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Ssengooba W, de Dieu Iragena J, Komakech K, Okello I, Nalunjogi J, Katagira W, Kimuli I, Adakun S, Joloba ML, Torrea G, Kirenga BJ. Discordance of the Repeat GeneXpert MTB/RIF Test for Rifampicin Resistance Detection Among Patients Initiating MDR-TB Treatment in Uganda. Open Forum Infect Dis 2021; 8:ofab173. [PMID: 34189166 PMCID: PMC8223903 DOI: 10.1093/ofid/ofab173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/31/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The Global Laboratory Initiative (GLI) guidelines recommend repeat for GeneXpertMTB/RIF (XpertMTB/RIF) in patients with a low pretest probability of rifampicin resistance (RR). METHODS This was a cross-sectional study using results of sputum specimens collected from participants screened for the STREAM 2 trial. We recruited all patients with XpertMTB/RIF RR-TB detected who were referred for RR/multidrug-resistant (MDR) TB treatment initiation at Mulago National Referral Hospital, Kampala, between September 2017 and October 2019. At baseline, smear microscopy, repeat XpertMTB/RIF, Xpert Ultra, and MTBDRplus assays were done on sputum specimens. Culture-based drug susceptibility testing (DST) was performed on discordant specimens. We analyzed the prevalence and factors associated with discordance between initial and repeat XpertMTB/RIF RR and false XpertMTB/RIF RR. False XpertMTB/RIF RR was defined as no RR detected by any of Xpert Ultra, LPA, or culture DST (reference comparator). RESULTS A total of 126/130 patients had repeat XpertMTB/RIF results, of whom 97 (77.0%) had M. tuberculosis detected, 81 (83.5%) had RR detected, and 1 (1.0%) had RR indeterminate. The prevalence of discordant XpertMTB/RIF RR was 15/96 (15.6%), whereas false XpertMTB/RIF RR prevalence was 10/96 (10.4%).Low-bacillary load sputum specimens were more likely to have discordant XpertMTB/RIF RR and false XpertMTB/RIF RR results (adjusted odds ratio [aOR], 0.04; 95% CI, 0.00-0.37; P = .01; aOR, 0.02; 95% CI, 0.01-0.35; P = .01, respectively). CONCLUSIONS Our findings show a high false-positive rifampicin resistance rate in low-TB burden patients, which calls for repeat testing in order to prevent unnecessary prescription of anti-MDR-TB therapy.
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Affiliation(s)
- Willy Ssengooba
- College of Health Sciences, Makerere University Lung Institute, Kampala, Uganda
- Mycobacteriology (BSL-3) Laboratory, Department of Medical Microbiology, Makerere University, Kampala, Uganda
| | - Jean de Dieu Iragena
- Communicable Diseases Cluster, HIV/TB and Hepatitis Programme, World Health Organization Regional Office for Africa, Brazzaville, Congo
| | - Kevin Komakech
- Mycobacteriology (BSL-3) Laboratory, Department of Medical Microbiology, Makerere University, Kampala, Uganda
| | - Iginitius Okello
- College of Health Sciences, Makerere University Lung Institute, Kampala, Uganda
| | - Joanitah Nalunjogi
- College of Health Sciences, Makerere University Lung Institute, Kampala, Uganda
| | - Winceslaus Katagira
- College of Health Sciences, Makerere University Lung Institute, Kampala, Uganda
| | - Ivan Kimuli
- College of Health Sciences, Makerere University Lung Institute, Kampala, Uganda
| | - Susan Adakun
- College of Health Sciences, Makerere University Lung Institute, Kampala, Uganda
- National Tuberculosis Treatment Unit, Mulago Hospital, Kampala, Uganda
| | - Moses L Joloba
- College of Health Sciences, Makerere University Lung Institute, Kampala, Uganda
- Mycobacteriology (BSL-3) Laboratory, Department of Medical Microbiology, Makerere University, Kampala, Uganda
| | - Gabriela Torrea
- Unit of Mycobacteriology, Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bruce J Kirenga
- College of Health Sciences, Makerere University Lung Institute, Kampala, Uganda
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Foppiano Palacios C, Saleeb PG. Challenges in the diagnosis of tuberculous meningitis. J Clin Tuberc Other Mycobact Dis 2020; 20:100164. [PMID: 32462082 PMCID: PMC7240715 DOI: 10.1016/j.jctube.2020.100164] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Tuberculosis (TB) continues to pose a significant public health problem. Tuberculous meningitis (TBM) is the most severe form of extra-pulmonary TB. TBM carries a high mortality rate, including for those receiving treatment for TB. Diagnosis of TBM is difficult for clinicians as it can clinically present similarly to other forms of meningitis. The difficulty in diagnosis often leads to a delay in treatment and subsequent mortality. Those who survive are left with long-term sequelae leading to lifelong disability. The microbiologic diagnosis of TBM requires the isolation of Mycobacterium tuberculosis from the cerebrospinal fluid (CSF) of an infected