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Grebely J, Matthews S, Causer LM, Feld JJ, Cunningham P, Dore GJ, Applegate TL. We have reached single-visit testing, diagnosis, and treatment for hepatitis C infection, now what? Expert Rev Mol Diagn 2024; 24:177-191. [PMID: 38173401 DOI: 10.1080/14737159.2023.2292645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION Progress toward hepatitis C virus (HCV) elimination is impeded by low testing and treatment due to the current diagnostic pathway requiring multiple visits leading to loss to follow-up. Point-of-care testing technologies capable of detecting current HCV infection in one hour are a 'game-changer.' These tests enable diagnosis and treatment in a single visit, overcoming the barrier of multiple visits that frequently leads to loss to follow-up. Combining point-of-care HCV antibody and RNA tests should improve cost-effectiveness, patient/provider acceptability, and testing efficiency. However, implementing HCV point-of-care testing programs at scale requires multiple considerations. AREAS COVERED This commentary explores the need for point-of-care HCV tests, diagnostic strategies to improve HCV testing, key considerations for implementing point-of-care HCV testing programs, and remaining challenges for point-of-care testing (including operator training, quality management, connectivity and reporting systems, regulatory approval processes, and the need for more efficient tests). EXPERT OPINION It is exciting that single-visit testing, diagnosis, and treatment for HCV infection have been achieved. Innovations afforded through COVID-19 should facilitate the accelerated development of low-cost, rapid, and accurate tests to improve HCV testing. The next challenge will be to address barriers and facilitators for implementing point-of-care testing to deliver them at scale.
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Affiliation(s)
- Jason Grebely
- The Kirby Institute, UNSW, Sydney, New South Wales, Australia
| | - Susan Matthews
- Flinders University International Centre for Point-of-Care Testing, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia
| | - Louise M Causer
- The Kirby Institute, UNSW, Sydney, New South Wales, Australia
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Canada
| | - Philip Cunningham
- Flinders University International Centre for Point-of-Care Testing, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia
| | - Gregory J Dore
- The Kirby Institute, UNSW, Sydney, New South Wales, Australia
| | - Tanya L Applegate
- The Kirby Institute, UNSW, Sydney, New South Wales, Australia
- NSW State Reference Laboratory for HIV, St Vincent's Centre for Applied Medical Research, Sydney, New South Wales, Australia
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2
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Wang Y, Zhang X, Zhou Q, Xu X. Impact of selective reporting of antimicrobial susceptibility testing report on clinicians' prescribing behavior of antibiotics. Front Pharmacol 2023; 14:1225531. [PMID: 37841913 PMCID: PMC10571699 DOI: 10.3389/fphar.2023.1225531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023] Open
Abstract
Background: Selective reporting has important value in antibiotic management. The purpose of this study was to explore the impact of AST selective reporting on prescribing behavior, so as to provide evidence for the implementation and improvement of selective reporting policies in microbiology laboratories at home and abroad. Methods: A cross-sectional study was conducted in a teaching tertiary hospital in China in July 2021. We designed selective reports and routine reports for urinary tract infections caused by Escherichia coli and lower respiratory tract infections caused by Pseudomonas aeruginosa. Questionnaires were conducted among participants by case vignettes, and 116 valid questionnaires were collected. The appropriateness rate of antibiotic prescription and the prescription rate of drug-resistant antibiotics, cephalosporins, fluoroquinolones, and carbapenems were calculated and compared between the selective reporting group and the routine reporting group in each case. Results: In most cases, we found that AST selective reporting could increase the appropriateness rate of antibiotic prescription (p < 0.05) and reduce the drug-resistant antibiotic prescription rate (p < 0.01), cephalosporin drug prescription rate (p < 0.05) and fluoroquinolone drug prescription rate (p < 0.01). Although the difference in carbapenems prescription rate was not significant, selective reporting could reduce the number of its prescriptions to some extent. Conclusion: AST selective reporting can help promote the appropriate use of antibiotics and reduce the use of broad-spectrum antibiotics. It is suggested to develop scientific and effective selective reporting practices and strengthen the two-way communication between clinicians and microbiology laboratories, thereby enabling microbiology laboratories to play a more important role in clinical antimicrobial management.
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Affiliation(s)
- Ying Wang
- Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Xinping Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Qian Zhou
- Wuhan Children’s Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaojun Xu
- The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
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Malhotra A, Thompson R, De Vos M, David A, Schumacher S, Sohn H. Determining cost and placement decisions for moderate complexity NAATs for tuberculosis drug susceptibility testing. PLoS One 2023; 18:e0290496. [PMID: 37616318 PMCID: PMC10449112 DOI: 10.1371/journal.pone.0290496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 08/10/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Access to drug resistant testing for tuberculosis (TB) remains a challenge in high burden countries. Recently, the World Health Organization approved the use of several moderate complexity automated nucleic acid amplification tests (MC-NAAT) that have performance profiles suitable for placement in a range of TB laboratory tiers to improve drug susceptibility tests (DST) coverage. METHODS We conducted cost analysis of two MC-NAATs with different testing throughput: Lower Throughput (LT, < 24 tests per run) and Higher Throughput (HT, upto 90+ tests per run) for placement in a hypothetical laboratory in a resource limited setting. We used per-test cost as the main indicator to assess 1) drivers of cost by resource types and 2) optimized levels of annual testing volumes for the respective MC-NAATs. RESULTS The base-case per test cost of $18.52 (range: $13.79 - $40.70) for LT test and $15.37 (range: $9.61 - $37.40) for HT test. Per test cost estimates were most sensitive to the number of testing days per week, followed by equipment costs and TB-specific workloads. In general, HT NAATs were cheaper at all testing volume levels, but at lower testing volumes (less than 2,000 per year) LT tests can be cheaper if the durability of the testing system is markedly better and/or procured equipment costs are lower than that of HT NAAT. CONCLUSION Assuming equivalent performance and infrastructural needs, placement strategies for MC-NAATs need to be prioritized by laboratory system's operational factors, testing demands, and costs.
