum culture as a reference standard. To investigate the performance of NAATs in excluding non-tuberculous mycobacteria (NTM), we quantified the false-positive proportion of NAATs in patients infected with NTM. RESULTS Of the 4126 enrollees, 860 (20.8%) had positive NAATs. The sensitivity and specificity of NAATs were 83.2% and 96.7%, respectively, compared to 81.5% and 55.3% for smear. There was no significant difference in sensitivity between the NAATs and smear; however, the specificity of smear was significantly lower than that of the NAATs [difference 41.4%, 95% confidence interval (CI) 39.6-43.2%]. There was no significant difference in sensitivity among Roche Cobas Amplicor Mycobacterium tuberculosis assay (Amplicor), Xpert MTB/RIF assay (Xpert) and in-house polymerase chain reaction (in-house PCR) (82.2% versus 83.8% versus 82.4%); however, in-house PCR was significantly less specific than Amplicor (difference 5.3%, 95% CI 2.4-8.2%) and Xpert (difference 5.8%, 95% CI 3.1-8.5%). The sensitivity of NAATs among smear-negative cases was 33.1% (95% CI 26.0-40.3%). In-house PCR had a significantly higher false-positive rate among specimens that were culture positive for NTM than Amplicor (7.7% versus 0.3%; difference 7.4%, 95% CI 3.4-11.5%) and Xpert (7.7% versus 0.7%; difference 7.0%, 95% CI 2.9-11.0%). CONCLUSION The NAATs overall had a relatively high sensitivity and specificity in detecting MTBC while Amplicor and Xpert performed better than in-house PCR in excluding NTM. Our findings will be useful for the development of national policy.
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Affiliation(s)
- Wei-Chang Huang
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, 407, Taiwan.,Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, 402, Taiwan.,Department of Translational Medicine, National Chung Hsing University, Taichung, 402, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, 402, Taiwan.,Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, 407, Taiwan.,Department of Medical Technology, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli, 350, Taiwan
| | - Chih-Bin Lin
- Division of Chest Medicine, Department of Internal Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, 970, Taiwan.,School of Medicine, Tzu Chi University, Hualien, 970, Taiwan
| | - Shun-Tien Chien
- Chest Hospital, Ministry of Health and Welfare, Tainan, 701, Taiwan
| | - Jann-Yuan Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, 100, Taiwan.,School of Medicine, College of Medicine, National Taiwan University, Taipei, 100, Taiwan
| | - Chou-Jui Lin
- Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, 330, Taiwan
| | - Jia-Yih Feng
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, 112, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, 112, Taiwan.,Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, 112, Taiwan
| | - Chih-Hsin Lee
- Division of Pulmonary Medicine & Pulmonary Research Center, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, 111 Xing-Long Road, Section 3, Taipei, 116, Taiwan.,Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan
| | - Chin-Chung Shu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, 100, Taiwan.,School of Medicine, College of Medicine, National Taiwan University, Taipei, 100, Taiwan
| | - Ming-Chih Yu
- Division of Pulmonary Medicine & Pulmonary Research Center, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, 111 Xing-Long Road, Section 3, Taipei, 116, Taiwan.,School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan
| | - Jen-Jyh Lee
- Division of Chest Medicine, Department of Internal Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, 970, Taiwan.,School of Medicine, Tzu Chi University, Hualien, 970, Taiwan
| | - Chen-Yuan Chiang
- Division of Pulmonary Medicine & Pulmonary Research Center, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, 111 Xing-Long Road, Section 3, Taipei, 116, Taiwan. .,Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan. .,International Union Against Tuberculosis and Lung Disease, Paris, France.
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Eckbo EJ, Rodrigues M, Hird T, Ng M, Lam K, Sekirov I. Needle in a haystack: Looking for tuberculosis in a low-incidence setting. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2021; 6:49-54. [PMID: 36340213 PMCID: PMC9612438 DOI: 10.3138/jammi-2020-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 08/26/2020] [Indexed: 06/16/2023]
Abstract
BACKGROUND Canada is a low-incidence country for tuberculosis (TB). The BC Public Health Laboratory diagnostic algorithm for pulmonary TB includes acid fast bacilli (AFB) smear and mycobacterial culture of all submitted sputa. TB nucleic acid amplification testing (NAT) is routinely performed on AFB-smear-positive (AFB+) sputa only. We assessed the laboratory-associated costs of implementing the international recommendations for TB NAT on AFB-smear-negative (AFB-) sputa. METHODS Two data sets were obtained: (1) all AFB- samples for a 3-year period (October 1, 2014-September 30, 2017) and (2) all AFB-, TB-culture-positive samples for the same period. One AFB- sample/patient from each defined diagnostic set of sputa was deemed eligible for TB NAT. To stratify patients by ordering location, a 1-year subset of data (October 1, 2016-September 30, 2017) was examined. RESULTS In the 3-year period, 0.7% of all diagnostic sets were AFB- and culture-positive. In the 1-year period, the provincial TB Services clinics submitted 26% of all AFB- samples received, but these constituted 78% of AFB-, culture-positive samples. CONCLUSIONS The annual cost of TB NAT on one AFB- sputum sample from each eligible diagnostic set would total approximately $247,000. Targeting only TB Services clinic patients would reduce this cost to approximately $64,000/year while capturing more than 75% of AFB-, culture-positive patients. On the basis of our provincial positivity rate, it would cost approximately $6,000 to provide an early TB diagnosis for an AFB-, culture-positive patient. The cost-effectiveness to public health of this approach in a TB low-incidence setting needs to be carefully evaluated.