patient. The diagnosis of tuberculous meningitis continues to be challenging for clinicians. Unfortunately, many cases of TBM cannot be confirmed based on clinical and imaging findings as the clinical findings are nonspecific, while laboratory techniques are largely insensitive or slow. Until recently, the lack of accessible and timely tests has contributed to a delay in diagnosis and subsequent morbidity and mortality for many patients, particularly those in resourcelimited settings. The availability of Xpert Ultra and point-of-care lipoarabinomannan (LAM) testing could represent a new era of prompt diagnosis and early treatment of tuberculous meningitis. However, clinicians must be cautious when ruling out TBM with Xpert Ultra due to its low negative predictive value. Due to the limitations of current diagnostics, clinicians should utilize a combination of diagnostic modalities in order to prevent morbidity in patients with TBM.
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Affiliation(s)
- Carlo Foppiano Palacios
- Departments of Internal Medicine and Pediatrics, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201, United States
| | - Paul G. Saleeb
- Institute of Human Virology, University of Maryland School of Medicine, 725 W Lombard St, Baltimore, MD 21201, United States
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Ngabonziza JCS, Decroo T, Migambi P, Habimana YM, Van Deun A, Meehan CJ, Torrea G, Massou F, de Rijk WB, Ushizimpumu B, Niyigena EB, Ivan E, Semahore JM, Mazarati JB, Merle CS, Supply P, Affolabi D, Rigouts L, de Jong BC. Prevalence and drivers of false-positive rifampicin-resistant Xpert MTB/RIF results: a prospective observational study in Rwanda. THE LANCET. MICROBE 2020; 1:e74-e83. [PMID: 35544156 DOI: 10.1016/s2666-5247(20)30007-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/03/2020] [Accepted: 04/07/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND The Xpert MTB/RIF (Xpert) assay is used globally to rapidly diagnose tuberculosis and resistance to rifampicin. We investigated the frequency and predictors of false-positive findings of rifampicin resistance with Xpert. METHODS We did a prospective, observational study of individuals who were enrolled in a Rwandan nationwide diagnostic cohort study (DIAMA trial; NCT03303963). We included patients identified to have rifampicin resistance on initial Xpert testing. We did a repeat Xpert assay and used rpoB Sanger and deep sequencing alongside phenotypic drug susceptibility testing (pDST) to ascertain final rifampicin susceptibility status, with any (hetero)resistant result overriding. We used multivariable logistic regression to assess predictors of false rifampicin resistance on initial Xpert testing, adjusted for HIV status, tuberculosis treatment history, initial Xpert semi-quantitative bacillary load, and initial Xpert probe. FINDINGS Between May 4, 2017, and April 30, 2019, 175 people were identified with rifampicin resistance at initial Xpert testing, of whom 154 (88%) underwent repeat Xpert assay. 54 (35%) patients were confirmed as rifampicin resistant on repeat testing and 100 (65%) were not confirmed with resistance. After further testing and sequencing, 121 (79%) of 154 patients had a final confirmed status for rifampicin susceptibility. 57 (47%) of 121 patients were confirmed to have a false rifampicin resistance result and 64 (53%) had true rifampicin resistance. A high pretest probability of rifampicin resistance did not decrease the odds of false rifampicin resistance (adjusted odds ratio [aOR] 6·0, 95% CI 1·0-35·0, for new tuberculosis patients vs patients who needed retreatment). Ten (16%) of the 64 patients with true rifampicin resistance did not have confirmed rifampicin resistance on repeat Xpert testing, of whom four had heteroresistance. Of 63 patients with a very low bacillary load on Xpert testing, 54 (86%) were falsely diagnosed with rifampicin-resistant tuberculosis. Having a very low bacillary load on Xpert testing was strongly associated with false rifampicin resistance at the initial Xpert assay (aOR 63·6, 95% CI 9·9-410·4). INTERPRETATION The Xpert testing algorithm should include an assessment of bacillary load and retesting in case rifampicin resistance is detected on a paucibacillary sputum sample. Only when rifampicin resistance has been confirmed on repeat testing should multidrug-resistant tuberculosis treatment be started. When rifampicin resistance has not been confirmed on repeat testing, we propose that patients should be given first-line anti-tuberculosis drugs and monitored closely during treatment, including by baseline culture, pDST, and further Xpert testing. FUNDING The European & Developing Countries Clinical Trials Partnership 2 programme, and Belgian Directorate General for Development Cooperation.