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Affiliation(s)
- Akash Malhotra
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Ryan Thompson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Margaretha De Vos
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Anura David
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Hojoon Sohn
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, South Korea
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Valeyre D, Brauner M, Bernaudin JF, Carbonnelle E, Duchemann B, Rotenberg C, Berger I, Martin A, Nunes H, Naccache JM, Jeny F. Differential diagnosis of pulmonary sarcoidosis: a review. Front Med (Lausanne) 2023; 10:1150751. [PMID: 37250639 PMCID: PMC10213276 DOI: 10.3389/fmed.2023.1150751] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/24/2023] [Indexed: 05/31/2023] Open
Abstract
Diagnosing pulmonary sarcoidosis raises challenges due to both the absence of a specific diagnostic criterion and the varied presentations capable of mimicking many other conditions. The aim of this review is to help non-sarcoidosis experts establish optimal differential-diagnosis strategies tailored to each situation. Alternative granulomatous diseases that must be ruled out include infections (notably tuberculosis, nontuberculous mycobacterial infections, and histoplasmosis), chronic beryllium disease, hypersensitivity pneumonitis, granulomatous talcosis, drug-induced granulomatosis (notably due to TNF-a antagonists, immune checkpoint inhibitors, targeted therapies, and interferons), immune deficiencies, genetic disorders (Blau syndrome), Crohn's disease, granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, and malignancy-associated granulomatosis. Ruling out lymphoproliferative disorders may also be very challenging before obtaining typical biopsy specimen. The first step is an assessment of epidemiological factors, notably the incidence of sarcoidosis and of alternative diagnoses; exposure to risk factors (e.g., infectious, occupational, and environmental agents); and exposure to drugs taken for therapeutic or recreational purposes. The clinical history, physical examination and, above all, chest computed tomography indicate which differential diagnoses are most likely, thereby guiding the choice of subsequent investigations (e.g., microbiological investigations, lymphocyte proliferation tests with metals, autoantibody assays, and genetic tests). The goal is to rule out all diagnoses other than sarcoidosis that are consistent with the clinical situation. Chest computed tomography findings, from common to rare and from typical to atypical, are described for sarcoidosis and the alternatives. The pathology of granulomas and associated lesions is discussed and diagnostically helpful stains specified. In some patients, the definite diagnosis may require the continuous gathering of information during follow-up. Diseases that often closely mimic sarcoidosis include chronic beryllium disease and drug-induced granulomatosis. Tuberculosis rarely resembles sarcoidosis but is a leading differential diagnosis in regions of high tuberculosis endemicity.
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Affiliation(s)
- Dominique Valeyre
- Pulmonology Department, Groupe Hospitalier Paris Saint Joseph, Paris, France
- INSERM UMR 1272, Sorbonne University Paris-Nord, Paris, France
| | - Michel Brauner
- Radiology Department, Avicenne University Hospital, Bobigny, France
| | - Jean-François Bernaudin
- INSERM UMR 1272, Sorbonne University Paris-Nord, Paris, France
- Faculté de Médecine, Sorbonne University Paris, Paris, France
| | | | - Boris Duchemann
- INSERM UMR 1272, Sorbonne University Paris-Nord, Paris, France
- Thoracic and Oncology Department, Avicenne University Hospital, Bobigny, France
| | - Cécile Rotenberg
- INSERM UMR 1272, Sorbonne University Paris-Nord, Paris, France
- Pulmonology Department, Avicenne University Hospital, Bobigny, France
| | - Ingrid Berger
- Pulmonology Department, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Antoine Martin
- Pathology Department, Avicenne University Hospital, Bobigny, France
| | - Hilario Nunes
- INSERM UMR 1272, Sorbonne University Paris-Nord, Paris, France
- Pulmonology Department, Avicenne University Hospital, Bobigny, France
| | - Jean-Marc Naccache
- Pulmonology Department, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Florence Jeny
- INSERM UMR 1272, Sorbonne University Paris-Nord, Paris, France
- Pulmonology Department, Avicenne University Hospital, Bobigny, France
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Gonzalo X, Yrah S, Broda A, Laurenson I, Claxton P, Kostrzewa M, Drobniewski F, Larrouy-Maumus G. Performance of lipid fingerprint by routine matrix-assisted laser desorption/ionization time of flight for the diagnosis of Mycobacterium tuberculosis complex species. Clin Microbiol Infect 2023; 29:387.e1-387.e6. [PMID: 36270589 DOI: 10.1016/j.cmi.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 09/21/2022] [Accepted: 10/13/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Rapid detection of bacterial pathogens at species and sub-species levels is crucial for appropriate treatment, infection control, and public health management. Currently, one of the challenges in clinical microbiology is the discrimination of mycobacterial sub-species within the M. tuberculosis complex (MTBC). Our objective was to evaluate the ability of a biosafe mycobacterial lipid-based approach to identify MTBC cultures and sub-species. METHODS A blinded study was conducted using 90 mycobacterial clinical isolate strains comprising MTBC strains sub-cultured in Middlebrook 7H11 medium supplemented with 10% oleic-acid, dextrose, catalase growth supplement and incubated for up to 6 weeks at 37°C and using the following seven reference strains (M. tuberculosis H37Rv, M canettii, M. africanum, M. pinnipedii, M. caprae, M. bovis, and M. bovis BCG) grown under the same conditions, to set the reference lipid database and test it against the 90 MTBC clinical isolates. Cultured mycobacteria were heat-inactivated and loaded onto the matrix-assisted laser desorption/ionization target followed by the addition of the matrix. Acquisition of the data was performed using the positive ion mode. RESULTS Based on the identification of clear and defined lipid signatures from the seven reference strains, the method that we developed was fast (<10 minutes) and produced interpretable profiles for all but four isolates, caused by poor ionization giving an n = 86 with interpretable spectra. The sensitivity and specificity of the matrix-assisted laser desorption/ionization time of flight were 94.4 (95% CI, 86.4-98.5) and 94.4 (95% CI, 72.7-99.9), respectively. CONCLUSIONS Mycobacterial lipid profiling provides a means of rapid, safe, and accurate discrimination of species within the MTBC.