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Affiliation(s)
- Eric J Eckbo
- Department of Pathology & Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mabel Rodrigues
- British Columbia Centre for Disease Control, Public Health Laboratory, Vancouver, British Columbia, Canada
| | - Trevor Hird
- British Columbia Centre for Disease Control, Public Health Laboratory, Vancouver, British Columbia, Canada
| | - Monica Ng
- British Columbia Centre for Disease Control, Public Health Laboratory, Vancouver, British Columbia, Canada
| | - Kelvin Lam
- British Columbia Centre for Disease Control, Public Health Laboratory, Vancouver, British Columbia, Canada
| | - Inna Sekirov
- Department of Pathology & Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre for Disease Control, Public Health Laboratory, Vancouver, British Columbia, Canada
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Sorsa A, Kaso M. Diagnostic performance of GeneXpert in tuberculosis-HIV co-infected patients at Asella Teaching and Referral Hospital, Southeastern Ethiopia: A cross sectional study. PLoS One 2021; 16:e0242205. [PMID: 33503051 PMCID: PMC7840185 DOI: 10.1371/journal.pone.0242205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 10/28/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND GeneXpert is a new introduction in the diagnostic modality to fight tuberculosis (TB) among people living with HIV (PLHIV) under the program of intensified TB case finding. This study aimed to evaluate the diagnostic performance of GeneXpert under the program of intensified TB cases finding among PLHIV. METHODS Cross-sectional study was conducted by recruiting individuals attending an HIV clinic from February 2018 to January 2019. Data on clinical parameters were collected using a standardized tool. Two-morning sputum samples were collected and processed for smear microscopy and GeneXpert. SPSS 21 used for data analysis. Proportion, percentage, and mean with SD were used to describe variables. Univariate and multivariable logistic regressions were used to assess factors associated with the GeneXpert. Values for which the 95% CI interval not includes 1 and for which P<0.05 were considered significant. RESULT A total of 384 presumptive TB-HIV co-infection cases were included, of which 166 (43%) were diagnosed to have TB. Fifty-four (32.5%) TB cases were smear AFB positive while 79 (47.7%) TB cases were GeneXpert positive. The GeneXpert detection rate was almost two-fold of that of smear microscopy and all smear positive TB cases were detected by GeneXpert. Moreover, GeneXpert was able to detect an additional third of TB confirmed cases among smear AFB negative cases. Advanced stage of the disease, high viral load and presence of anemia were significantly associated with TB. The WHO TB screening tool remained least sensitive with the lowest positive predictive value. CONCLUSION GeneXpert demonstrated two-fold case detection rate compared to the sputum smear microscopy and additional third TB case detection rate among smear AFB negative cases. Clinical screening tool for evaluation of TB-HIV co-infection showed poor performance in TB case notification.
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Affiliation(s)
- Abebe Sorsa
- Arsi University College of Health Science and Referral Hospital, Asella, Ethiopia
| | - Muhammedawel Kaso
- Arsi University College of Health Science and Referral Hospital, Asella, Ethiopia
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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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9
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Das S, Mangold KA, Shah NS, Peterson LR, Thomson RB, Kaul KL. Performance and Utilization of a Laboratory-Developed Nucleic Acid Amplification Test (NAAT) for the Diagnosis of Pulmonary and Extrapulmonary Tuberculosis in a Low-Prevalence Area. Am J Clin Pathol 2020; 154:115-123. [PMID: 32249294 DOI: 10.1093/ajcp/aqaa031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Tuberculosis (TB) is a significant global health problem. In low-prevalence areas and low clinical suspicion, nucleic acid amplification tests (NAAT) for direct detection of Mycobacterium tuberculosis complex (MTBC) can speed therapy initiation and infection control. An NAAT assay (TBPCR) targeting MTBC IS6110 is used for detecting MTBC in our low-prevalence population. METHODS Fifteen-year review of patient records identified 146 patients with culture-positive pulmonary tuberculosis (PTB) or extrapulmonary tuberculosis (EPTB). Laboratory-developed TBPCR was retrospectively compared with standard stain and cultures for PTB and EPTB diagnoses. RESULTS TBPCR assay was used in 57% of patients with PTB and 33% of patients with EPTB. TBPCR detected 88.4% of all TB (smear-positive, 97%; smear-negative, 79%) with 100% specificity. Low bacterial load was indicated in TBPCR-negative PTB (P = .002) and EPTB (P < .008). CONCLUSIONS TBPCR performance was optimum but significantly underused. Guidelines are proposed for mandated use of TBPCR that capture patients with clinically suspected PTB. Focused TBPCR use in low prevalence populations will benefit patient care, infection prevention, and public health.