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Affiliation(s)
- Jean Claude Semuto Ngabonziza
- National Reference Laboratory Division, Department of Biomedical Services, Rwanda Biomedical Centre, Kigali, Rwanda; Mycobacteriology Unit, Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium.
| | - Tom Decroo
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Research Foundation Flanders, Brussels, Belgium
| | - Patrick Migambi
- Tuberculosis and Other Respiratory Diseases Division, Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Yves Mucyo Habimana
- Tuberculosis and Other Respiratory Diseases Division, Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | | | - Conor J Meehan
- Mycobacteriology Unit, Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; School of Chemistry and Biosciences, University of Bradford, UK
| | - Gabriela Torrea
- Mycobacteriology Unit, Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Willem Bram de Rijk
- Mycobacteriology Unit, Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bertin Ushizimpumu
- National Reference Laboratory Division, Department of Biomedical Services, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Esdras Belamo Niyigena
- National Reference Laboratory Division, Department of Biomedical Services, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Emil Ivan
- National Reference Laboratory Division, Department of Biomedical Services, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Jules Mugabo Semahore
- HIV, STIs, Hepatitis and Tuberculosis Programmes, WHO Country Office, Kigali, Rwanda
| | | | - Corinne Simone Merle
- UNICEF/UNDP/World Bank/WHO Special Programme on Research and Training in Tropical Diseases, Geneva, Switzerland; London School of Hygiene & Tropical Medicine, London, UK
| | - Philip Supply
- University of Lille, CNRS, INSERM, CHU Lille, Institut Pasteur de Lille, U1019 - UMR 9017 - CIIL - Center for Infection and Immunity of Lille, F-59000 Lille, France
| | | | - Leen Rigouts
- Mycobacteriology Unit, Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Bouke Catherine de Jong
- Mycobacteriology Unit, Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
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Opota O, Mazza-Stalder J, Greub G, Jaton K. The rapid molecular test Xpert MTB/RIF ultra: towards improved tuberculosis diagnosis and rifampicin resistance detection. Clin Microbiol Infect 2019; 25:1370-1376. [PMID: 30928564 DOI: 10.1016/j.cmi.2019.03.021] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/14/2019] [Accepted: 03/16/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Tuberculosis diagnosis has dramatically improved since the introduction of the rapid molecular test Xpert MTB/RIF (Xpert) detecting M. tuberculosis and rifampicin resistance directly from clinical specimens, therefore shortening the turnaround time, reducing patient's isolation period and decreasing the time to start anti-TB drugs. The new version, Xpert MTB/RIF Ultra (Ultra), displays a higher sensitivity and an improved rifampicin resistance detection. Both tests have been endorsed by the World Health Organisation. AIMS Xpert and Ultra rapidly became widespread and paved the way for new approaches and new paradigms as well as for the development of molecular point-of-care tests (POCTs). In this narrative review, we aimed to address their performance in the diagnosis of tuberculosis and to discuss the expectations of these tests as well as their limits and the unmet needs. SOURCES Peer-reviewed publications addressing the diagnostic performance of Ultra and Xpert. CONTENT We focused on publications that evaluated the performance of Ultra and Xpert on the same group of patients or the same set of specimens in different tuberculosis-burden settings. IMPLICATIONS The studies published so far reported an increased sensitivity of Ultra when compared to Xpert, which represents a benefit for tuberculosis diagnosis. The fact that such a sensitive assay cannot distinguish between alive and dead bacilli emphasizes that caution should be exercised regarding indications and interpretation of results. Additional studies are needed to determine the true performance for the diagnosis of extrapulmonary tuberculosis because of the great diversity of the specimens.