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Affiliation(s)
- Ximena Gonzalo
- Department of Infectious Diseases, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Shih Yrah
- Department of Infectious Diseases, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Agnieszka Broda
- Department of Infectious Diseases, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Ian Laurenson
- Scottish Mycobacteria Reference Laboratory, Edinburgh, United Kingdom
| | - Pauline Claxton
- Scottish Mycobacteria Reference Laboratory, Edinburgh, United Kingdom
| | | | - Francis Drobniewski
- Department of Infectious Diseases, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Gerald Larrouy-Maumus
- MRC Centre for Molecular Bacteriology and Infection, Department of Life Sciences, Faculty of Natural Sciences, Imperial College London, London, United Kingdom.
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Pillay S, de Vos M, Derendinger B, Streicher EM, Dolby T, Scott LA, Steinhobel AD, Warren RM, Theron G. Non-actionable Results, Accuracy, and Effect of First- and Second-line Line Probe Assays for Diagnosing Drug-Resistant Tuberculosis, Including on Smear-Negative Specimens, in a High-Volume Laboratory. Clin Infect Dis 2023; 76:e920-e929. [PMID: 35788278 PMCID: PMC7614164 DOI: 10.1093/cid/ciac556] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/23/2022] [Accepted: 06/30/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Rapid tuberculosis (TB) drug susceptibility testing (DST) is crucial. Genotype MTBDRsl is a widely deployed World Health Organization (WHO)-endorsed assay. Programmatic performance data, including non-actionable results from smear-negative sputum, are scarce. METHODS Sputa from Xpert MTB/RIF individuals (n = 951) were routinely-tested using Genotype MTBDRplus and MTBDRsl (both version 2). Phenotypic DST was the second-line drug reference standard. Discrepant results underwent Sanger sequencing. FINDINGS 89% (849 of 951) of individuals were culture-positive (56%, 476 of 849 smear-negative). MTBDRplus had at least 1 nonactionable result (control and/or TB-detection bands absent or invalid, precluding resistance reporting) in 19% (92 of 476) of smear-negatives; for MTBDRsl, 40% (171 of 427) were nonactionable (28%, 120 of 427 false-negative TB; 17%, 51 of 427 indeterminate). In smear-negatives, MTBDRsl sensitivity for fluoroquinolones was 84% (95% confidence interval, 67%-93), 81% (54%-95%) for second-line injectable drugs, and 57% (28%-82%) for both. Specificities were 93% (89%-98%), 88% (81%-93%), and 97% (91%-99%), respectively. Twenty-three percent (172 of 746) of Xpert rifampicin-resistant specimens were MTBDRplus isoniazid-susceptible. Days-to-second-line-susceptibility reporting with the programmatic advent of MTBDRsl improved (6 [5-7] vs 37 [35-46]; P < .001). CONCLUSIONS MTBDRsl did not generate a result in 4 of 10 smear-negatives, resulting in substantial missed resistance. However, if MTBDRsl generates an actionable result, that is accurate in ruling-in resistance. Isoniazid DST remains crucial. This study provides real-world, direct, second-line susceptibility testing performance data on non-actionable results (that, if unaccounted for, cause an overestimation of test utility), accuracy, and care cascade impact.
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Affiliation(s)
- Samantha Pillay
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- National Health Laboratory Services, Green Point, Cape Town, South Africa
| | - Margaretha de Vos
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Brigitta Derendinger
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Elizabeth Maria Streicher
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Tania Dolby
- National Health Laboratory Services, Green Point, Cape Town, South Africa
| | - Leeré Ann Scott
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Amy Debra Steinhobel
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Rob Mark Warren
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Grant Theron
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
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Wang Y, Zhang X, Zhou Q, Xu X, Liu X, Lu S. Information Complexity and Behavior Intention to Prescribe Antibiotics Based on the Antimicrobial Susceptibility Testing Report: The Mediating Roles of Information Overload and Attitude. Front Pharmacol 2021; 12:778664. [PMID: 34899342 PMCID: PMC8660084 DOI: 10.3389/fphar.2021.778664] [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: 09/17/2021] [Accepted: 10/25/2021] [Indexed: 11/24/2022] Open
Abstract
Background: The antimicrobial susceptibility testing (AST) report has guiding significance for physicians to prescribe antibiotics. This study aims to examine the effect of the AST report information complexity on physician’s intention to prescribe antibiotics based on the AST report, as well as the mediating role of information overload and attitude. Methods: A cross-sectional study conducted on 411 physicians in a general hospital in China in July 2021. Data were collected by a self-reported questionnaire. A serial multiple mediation model was tested to explore the sequential causality between the information complexity of the AST report, information overload, attitude, and behavior intention to prescribe antibiotics based on the AST report by using the SPSS macro PROCESS program. Results: Information complexity, information overload, attitude and behavior intention were significantly correlated (p < 0.01). Information complexity can not only have a direct positive impact on the intention to prescribe antibiotics based on the AST report (effect = 0.173; SE = 0.044; Boot95%CI: LL = 0.089, UL = 0.260), but also have an indirect impact on behavior intention through the independent mediating role of information overload (effect = 0.025; SE = 0.011; Boot 95%CI: LL = 0.008, UL = 0.050) and the independent mediating role of attitude (effect = 0.130; SE = 0.025; Boot 95%CI: LL = 0.086, UL = 0.180), while the chain of information overload and attitude played a masking effect between information complexity and behavior intention (effect = −0.013; SE = 0.004; Boot 95%CI: LL = −0.023, UL = −0.005). Conclusion: The increase in information complexity can encourage physicians to prescribe antibiotics based on the AST report, information overload and attitude can promote this effect. It is necessary to provide physicians with sufficient information to prescribe antibiotics without increasing the burden on them. At the same time, publicity and standardized training should be conducted for physicians to interpret the AST report better and faster.