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Affiliation(s)
- Sanchita Das
- Departments of 1Pathology and Laboratory Medicine, Evanston, IL
- Department of Pathology, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Kathy A Mangold
- Departments of 1Pathology and Laboratory Medicine, Evanston, IL
- Department of Pathology, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Nirav S Shah
- Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Lance R Peterson
- Departments of 1Pathology and Laboratory Medicine, Evanston, IL
- Department of Pathology, University of Chicago Pritzker School of Medicine, Chicago, IL
- Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Richard B Thomson
- Departments of 1Pathology and Laboratory Medicine, Evanston, IL
- Department of Pathology, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Karen L Kaul
- Departments of 1Pathology and Laboratory Medicine, Evanston, IL
- Department of Pathology, University of Chicago Pritzker School of Medicine, Chicago, IL
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Martino RJ, Chirenda J, Mujuru HA, Ye W, Yang Z. Characteristics Indicative of Tuberculosis/HIV Coinfection in a High-Burden Setting: Lessons from 13,802 Incident Tuberculosis Cases in Harare, Zimbabwe. Am J Trop Med Hyg 2020; 103:214-220. [PMID: 32431282 DOI: 10.4269/ajtmh.19-0856] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Country-specific interventions targeting high-risk groups are necessary for a global reduction in Tuberculosis (TB)/HIV burden. We analyzed the data of 13,802 TB cases diagnosed in Harare, Zimbabwe, during 2013-2017. Pearson's chi-square tests and multivariate logistic regression models were used to identify patient characteristics significantly associated with TB/HIV coinfection. Of the 13,802 TB cases analyzed, 9,725 (70.5%) were HIV positive. A significantly higher odds of having TB/HIV coinfection diagnosis was found among females, patients aged 25-64 years, previously treated cases, and acid-fast bacillus sputum smear-negative cases. Compared with nondisseminated pulmonary TB, miliary TB (adjusted odds ratio [aOR]: 1.469, 95% CI: 1.071, 2.015) and TB meningitis (aOR: 1.715, 95% CI: 1.074, 2.736) both had a significantly higher odds for TB/HIV coinfection, whereas pleural TB (aOR 0.420, 95% CI: 0.354, 0.497) and all other extrapulmonary TB (EPTB) (aOR: 0.606, 95% CI: 0.516 0.712) were significantly less likely to have TB/HIV coinfection. The risk for TB/HIV coinfection varied significantly by patients' sociodemographic and clinical characteristics in Harare. Our finding that different forms of EPTB have different relationships with HIV coinfection has extended the knowledge base about clinical markers for TB/HIV coinfection which can lead to a greater public health impact on eliminating TB/HIV infection.
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Affiliation(s)
- Richard J Martino
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Joconiah Chirenda
- Department of Community Medicine, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Hilda A Mujuru
- Department of Pediatrics, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Wen Ye
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Zhenhua Yang
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
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11
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Performances and usefulness of Xpert MTB/RIF assay in low-incidence settings: not that bad? Eur J Clin Microbiol Infect Dis 2020; 39:1645-1649. [PMID: 32306143 DOI: 10.1007/s10096-020-03887-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/30/2020] [Indexed: 10/23/2022]
Abstract
Xpert MTB/RIF assay, a real-time PCR assay designed to detect Mycobacterium tuberculosis, has proven sensitive and specific when performed on respiratory samples in a high prevalence setting. However, it was suggested as less accurate in a low-incidence environment. We evaluated the accuracy of the Xpert for the diagnosis of tuberculosis (TB) on pulmonary and extrapulmonary samples in Geneva (Switzerland), where the prevalence of active TB is very low. From March 2009 to February 2013, the Xpert was performed on clinical samples. All specimens were also processed using auramine, AFB staining, and mycobacterial culture with both solid and liquid media. The accuracy of both microscopy and Xpert was determined retrospectively using cultures as the reference method. A total of 732 clinical specimens were processed with the Xpert. The Xpert had a high specificity (97.5%; 95% confidence interval (CI), 95.8-98.5%) and revealed much more sensitive (82.7%; 95% CI, 74.1-89.0%) than microscopy (55.5%; 95% CI, 45.7-64.8%) for the diagnosis of TB, with a high negative predictive value (96.8%; 95% CI, 95.0-98.0%). The advantage of PCR over microscopy was even more pronounced for extrapulmonary specimens (sensitivity of 70% (95% CI, 50.4-84.6%) compared with 23.3% (95% CI, 10.6-42.7%)). Despite the low prevalence of TB in Switzerland, results performance for respiratory samples was similar to that reported in high prevalence countries. The high negative predictive value is clinically helpful in our setting, where pulmonary TB needs to be reasonably ruled out. When considering extrapulmonary samples, microscopy performed poorly compared with Xpert. This study shows that the Xpert remains accurate and useful in a low-incidence setting.
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Difficulties with the implemented xpert MTB/RIF for determining diagnosis of pulmonary and extrapulmonary tuberculosis in adults and children. J Clin Tuberc Other Mycobact Dis 2020; 19:100159. [PMID: 32258438 PMCID: PMC7109450 DOI: 10.1016/j.jctube.2020.100159] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background and aims Handling of PTB and EPTB patients with adequate standard detection of MTBC and anti-TB drug sensitivity using accurate and rapid methods could provide good TB management and clinical treatment outcomes. The Xpert MTB/RIF assay is an automated, cartridge-based NAAT that can simultaneously detect MTBC and RIF resistance within 2 h. The aim of this study was to evaluate the implementation of Xpert for determining diagnosis of PTB and EPTB in adults and children. Methods A descriptive study was performed using e-TB Manager data from the MDR-TB Clinic at Dr. Soetomo Academic Hospital. Suspected TB cases were from the areas of East Java Province from January 2016 to December 2018. Xpert assay was conducted using standardized criteria for clinically suspected TB, and MTBC-positive results with RR were examined by the culture method using MGIT 960 BACTEC System. Results A total of 1181 (1181/3009, 39.25%) sputum samples from suspected new MDR-PTB cases tested positive for MTBC with 3.02% RR. Among 3893 sputum samples from previously treated probable MDR-PTB cases tested using Xpert, 1936 (49.73%) were MTBC positive with 13.20% RR. Among 59 new suspected MDR-PTB cases tested using MGIT 960 BACTEC System, 55 tested positive for MTBC, although all RR strains were highly sensitive to amikacin (100%), kanamycin (95%), and ofloxacin (89%). A total of 49 children with suspected PTB were tested using Xpert, revealing low positivity (12%) for MTBC, with all RR strains being rifampicin sensitive (RS). Of the 86 suspected EPTB cases tested using Xpert, very few were MTBC-positive (26%), with 91% RS. Conclusions This study revealed that in adults and children with PTB and EPTB, the Xpert assay achieved a low positivity detection rate for MTBC in samples from new or previously treated cases, and this could be the result of many factors.