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Affiliation(s)
- O Opota
- Institute of Microbiology, University of Lausanne, University Hospital of Lausanne, Lausanne, Switzerland.
| | - J Mazza-Stalder
- Pneumology Service, University Hospital of Lausanne, Lausanne, Switzerland
| | - G Greub
- Institute of Microbiology, University of Lausanne, University Hospital of Lausanne, Lausanne, Switzerland; Infectious Diseases Service, University Hospital of Lausanne, Lausanne, Switzerland
| | - K Jaton
- Institute of Microbiology, University of Lausanne, University Hospital of Lausanne, Lausanne, Switzerland
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Mwanza W, Milimo D, Chilufya MM, Kasese N, Lengwe MC, Munkondya S, de Haas P, Ayles H, Muyoyeta M. Diagnosis of rifampicin-resistant tuberculosis: Discordant results by diagnostic methods. Afr J Lab Med 2018; 7:806. [PMID: 30568904 PMCID: PMC6295983 DOI: 10.4102/ajlm.v7i2.806] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 09/26/2018] [Indexed: 11/11/2022] Open
Abstract
The performance of the Xpert© MTB/RIF and MTBDRplus assays for the detection of rifampicin resistant Mycobacterium tuberculosis was compared to culture-based drug susceptibility testing in 30 specimens with rifampicin-resistant and rifampicin-indeterminate Xpert MTB/RIF results collected between March 2012 and March 2014. Xpert MTB/RIF and MTBDRplus were 100% sensitive and 100% concordant for rifampicin resistance detection, but 3 of 13 samples (23%) positive for rifampicin resistance on Xpert MTB/RIF and MTBDRplus were negative for rifampicin resistance on mycobacteria growth indicator tube drug susceptibility testing. Specificity was 72% for Xpert MTB/RIF and 80% for MTBDRplus. Positive predictive value for Xpert MTB/RIF for multidrug resistant tuberculosis was 47.8% for new patients and 77.8% for previously treated patients; negative predictive value was 100% for both new and previously treated patients. The discordant rifampicin resistance test results indicate a need to fully characterise circulating rifampicin resistant Mycobacterium tuberculosis strains in Zambia and to inform the development of guidelines for decision-making in relation to diagnosis of drug-resistant tuberculosis.
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Affiliation(s)
- Winnie Mwanza
- Zambia AIDS Related Tuberculosis (ZAMBART) Project, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Deborah Milimo
- Zambia AIDS Related Tuberculosis (ZAMBART) Project, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Maureen M Chilufya
- Zambia AIDS Related Tuberculosis (ZAMBART) Project, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Nkatya Kasese
- Zambia AIDS Related Tuberculosis (ZAMBART) Project, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Maina C Lengwe
- Zambia AIDS Related Tuberculosis (ZAMBART) Project, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Stembiso Munkondya
- Zambia AIDS Related Tuberculosis (ZAMBART) Project, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Petra de Haas
- Zambia AIDS Related Tuberculosis (ZAMBART) Project, School of Medicine, University of Zambia, Lusaka, Zambia.,Department of Infectious and Tropical diseases, London School of Hygiene and Tropical Medicine, Bloomsburg, London, United Kingdom
| | - Helen Ayles
- Zambia AIDS Related Tuberculosis (ZAMBART) Project, School of Medicine, University of Zambia, Lusaka, Zambia.,Department of Infectious and Tropical diseases, London School of Hygiene and Tropical Medicine, Bloomsburg, London, United Kingdom
| | - Monde Muyoyeta
- Zambia AIDS Related Tuberculosis (ZAMBART) Project, School of Medicine, University of Zambia, Lusaka, Zambia
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