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Affiliation(s)
- Ying Wang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinping Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qian Zhou
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaojun Xu
- The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Xiaofeng Liu
- The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Shaohui Lu
- The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
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Goscé L, Abou Jaoude GJ, Kedziora DJ, Benedikt C, Hussain A, Jarvis S, Skrahina A, Klimuk D, Hurevich H, Zhao F, Fraser-Hurt N, Cheikh N, Gorgens M, Wilson DJ, Abeysuriya R, Martin-Hughes R, Kelly SL, Roberts A, Stuart RM, Palmer T, Panovska-Griffiths J, Kerr CC, Wilson DP, Haghparast-Bidgoli H, Skordis J, Abubakar I. Optima TB: A tool to help optimally allocate tuberculosis spending. PLoS Comput Biol 2021; 17:e1009255. [PMID: 34570767 PMCID: PMC8496838 DOI: 10.1371/journal.pcbi.1009255] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 10/07/2021] [Accepted: 07/07/2021] [Indexed: 12/02/2022] Open
Abstract
Approximately 85% of tuberculosis (TB) related deaths occur in low- and middle-income countries where health resources are scarce. Effective priority setting is required to maximise the impact of limited budgets. The Optima TB tool has been developed to support analytical capacity and inform evidence-based priority setting processes for TB health benefits package design. This paper outlines the Optima TB framework and how it was applied in Belarus, an upper-middle income country in Eastern Europe with a relatively high burden of TB. Optima TB is a population-based disease transmission model, with programmatic cost functions and an optimisation algorithm. Modelled populations include age-differentiated general populations and higher-risk populations such as people living with HIV. Populations and prospective interventions are defined in consultation with local stakeholders. In partnership with the latter, demographic, epidemiological, programmatic, as well as cost and spending data for these populations and interventions are then collated. An optimisation analysis of TB spending was conducted in Belarus, using program objectives and constraints defined in collaboration with local stakeholders, which included experts, decision makers, funders and organisations involved in service delivery, support and technical assistance. These analyses show that it is possible to improve health impact by redistributing current TB spending in Belarus. Specifically, shifting funding from inpatient- to outpatient-focused care models, and from mass screening to active case finding strategies, could reduce TB prevalence and mortality by up to 45% and 50%, respectively, by 2035. In addition, an optimised allocation of TB spending could lead to a reduction in drug-resistant TB infections by 40% over this period. This would support progress towards national TB targets without additional financial resources. The case study in Belarus demonstrates how reallocations of spending across existing and new interventions could have a substantial impact on TB outcomes. This highlights the potential for Optima TB and similar modelling tools to support evidence-based priority setting. Tuberculosis (TB) remains a leading global cause of death and morbidity, and 85% of deaths occur in countries where resources for TB care and control are limited. Many countries cannot finance all TB interventions or technologies, which means difficult decisions on what to prioritise and publically finance. Modelling tools can help decision-makers set priorities based on evidence, in a systematic and transparent way. This study presents Optima TB, a tool that estimates which allocations of spending across interventions will most likely maximise specified objectives—such as minimising TB deaths, prevalence and incidence. In partnership with local decision-makers and stakeholders, Optima TB was applied in Belarus. Recommendations from the model findings include focussing investment on outpatient rather than inpatient care and actively finding people with TB (e.g. through contact tracing) rather than mass testing of the population. The recommended reallocations of spending could reduce TB prevalence and deaths by up to 45% and 50%, respectively, by 2035 for the same amount of spending. Key stakeholders were engaged throughout the analysis and findings and uncertainty around the results were clearly communicated with decision-makers. The timeliness of the results helped inform national dialogue on TB care reform, among other key policy discussions.