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Wu CW, Wu YK, Lan CC, Yang MC, Dong TQ, Tzeng IS, Hsiao SS. Impact of nucleic acid amplification test on pulmonary tuberculosis notifications and treatments in Taiwan: a 7-year single-center cohort study. BMC Infect Dis 2019; 19:726. [PMID: 31420059 PMCID: PMC6697961 DOI: 10.1186/s12879-019-4358-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 08/05/2019] [Indexed: 01/05/2023] Open
Abstract
Background Nucleic acid amplification tests (NAAT) have been used as a diagnostic tool for pulmonary tuberculosis (PTB) in Taiwan for many years. In accordance with Taiwanese legislation, health care personnel are required to notify the Centers for Disease Control and Prevention (CDC) in case of suspected PTB. This study aimed to investigate the impact of NAAT(Gen-Probe) on the notification system for PTB and anti-tuberculosis treatments in Taiwan. Methods A retrospective study on the impact of NAAT (Enhanced Amplified Mycobacterium tuberculosis Direct Test [E-MTD], Gen-Probe, San Diego, CA, USA) [NAAT(Gen-Probe)] was carried out at Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation from March 2011 to December 2017. During the study period, microscopic acid-fast-bacilli smears and mycobacterial cultures were available for PTB diagnosis. NAAT(Gen-Probe) was first introduced at the hospital in January 2014 for use as a diagnostic method for PTB. Positive sputum culture was considered as the gold standard for PTB diagnosis. We excluded clinically-diagnosed PTB cases. Results When NAAT(Gen-Probe) was applied, the rate of error notification to CDC decreased from 64.3 to 7.0% (P < 0.001), and unnecessary anti-TB treatments administered to suspected cases decreased from 14.9 to 6.5% (P = 0.005). In the non-PTB group, the mean duration of unnecessary anti-TB treatments changed from 38.9 ± 38.3 days to 37.0 ± 37.9 days (P = 0.874). In the PTB group, the mean time from notifying CDC to initiating treatment decreased from 3.05 ± 6.95 days to 1.48 ± 1.99 days (P = 0.004). The sensitivity, specificity, positive predictive value, and negative predictive value of NAAT(Gen-Probe) were 99.0, 92.3, 99.0, and 92.3%, respectively. Conclusions Use of NAAT(Gen-Probe) led to decrease in the rate of error notification of suspected PTB cases to the CDC, avoidance of unnecessary use of anti-TB treatments, and accelerated initiation of appropriate treatments.
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Affiliation(s)
- Chih-Wei Wu
- Division of Pulmonary Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan.
| | - Yao-Kuang Wu
- Division of Pulmonary Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Chou-Chin Lan
- Division of Pulmonary Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Mei-Chen Yang
- Division of Pulmonary Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Ting-Qian Dong
- Division of Infection Control, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - I-Shiang Tzeng
- Division of Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Shu-Shien Hsiao
- Division of Nursing, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
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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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Bonney W, Price SF, Miramontes R. Design and Implementation of Data Exchange Formats for Molecular Detection of Drug-Resistant Tuberculosis. AMIA JOINT SUMMITS ON TRANSLATIONAL SCIENCE PROCEEDINGS. AMIA JOINT SUMMITS ON TRANSLATIONAL SCIENCE 2019; 2019:686-695. [PMID: 31259025 PMCID: PMC6568111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Drug-resistant tuberculosis (TB) remains a public health threat to the United States and worldwide control of TB. Rapid and reliable drug susceptibility testing (DST) is essential for aiding clinicians in selecting an optimal treatment regimen for TB patients and to prevent ongoing transmission. Growth-based DST results for culture-confirmed cases are routinely reported to the U.S. Centers for Disease Control and Prevention through the National TB Surveillance System (NTSS). However, the NTSS currently lacks the capacity and functionality to accept laboratory results from advanced molecular methods that detect mutations associated with drug resistance. The objective of this study is to design and implement novel comprehensive data exchange formats that utilize the Health Level Seven (HL7) version 2.5.1 messaging hierarchy to capture, store, and monitor molecular DST data, thereby, improving the quality of data, specifications and exchange formats within the NTSS as well as ensuring full reporting of drug-resistant TB.