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Affiliation(s)
- Lara Goscé
- University College London, London, United Kingdom
- * E-mail:
| | | | | | - Clemens Benedikt
- World Bank, Washington, District of Columbia, United States of America
| | | | | | - Alena Skrahina
- The Republican Scientific and Practice Centre for Pulmonology and Tuberculosis, Minsk, Belarus
| | - Dzmitry Klimuk
- The Republican Scientific and Practice Centre for Pulmonology and Tuberculosis, Minsk, Belarus
| | - Henadz Hurevich
- The Republican Scientific and Practice Centre for Pulmonology and Tuberculosis, Minsk, Belarus
| | - Feng Zhao
- World Bank, Washington, District of Columbia, United States of America
| | | | - Nejma Cheikh
- World Bank, Washington, District of Columbia, United States of America
| | - Marelize Gorgens
- World Bank, Washington, District of Columbia, United States of America
| | - David J. Wilson
- World Bank, Washington, District of Columbia, United States of America
| | | | | | | | | | - Robyn M. Stuart
- Burnet Institute, Melbourne, Australia
- University of Copenhagen, Copenhagen, Denmark
| | - Tom Palmer
- University College London, London, United Kingdom
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Shah M, Paradis S, Betz J, Beylis N, Bharadwaj R, Caceres T, Gotuzzo E, Joloba M, Mave V, Nakiyingi L, Nicol MP, Pradhan N, King B, Armstrong D, Knecht D, Maus CE, Cooper CK, Dorman SE, Manabe YC. Multicenter Study of the Accuracy of the BD MAX Multidrug-resistant Tuberculosis Assay for Detection of Mycobacterium tuberculosis Complex and Mutations Associated With Resistance to Rifampin and Isoniazid. Clin Infect Dis 2021; 71:1161-1167. [PMID: 31560049 PMCID: PMC7442848 DOI: 10.1093/cid/ciz932] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 10/08/2019] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) control is hindered by absence of rapid tests to identify Mycobacterium tuberculosis (MTB) and detect isoniazid (INH) and rifampin (RIF) resistance. We evaluated the accuracy of the BD MAX multidrug-resistant (MDR)-TB assay (BD MAX) in South Africa, Uganda, India, and Peru. METHODS Outpatient adults with signs/symptoms of pulmonary TB were prospectively enrolled. Sputum smear microscopy and BD MAX were performed on a single raw sputum, which was then processed for culture and phenotypic drug susceptibility testing (DST), BD MAX, and Xpert MTB/RIF (Xpert). RESULTS 1053 participants with presumptive TB were enrolled (47% female; 32% with human immunodeficiency virus). In patients with confirmed TB, BD MAX sensitivity was 93% (262/282 [95% CI, 89-95%]); specificity was 97% (593/610 [96-98%]) among participants with negative cultures on raw sputa. BD MAX sensitivity was 100% (175/175 [98-100%]) for smear-positive samples (fluorescence microscopy), and 81% (87/107 [73-88%]) in smear-negative samples. Among participants with both BD MAX and Xpert, sensitivity was 91% (249/274 [87-94%]) for BD MAX and 90% (246/274 [86-93%]) for Xpert on processed sputa. Sensitivity and specificity for RIF resistance compared with phenotypic DST were 90% (9/10 [60-98%]) and 95% (211/222 [91-97%]), respectively. Sensitivity and specificity for detection of INH resistance were 82% (22/27 [63-92%]) and 100% (205/205 [98-100%]), respectively. CONCLUSIONS The BD MAX MDR-TB assay had high sensitivity and specificity for detection of MTB and RIF and INH drug resistance and may be an important tool for rapid detection of TB and MDR-TB globally.
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Affiliation(s)
- Maunank Shah
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sonia Paradis
- Becton, Dickinson and Company, Sparks, Maryland, USA
| | - Joshua Betz
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Natalie Beylis
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa.,Medical Microbiology Laboratory National Health Laboratory Services Groote Schuur Hospital, Cape Town, South Africa
| | - Renu Bharadwaj
- Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Tatiana Caceres
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Eduardo Gotuzzo
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Moses Joloba
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Vidya Mave
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Lydia Nakiyingi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mark P Nicol
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa.,Division of Infection and Immunity, School of Biomedical Sciences, University of Western Australia, Perth, Australia
| | - Neeta Pradhan
- Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Bonnie King
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Derek Armstrong
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | | | - Susan E Dorman
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Yukari C Manabe
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
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10
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Story A, Garber E, Aldridge RW, Smith CM, Hall J, Ferenando G, Possas L, Hemming S, Wurie F, Luchenski S, Abubakar I, McHugh TD, White PJ, Watson JM, Lipman M, Garfein R, Hayward AC. Management and control of tuberculosis control in socially complex groups: a research programme including three RCTs. PROGRAMME GRANTS FOR APPLIED RESEARCH 2020. [DOI: 10.3310/pgfar08090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background
Socially complex groups, including people experiencing homelessness, prisoners and drug users, have very high levels of tuberculosis, often complicated by late diagnosis and difficulty in adhering to treatment.
Objective
To assess a series of interventions to improve tuberculosis control in socially complex groups.
Design
A series of observational surveys, evaluations and trials of interventions.
Setting
The pan-London Find&Treat service, which supports tuberculosis screening and case management in socially complex groups across London.
Participants
Socially complex groups with tuberculosis or at risk of tuberculosis, including people experiencing homelessness, prisoners, drug users and those at high risk of poor adherence to tuberculosis treatment.
Interventions and main outcome measures
We screened 491 people in homeless hostels and 511 people in prison for latent tuberculosis infection, human immunodeficiency virus, hepatitis B and hepatitis C. We evaluated an NHS-led prison radiographic screening programme. We conducted a cluster randomised controlled trial (2348 eligible people experiencing homelessness in 46 hostels) of the effectiveness of peer educators (22 hostels) compared with NHS staff (24 hostels) at encouraging the uptake of mobile radiographic screening. We initiated a trial of the use of point-of-care polymerase chain reaction diagnostics to rapidly confirm tuberculosis alongside mobile radiographic screening. We undertook a randomised controlled trial to improve treatment adherence, comparing face-to-face, directly observed treatment with video-observed treatment using a smartphone application. The primary outcome was completion of ≥ 80% of scheduled treatment observations over the first 2 months following enrolment. We assessed the cost-effectiveness of latent tuberculosis screening alongside radiographic screening of people experiencing homelessness. The costs of video-observed treatment and directly observed treatment were compared.
Results
In the homeless hostels, 16.5% of people experiencing homelessness had latent tuberculosis infection, 1.4% had current hepatitis B infection, 10.4% had hepatitis C infection and 1.0% had human immunodeficiency virus infection. When a quality-adjusted life-year is valued at £30,000, the latent tuberculosis screening of people experiencing homelessness was cost-effective provided treatment uptake was ≥ 25% (for a £20,000 quality-adjusted life-year threshold, treatment uptake would need to be > 50%). In prison, 12.6% of prisoners had latent tuberculosis infection, 1.9% had current hepatitis B infection, 4.2% had hepatitis C infection and 0.0% had human immunodeficiency virus infection. In both settings, levels of latent tuberculosis infection and blood-borne viruses were higher among injecting drug users. A total of 1484 prisoners were screened using chest radiography over a total of 112 screening days (new prisoner screening coverage was 43%). Twenty-nine radiographs were reported as potentially indicating tuberculosis. One prisoner began, and completed, antituberculosis treatment in prison. In the cluster randomised controlled trial of peer educators to increase screening uptake, the median uptake was 45% in the control arm and 40% in the intervention arm (adjusted risk ratio 0.98, 95% confidence interval 0.80 to 1.20). A rapid diagnostic service was established on the mobile radiographic unit but the trial of rapid diagnostics was abandoned because of recruitment and follow-up difficulties. We randomly assigned 112 patients to video-observed treatment and 114 patients to directly observed treatment. Fifty-eight per cent of those recruited had a history of homelessness, addiction, imprisonment or severe mental health problems. Seventy-eight (70%) of 112 patients on video-observed treatment achieved the primary outcome, compared with 35 (31%) of 114 patients on directly observed treatment (adjusted odds ratio 5.48, 95% confidence interval 3.10 to 9.68; p < 0.0001). Video-observed treatment was superior to directly observed treatment in all demographic and social risk factor subgroups. The cost for 6 months of treatment observation was £1645 for daily video-observed treatment, £3420 for directly observed treatment three times per week and £5700 for directly observed treatment five times per week.
Limitations
Recruitment was lower than anticipated for most of the studies. The peer advocate study may have been contaminated by the fact that the service was already using peer educators to support its work.
Conclusions
There are very high levels of latent tuberculosis infection among prisoners, people experiencing homelessness and drug users. Screening for latent infection in people experiencing homelessness alongside mobile radiographic screening would be cost-effective, providing the uptake of treatment was 25–50%. Despite ring-fenced funding, the NHS was unable to establish static radiographic screening programmes. Although we found no evidence that peer educators were more effective than health-care workers in encouraging the uptake of mobile radiographic screening, there may be wider benefits of including peer educators as part of the Find&Treat team. Utilising polymerase chain reaction-based rapid diagnostic testing on a mobile radiographic unit is feasible. Smartphone-enabled video-observed treatment is more effective and cheaper than directly observed treatment for ensuring that treatment is observed.
Future work
Trials of video-observed treatment in high-incidence settings are needed.
Trial registration
Current Controlled Trials ISRCTN17270334 and ISRCTN26184967.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 9. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Alistair Story
- Institute of Health Informatics, University College London, London, UK
- Find&Treat, University College Hospitals NHS Foundation Trust, London, UK
| | - Elizabeth Garber
- Institute of Health Informatics, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Robert W Aldridge
- Institute of Health Informatics, University College London, London, UK
| | - Catherine M Smith
- Institute of Health Informatics, University College London, London, UK
| | - Joe Hall
- Institute of Health Informatics, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Gloria Ferenando
- Institute of Health Informatics, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Lucia Possas
- Institute of Health Informatics, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Sara Hemming
- Institute of Health Informatics, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Fatima Wurie
- Institute of Health Informatics, University College London, London, UK
| | - Serena Luchenski
- Institute of Health Informatics, University College London, London, UK
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK
| | - Timothy D McHugh
- Centre for Clinical Microbiology, University College London, London, UK
| | - Peter J White
- Medical Research Council Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
- National Institute for Health Research Health Protection Research Unit in Modelling Methodology, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
- Modelling and Economics Unit, National Infection Service, Public Health England, London, UK
| | - John M Watson
- Research Department of Infection and Population Health, University College London, London, UK
| | - Marc Lipman
- Royal Free London NHS Foundation Trust, London, UK
- Respiratory Medicine, Division of Medicine, University College London, London, UK
| | - Richard Garfein
- Division of Global Public Health, School of Medicine, University of California, San Diego, CA, USA
| | - Andrew C Hayward
- Institute of Epidemiology and Health Care, University College London, London, UK
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11
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Simmons MD, Miller LM, Sundström MO, Johnson S. Aptamer-Based Detection of Ampicillin in Urine Samples. Antibiotics (Basel) 2020; 9:E655. [PMID: 33003560 PMCID: PMC7601551 DOI: 10.3390/antibiotics9100655] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/17/2020] [Accepted: 09/23/2020] [Indexed: 12/12/2022] Open
Abstract
The misuse of antibiotics in health care has led to increasing levels of drug resistant infections (DRI's) occurring in the general population. Most technologies developed for the detection of DRI's typically focus on phenotyping or genotyping bacterial resistance rather than on the underlying cause and spread of DRI's; namely the misuse of antibiotics. An aptameric based assay has been developed for the monitoring of ampicillin in urine samples, for use in determining optimal antibiotic dosage and monitoring patient compliance with treatment. The fluorescently labelled aptamers were shown to perform optimally at pH 7, ideal for buffered clinical urine samples, with limits of detection as low as 20.6 nM, allowing for determination of ampicillin in urine in the clinically relevant range of concentrations (100 nM to 100 µM). As the assay requires incubation for only 1 h with a small sample volume, 50 to 150 µL, the test would fit within current healthcare pathways, simplifying the adoption of the technology.