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Affiliation(s)
- Wilfred Bonney
- Data Management, Statistics and Evaluation Branch, Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Office of Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Public Health Informatics Fellowship Program, Division of Scientific Education and Professional Development, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sandy F Price
- Data Management, Statistics and Evaluation Branch, Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Office of Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Roque Miramontes
- Data Management, Statistics and Evaluation Branch, Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Office of Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Luukinen BV, Vuento R, Hirvonen JJ. Evaluation of two tuberculosis PCR assays for routine use in a clinical setting of low population and low tuberculosis prevalence. APMIS 2019; 127:462-467. [PMID: 30901113 DOI: 10.1111/apm.12947] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 03/14/2019] [Indexed: 11/28/2022]
Abstract
Today, there are numerous different molecular diagnostic assays for the detection of tuberculosis (TB), allowing the optimization of rapid detection of TB according to the clinical need. In this study, two high-throughput TB PCR assays with combined antimicrobial resistance detection, Anyplex™ II MTB/MDR (Seegene) and RealTime MTB + RealTime MTB RIF/INH Resistance (Abbott Molecular), were evaluated for routine use in a clinical setting of low population and low TB prevalence in Finland. The RealTime MTB assay was 100% concordant (22/22 positive, n = 169) with the reference methods (culture and Xpert MTB/RIF PCR assay, Cepheid). However, with a limitation of four separate PCR cycles per kit, the routine use in a low TB-prevalence setting would easily lead to wasting most of the RIF/INH Resistance reagents. The Anyplex™ II MTB/MDR assay usability was more adaptive to suit the clinical setting but the assay sensitivity was considerably lower (86%, 19/22 positive, n = 76) being closer to the sensitivity of smear microscopy. The findings of this study suggest that the evaluated high-throughput MTB/MDR assays are evidently suboptimal for routine use in a low population, low TB-prevalence setting. In addition, neither of the two assays covers non-tuberculous mycobacteria and could therefore not fully replace acid-fast staining as the initial screening method.
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Affiliation(s)
- Bruno Vincent Luukinen
- Department of Clinical Microbiology, Fimlab Laboratories Ltd., Tampere, Finland.,Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Risto Vuento
- Department of Clinical Microbiology, Fimlab Laboratories Ltd., Tampere, Finland
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Baron EJ, Tenover FC, Gnanashanmugam D. Direct Detection of Mycobacterium tuberculosis in Clinical Specimens Using Nucleic Acid Amplification Tests. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.clinmicnews.2018.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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18
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Sulis G, Agliati A, Pinsi G, Bozzola G, Foccoli P, Gulletta M, Caligaris S, Tomasoni LR, El-Hamad I, Matteelli A. Xpert MTB/RIF as add-on test to microscopy in a low tuberculosis incidence setting. Eur Respir J 2018; 51:13993003.02345-2017. [DOI: 10.1183/13993003.02345-2017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 01/10/2018] [Indexed: 11/05/2022]
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Tenover FC. The role for rapid molecular diagnostic tests for infectious diseases in precision medicine. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2018. [DOI: 10.1080/23808993.2018.1425611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Cowan JF, Chandler AS, Kracen E, Park DR, Wallis CK, Liu E, Song C, Persing DH, Fang FC. Clinical Impact and Cost-effectiveness of Xpert MTB/RIF Testing in Hospitalized Patients With Presumptive Pulmonary Tuberculosis in the United States. Clin Infect Dis 2017; 64:482-489. [PMID: 28172666 PMCID: PMC5399932 DOI: 10.1093/cid/ciw803] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 12/01/2016] [Indexed: 11/12/2022] Open
Abstract
Background Microscopic examination of acid-fast-stained sputum smears is the current standard of care in the United States to determine airborne infection isolation (AII) of inpatients with presumptive pulmonary tuberculosis (PTB). However, nucleic acid amplification testing (NAAT) with the Xpert MTB/RIF assay (Xpert) may be more efficient and less costly. Methods This prospective observational cohort study enrolled a consecutive sample of 318 AII-eligible inpatients from a public hospital in Seattle, Washington, from March 2012 to October 2013. Sputum samples were collected from each inpatient and analyzed using smear microscopy, culture, drug susceptibility testing, and NAAT. The performance, clinical utility (AII duration and survival), and cost-effectiveness from an institutional perspective were compared for 5 testing strategies. Results Among the 318 admissions with presumptive PTB, 20 (6.3%) were culture-positive for Mycobacterium tuberculosis. The sensitivity of 1 Xpert, 2 Xperts, 2 smears, or 3 smears compared to culture was 0.85 (95% confidence interval [CI], .61–.96), 0.95 (95% CI, .73–1.0), 0.70 (95% CI, .46–.88), and 0.80 (95% CI, .56–.93), respectively. A cost-effectiveness analysis of the study results demonstrated that an Xpert test on 1 unconcentrated sputum sample (assuming equivalent results for unconcentrated and concentrated sputum samples) is the most cost-effective strategy (99.9% preferred at willingness-to-pay of US$50000) and on average would save 51.5 patient-hours in AII and up to $11466 relative to microscopy without a compromise in sensitivity. Conclusions In hospitalized patients with presumptive PTB in a low-burden setting, NAAT can reduce AII and is comparably sensitive, more specific, and more cost-effective than smear microscopy.
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Affiliation(s)
- James F Cowan
- Department of Global Health, University of Washington Schools of Medicine and Public Health
| | | | - Elizabeth Kracen
- Department of Medicine, University of Washington School of Medicine
| | - David R Park
- Department of Global Health, University of Washington Schools of Medicine and Public Health
- Harborview Medical Center
| | - Carolyn K Wallis
- Harborview Medical Center
- Department of Laboratory Medicine, University of Washington School of Medicine, Seattle
| | | | | | | | - Ferric C Fang
- Harborview Medical Center
- Department of Laboratory Medicine, University of Washington School of Medicine, Seattle
- Department of Microbiology, University of Washington School of Medicine, Seattle
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21
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Stevens WS, Scott L, Noble L, Gous N, Dheda K. Impact of the GeneXpert MTB/RIF Technology on Tuberculosis Control. Microbiol Spectr 2017; 5. [PMID: 28155817 DOI: 10.1128/microbiolspec.tbtb2-0040-2016] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Indexed: 11/20/2022] Open
Abstract
Molecular technology revolutionized the diagnosis of tuberculosis (TB) with a paradigm shift to faster, more sensitive, clinically relevant patient care. The most recent molecular leader is the GeneXpert MTB/RIF assay (Xpert) (Cepheid, Sunnyvale, CA), which was endorsed by the World Health Organization with unprecedented speed in December 2010 as the initial diagnostic for detection of HIV-associated TB and for where high rates of drug resistance are suspected. South Africa elected to take an aggressive smear replacement approach to facilitate earlier diagnosis and treatment through the decision to implement the Xpert assay nationally in March 2011, against the backdrop of approximately 6.3 million HIV-infected individuals, one of highest global TB and HIV coinfection rates, no available implementation models, uncertainties around field performance and program costs, and lack of guidance on how to operationalize the assay into existing complex clinical algorithms. South Africa's national implementation was conducted as a phased, forecasted, and managed approach (March 2011 to September 2013), through political will and both treasury-funded and donor-funded support. Today there are 314 GeneXperts across 207 microscopy centers; over 8 million assays have been conducted, and South Africa accounts for over half the global test cartridge usage. As with any implementation of new technology, challenges were encountered, both predicted and unexpected. This chapter discusses the challenges and consequences of such large-scale implementation efforts, the opportunities for new innovations, and the need to strengthen health systems, as well as the impact of the Xpert assay on rifampin-sensitive and multidrug-resistant TB patient care that translated into global TB control as we move toward the sustainable development goals.
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Affiliation(s)
- Wendy Susan Stevens
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, and National Health Laboratory Service and National Priority Program of the National Health Laboratory Service, Johannesburg, South Africa
| | - Lesley Scott
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Lara Noble
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Natasha Gous
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, and National Health Laboratory Service and National Priority Program of the National Health Laboratory Service, Johannesburg, South Africa
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Peralta G, Barry P, Pascopella L. Use of Nucleic Acid Amplification Tests in Tuberculosis Patients in California, 2010-2013. Open Forum Infect Dis 2016; 3:ofw230. [PMID: 27957506 PMCID: PMC5146759 DOI: 10.1093/ofid/ofw230] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 10/28/2016] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Nucleic acid amplification tests (NAATs) have been used as a diagnostic tool for tuberculosis (TB) in the United States for many years. We sought to assess NAAT use in TB patients in California during a period of time when NAAT availability increased throughout the world. METHODS We conducted a retrospective review of surveillance data from 6051 patients with culture-confirmed pulmonary TB who were reported to the California TB registry during 2010-2013. RESULTS Only 2336 of 6051 (39%) TB patients had a NAAT for diagnosis before culture results. Although 90% (N = 2101) with NAAT had positive test results, 9% (N = 217) had falsely negative NAAT results, and 0.8% (N = 18) had indeterminate NAAT results. The median time from specimen collection to TB treatment initiation was shorter when NAAT was used (3 vs 14 days, P < .0001), and patients with a positive NAAT result initiated treatment earlier than patients with a falsely negative result (1 vs 11 days from NAAT report, P < .0001). We confirmed the increased sensitivity of NAAT compared with acid-fast bacilli (AFB) smear microscopy in our study population; 92 of 145 AFB smear-negative patients had positive NAATs. Median time from specimen collection to NAAT result report differed by health jurisdiction, from 1 to 11 working days. CONCLUSIONS Increased use of NAATs in diagnosis of pulmonary TB could decrease the time-to-treatment initiation and consequently decrease transmission. However, differential use and access to NAAT may prevent full realization of NAAT benefits in California.