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Affiliation(s)
- Matthew D. Simmons
- Department of Electronic Engineering, University of York, Heslington, York, North Yorkshire YO10 5DD, UK;
| | - Lisa M. Miller
- Department of Chemistry, University of York, Heslington, York, North Yorkshire YO10 5DD, UK;
| | - Malin O. Sundström
- Department of Electronic Engineering, University of York, Heslington, York, North Yorkshire YO10 5DD, UK;
| | - Steven Johnson
- Department of Electronic Engineering, University of York, Heslington, York, North Yorkshire YO10 5DD, UK;
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12
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Figueredo LJDA, Miranda SSD, Santos LBD, Manso CGG, Soares VM, Alves S, Vater MC, Kritski AL, Carvalho WDS, Pádua CMD, Almeida IND. Cost analysis of smear microscopy and the Xpert assay for tuberculosis diagnosis: average turnaround time. Rev Soc Bras Med Trop 2020; 53:e20200314. [PMID: 32997053 PMCID: PMC7523521 DOI: 10.1590/0037-8682-0314-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 07/24/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Rapid and accurate tuberculosis detection is critical for improving patient diagnosis and decreasing tuberculosis transmission. Molecular assays can significantly increase laboratory costs; therefore, the average time and economic impact should be evaluated before implementing a new technology. The aim of this study was to evaluate the cost and average turnaround time of smear microscopy and Xpert assay at a university hospital. METHODS The turnaround time and cost of the laboratory diagnosis of tuberculosis were calculated based on the mean cost and activity based costing (ABC). RESULTS The average turnaround time for smear microscopy was 16.6 hours while that for Xpert was 24.1 hours. The Xpert had a mean cost of USD 17.37 with an ABC of USD 10.86, while smear microscopy had a mean cost of USD 13.31 with an ABC of USD 6.01. The sensitivity of smear microscopy was 42.9% and its specificity was 99.1%, while the Xpert assay had a sensitivity of 100% and a specificity of 96.7%. CONCLUSIONS The Xpert assay has high accuracy; however, the turnaround time and cost of smear microscopy were lower than those of Xpert.
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Affiliation(s)
| | - Silvana Spíndola de Miranda
- Universidade Federal de Minas Gerais, Grupo de Pesquisa em Micobacterioses, Faculdade de Medicina, Belo Horizonte, MG, Brasil
| | - Lucas Benício Dos Santos
- Universidade Federal de Minas Gerais, Laboratório de Pesquisa em Micobactérias, Belo Horizonte, MG, Brasil
| | | | - Valéria Martins Soares
- Fundação Hospitalar do Estado de Minas Gerais, Hospital Júlia Kubistchek, Laboratório de Microbiologia, Belo Horizonte, MG, Brasil
| | - Suely Alves
- Universidade Federal do Rio de Janeiro, Programa Acadêmico de Tuberculose, Rio de Janeiro, RJ, Brasil
| | - Maria Cláudia Vater
- Universidade Federal do Rio de Janeiro, Programa Acadêmico de Tuberculose, Rio de Janeiro, RJ, Brasil
| | - Afrânio Lineu Kritski
- Universidade Federal do Rio de Janeiro, Programa Acadêmico de Tuberculose, Rio de Janeiro, RJ, Brasil
| | | | | | - Isabela Neves de Almeida
- Universidade Federal de Minas Gerais, Laboratório de Pesquisa em Micobactérias, Belo Horizonte, MG, Brasil
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13
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Takwoingi Y, Whitworth H, Rees-Roberts M, Badhan A, Partlett C, Green N, Boakye A, Lambie H, Marongiu L, Jit M, White P, Deeks JJ, Kon OM, Lalvani A. Interferon gamma release assays for Diagnostic Evaluation of Active tuberculosis (IDEA): test accuracy study and economic evaluation. Health Technol Assess 2020; 23:1-152. [PMID: 31138395 DOI: 10.3310/hta23230] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Interferon gamma release assays (IGRAs) are blood tests recommended for the diagnosis of tuberculosis (TB) infection. There is currently uncertainty about the role and clinical utility of IGRAs in the diagnostic workup of suspected active TB in routine NHS clinical practice. OBJECTIVES To compare the diagnostic accuracy and cost-effectiveness of T-SPOT.TB ® (Oxford Immunotec, Abingdon, UK) and QuantiFERON® TB GOLD In-Tube (Cellestis, Carnegie, VIC, Australia) for diagnosis of suspected active TB and to estimate the diagnostic accuracy of second-generation IGRAs. DESIGN Prospective within-patient comparative diagnostic accuracy study. SETTING Secondary care. PARTICIPANTS Adults (aged ≥ 16 years) presenting as inpatients or outpatients at 12 NHS hospital trusts in London, Slough, Oxford, Leicester and Birmingham with suspected active TB. INTERVENTIONS The index tests [T-SPOT.TB and QuantiFERON GOLD In-Tube (QFT-GIT)] and new enzyme-linked immunospot assays utilising novel Mycobacterium tuberculosis antigens (Rv3615c, Rv2654, Rv3879c and Rv3873) were verified against a composite reference standard applied by a panel of clinical experts blinded to IGRA results. MAIN OUTCOME MEASURES Sensitivity, specificity, predictive values and likelihood ratios were calculated to determine diagnostic accuracy. A decision tree model was developed to calculate the incremental costs and incremental health utilities [quality-adjusted life-years (QALYs)] of changing from current practice to using an IGRA as an initial rule-out test. RESULTS A total of 363 patients had active TB (culture-confirmed and highly probable TB cases), 439 had no active TB and 43 had an indeterminate final diagnosis. Comparing T-SPOT.TB and QFT-GIT, the sensitivities [95% confidence