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Affiliation(s)
- Gianna Peralta
- Present Affiliation: Acute Disease Epidemiology Section, Georgia Department of Public Health , Georgia
| | - Pennan Barry
- Tuberculosis Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health , Richmond
| | - Lisa Pascopella
- Tuberculosis Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health , Richmond
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Oxlade O, Sugarman J, Alvarez GG, Pai M, Schwartzman K. Xpert®MTB/RIF for the Diagnosis of Tuberculosis in a Remote Arctic Setting: Impact on Cost and Time to Treatment Initiation. PLoS One 2016; 11:e0150119. [PMID: 26990299 PMCID: PMC4798714 DOI: 10.1371/journal.pone.0150119] [Citation(s) in RCA: 10] [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: 09/05/2015] [Accepted: 02/09/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) remains a significant health problem in the Canadian Arctic. Substantial health system delays in TB diagnosis can occur, in part due to the lack of capacity for onsite microbiologic testing. A study recently evaluated the yield and impact of a rapid automated PCR test (Xpert®MTB/RIF) for the diagnosis of TB in Iqaluit (Nunavut). We conducted an economic analysis to evaluate the expected cost relative to the expected reduction in time to treatment initiation, with the addition of Xpert®MTB/RIF to the current diagnostic and treatment algorithms used in this setting. METHODS A decision analysis model compared current microbiologic testing to a scenario where Xpert®MTB/RIF was added to the current diagnostic algorithm for active TB, and incorporated costs and clinical endpoints from the Iqaluit study. Several sensitivity analyses that considered alternative use were also considered. We estimated days to TB diagnosis and treatment initiation, health system costs, and the incremental cost per treatment day gained for each individual evaluated for possible TB. RESULTS With the addition of Xpert®MTB/RIF, costs increased while days to TB treatment initiation were reduced. The incremental cost per treatment day gained (per individual investigated for TB) was $164 (95% uncertainty range $85, $452). In a sensitivity analysis that considered hospital discharge after a single negative Xpert®MTB/RIF, the Xpert®MTB/RIF scenario was cost saving. INTERPRETATION Adding Xpert®MTB/RIF to the current diagnostic algorithm for TB in Nunavut appears to reduce time to diagnosis and treatment at reasonable cost. It may be especially well suited to overcome some of the other logistical barriers that are unique to this and other remote communities.
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Affiliation(s)
- Olivia Oxlade
- Respiratory Epidemiology and Clinical Research Unit, Department of Epidemiology, McGill University, Montreal, QC, Canada
- McGill International Tuberculosis Centre, McGill University, Montreal, QC, Canada
| | - Jordan Sugarman
- Respiratory Epidemiology and Clinical Research Unit, Department of Epidemiology, McGill University, Montreal, QC, Canada
| | - Gonzalo G. Alvarez
- Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Respirology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Madhukar Pai
- Respiratory Epidemiology and Clinical Research Unit, Department of Epidemiology, McGill University, Montreal, QC, Canada
- McGill International Tuberculosis Centre, McGill University, Montreal, QC, Canada
| | - Kevin Schwartzman
- Respiratory Epidemiology and Clinical Research Unit, Department of Epidemiology, McGill University, Montreal, QC, Canada
- McGill International Tuberculosis Centre, McGill University, Montreal, QC, Canada
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Schumacher SG, Sohn H, Qin ZZ, Gore G, Davis JL, Denkinger CM, Pai M. Impact of Molecular Diagnostics for Tuberculosis on Patient-Important Outcomes: A Systematic Review of Study Methodologies. PLoS One 2016; 11:e0151073. [PMID: 26954678 PMCID: PMC4783056 DOI: 10.1371/journal.pone.0151073] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 02/23/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Several reviews on the accuracy of Tuberculosis (TB) Nucleic Acid Amplification Tests (NAATs) have been performed but the evidence on their impact on patient-important outcomes has not been systematically reviewed. Given the recent increase in research evaluating such outcomes and the growing list of TB NAATs that will reach the market over the coming years, there is a need to bring together the existing evidence on impact, rather than accuracy. We aimed to assess the approaches that have been employed to measure the impact of TB NAATs on patient-important outcomes in adults with possible pulmonary TB and/or drug-resistant TB. METHODS We first develop a conceptual framework to clarify through which mechanisms the improved technical performance of a novel TB test may lead to improved patient outcomes and outline which designs may be used to measure them. We then systematically review the literature on studies attempting to assess the impact of molecular TB diagnostics on such outcomes and provide a narrative synthesis of designs used, outcomes assessed and risk of bias across different study designs. RESULTS We found 25 eligible studies that assessed a wide range of outcomes and utilized a variety of experimental and observational study designs. Many potentially strong design options have never been used. We found that much of the available evidence on patient-important outcomes comes from a small number of settings with particular epidemiological and operational context and that confounding, time trends and incomplete outcome data receive insufficient attention. CONCLUSIONS A broader range of designs should be considered when designing studies to assess the impact of TB diagnostics on patient outcomes and more attention needs to be paid to the analysis as concerns about confounding and selection bias become relevant in addition to those on measurement that are of greatest concern in accuracy studies.
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Affiliation(s)
- Samuel G. Schumacher
- McGill University Department of Epidemiology & Biostatistics, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
| | - Hojoon Sohn
- McGill University Department of Epidemiology & Biostatistics, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
| | - Zhi Zhen Qin
- McGill University Department of Epidemiology & Biostatistics, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
| | - Genevieve Gore
- McGill University, Schulich Library of Science and Engineering, Montreal, Canada
| | - J. Lucian Davis
- UCSF Pulmonary & Critical Care Medicine, San Francisco, United States of America
| | - Claudia M. Denkinger
- McGill University Department of Epidemiology & Biostatistics, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
- Beth Israel Deaconess Medical Centre, Division of Infectious Disease, Boston, MA, United States of America
| | - Madhukar Pai
- McGill University Department of Epidemiology & Biostatistics, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
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Elkington P, Zumla A. Update in Mycobacterium tuberculosis lung disease 2014. Am J Respir Crit Care Med 2016; 192:793-8. [PMID: 26426784 DOI: 10.1164/rccm.201505-1009up] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Paul Elkington
- 1 National Institute for Health Research (NIHR) Southampton Respiratory Biomedical Research Unit, Clinical and Experimental Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Alimuddin Zumla
- 2 Centre for Clinical Microbiology, Division of Infection and Immunity, University College London, London, United Kingdom; and.,3 NIHR Biomedical Research Centre, University College London Hospitals National Health Service Foundation Trust, London, United Kingdom
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Role of Molecular Methods in Improving Public Health Surveillance of Infections Caused by Antimicrobial-Resistant Bacteria in Health Care and Community Settings. Mol Microbiol 2016. [DOI: 10.1128/9781555819071.ch20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Fløe A, Hilberg O, Thomsen VØ, Lillebaek T, Wejse C. Shortening Isolation of Patients With Suspected Tuberculosis by Using Polymerase Chain Reaction Analysis: A Nationwide Cross-sectional Study. Clin Infect Dis 2015; 61:1365-73. [PMID: 26175524 DOI: 10.1093/cid/civ563] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 07/02/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Isolation of patients suspected for pulmonary tuberculosis is guided by serial sputum smears. This can result in isolation for days for patients with noncontagious tuberculosis. To determine whether a single sample negative for Mycobacterium tuberculosis complex at polymerase chain reaction (PCR) can guide isolation. METHODS We retrospectively evaluated sputum samples analyzed for M. tuberculosis complex at the International Reference Laboratory of Mycobacteriology, Copenhagen, Denmark in 2002-2011. We selected culture-confirmed tuberculosis cases with ≥3 samples within 14 days before or after the initial culture-positive sample. We repeated the process for those with ≥2 samples within 28 days. The primary outcome was PCR-negative, smear-positive patients. RESULTS We included 53 533 sputum samples from 20 928 individuals; 1636 had culture-confirmed tuberculosis. Of these, 856 had ≥3 sputum samples analyzed within the 28 days, and 482 had ≥1 PCR result. Nine patients (2.5% of smear-positive patients) were smear positive/PCR negative; 8 of the 9 had a smear-positive result in only 1 of 3 samples, and 5 had a low smear grade. Of 722 patients with 2 samples, 7 (1.3% of smear-positive patients) were smear positive/PCR negative. Overall, none were smear positive for the sample that produced the negative PCR result. CONCLUSIONS Primary PCR identified >97% of serial smear-positive cases. The majority of the missed cases had low-grade smears. Nevertheless, the occurrence of smear-positive/PCR-negative cases underlines the importance of increasing the quantity and quality of samples. Moreover, it is important that samples analyzed with PCR are cultured, owing to higher-sensitivity drug susceptibility testing, differential diagnosis, and surveillance.
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Affiliation(s)
| | - Ole Hilberg
- Departments of Respiratory Diseases and Allergy
| | | | - Troels Lillebaek
- International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark
| | - Christian Wejse
- Infectious Diseases, Aarhus University Hospital GloHAU Center for Global Health, Department of Public Health, Aarhus University
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Review of nucleic acid amplification tests and clinical prediction rules for diagnosis of tuberculosis in acute care facilities. Infect Control Hosp Epidemiol 2015; 36:1215-25. [PMID: 26166303 DOI: 10.1017/ice.2015.145] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Tuberculosis (TB) remains an important cause of hospitalization and mortality in the United States. Prevention of TB transmission in acute care facilities relies on prompt identification and implementation of airborne isolation, rapid diagnosis, and treatment of presumptive pulmonary TB patients. In areas with low TB burden, this strategy may result in inefficient utilization of airborne infection isolation rooms (AIIRs). We reviewed TB epidemiology and diagnostic approaches to inform optimal TB detection in low-burden settings. Published clinical prediction rules for individual studies have a sensitivity ranging from 81% to 100% and specificity ranging from 14% to 63% for detection of culture-positive pulmonary TB patients admitted to acute care facilities. Nucleic acid amplification tests (NAATs) have a specificity of >98%, and the sensitivity of NAATs varies by acid-fast bacilli sputum smear status (positive smear, ≥95%; negative smear, 50%-70%). We propose an infection prevention strategy using a clinical prediction rule to identify patients who warrant diagnostic evaluation for TB in an AIIR with an NAAT. Future studies are needed to evaluate whether use of clinical prediction rules and NAATs results in optimized utilization of AIIRs and improved detection and treatment of presumptive pulmonary TB patients.
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29
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Emerging technologies for the clinical microbiology laboratory. Clin Microbiol Rev 2015; 27:783-822. [PMID: 25278575 DOI: 10.1128/cmr.00003-14] [Citation(s) in RCA: 170] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
In this review we examine the literature related to emerging technologies that will help to reshape the clinical microbiology laboratory. These topics include nucleic acid amplification tests such as isothermal and point-of-care molecular diagnostics, multiplexed panels for syndromic diagnosis, digital PCR, next-generation sequencing, and automation of molecular tests. We also review matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) and electrospray ionization (ESI) mass spectrometry methods and their role in identification of microorganisms. Lastly, we review the shift to liquid-based microbiology and the integration of partial and full laboratory automation that are beginning to impact the clinical microbiology laboratory.
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30
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Pérez-Lago L, Martínez Lirola M, Herranz M, Comas I, Bouza E, García-de-Viedma D. Fast and low-cost decentralized surveillance of transmission of tuberculosis based on strain-specific PCRs tailored from whole genome sequencing data: a pilot study. Clin Microbiol Infect 2015; 21:249.e1-9. [DOI: 10.1016/j.cmi.2014.10.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 10/07/2014] [Accepted: 10/08/2014] [Indexed: 11/26/2022]
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