interval (CI)] were 82.3% (95% CI 77.7% to 85.9%) and 67.3% (95% CI 62.1% to 72.2%), respectively, whereas specificities were 82.6% (95% CI 78.6% to 86.1%) and 80.4% (95% CI 76.1% to 84.1%), respectively. T-SPOT.TB was more sensitive than QFT-GIT (relative sensitivity 1.22, 95% CI 1.14 to 1.31; p < 0.001), but the specificities were similar (relative specificity 1.02, 95% CI 0.97 to 1.08; p = 0.3). For both IGRAs the sensitivity was lower and the specificity was higher for human immunodeficiency virus (HIV)-positive than for HIV-negative patients. The most promising novel antigen was Rv3615c. The added value of Rv3615c to T-SPOT.TB was a 9% (95% CI 5% to 12%) relative increase in sensitivity at the expense of specificity, which had a relative decrease of 7% (95% CI 4% to 10%). The use of current IGRA tests for ruling out active TB is unlikely to be considered cost-effective if a QALY was valued at £20,000 or £30,000. For T-SPOT.TB, the probability of being cost-effective for a willingness to pay of £20,000/QALY was 26% and 21%, when patients with indeterminate test results were excluded or included, respectively. In comparison, the QFT-GIT probabilities were 8% and 6%. Although the use of IGRAs is cost saving, the health detriment is large owing to delay in diagnosing active TB, leading to prolonged illness. There was substantial between-patient variation in the tests used in the diagnostic pathway. LIMITATIONS The recruitment target for the HIV co-infected population was not achieved. CONCLUSIONS Although T-SPOT.TB was more sensitive than QFT-GIT for the diagnosis of active TB, the tests are insufficiently sensitive for ruling out active TB in routine clinical practice in the UK. Novel assays offer some promise. FUTURE WORK The novel assays require evaluation in distinct clinical settings and in immunosuppressed patient groups. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and the NIHR Health Protection Research Unit in Respiratory Infections, Imperial College London, London, UK.
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Affiliation(s)
- Yemisi Takwoingi
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Hilary Whitworth
- Tuberculosis Research Centre, National Heart and Lung Institute, Imperial College London, London, UK.,Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Melanie Rees-Roberts
- Tuberculosis Research Centre, National Heart and Lung Institute, Imperial College London, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit in Respiratory Infections, Imperial College London, London, UK
| | - Amarjit Badhan
- Tuberculosis Research Centre, National Heart and Lung Institute, Imperial College London, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit in Respiratory Infections, Imperial College London, London, UK
| | | | - Nathan Green
- NIHR Health Protection Research Unit in Modelling Methodology, Imperial College London, London, UK.,Medical Research Council (MRC) Centre for Outbreak Analysis and Modelling, Imperial College London, London, UK.,Department of Infectious Disease Epidemiology, Imperial College London, London, UK.,Modelling and Economics Unit, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK
| | - Aime Boakye
- Tuberculosis Research Centre, National Heart and Lung Institute, Imperial College London, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit in Respiratory Infections, Imperial College London, London, UK
| | - Heather Lambie
- Tuberculosis Research Centre, National Heart and Lung Institute, Imperial College London, London, UK
| | - Luigi Marongiu
- Tuberculosis Research Centre, National Heart and Lung Institute, Imperial College London, London, UK
| | - Mark Jit
- Modelling and Economics Unit, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK.,Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Peter White
- NIHR Health Protection Research Unit in Modelling Methodology, Imperial College London, London, UK.,Medical Research Council (MRC) Centre for Outbreak Analysis and Modelling, Imperial College London, London, UK.,Department of Infectious Disease Epidemiology, Imperial College London, London, UK.,Modelling and Economics Unit, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK
| | - Jonathan J Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Onn Min Kon
- Tuberculosis Research Centre, National Heart and Lung Institute, Imperial College London, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit in Respiratory Infections, Imperial College London, London, UK.,St Mary's Hospital, Imperial College Healthcare Trust, London, UK
| | - Ajit Lalvani
- Tuberculosis Research Centre, National Heart and Lung Institute, Imperial College London, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit in Respiratory Infections, Imperial College London, London, UK
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14
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Lv C, Wu J, Pierre-Audigier C, Lu L, Alame-Emane AK, Takiff H, Xu Y, Wang J, Gicquel B, Liu S. Combination of Xpert MTB/RIF and MTBDRplus for Diagnosing Tuberculosis in a Chinese District. Med Sci Monit 2020; 26:e923508. [PMID: 32504464 PMCID: PMC7297034 DOI: 10.12659/msm.923508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background The incidence of tuberculosis (TB) remains high in many countries, including some middle- and high-income countries without financial constraints for diagnosis and treatment. The implementation of an improved algorithm for diagnosis using 2 rapid molecular tests should help reduce the TB burden. Material/Methods Between April 2018 and March 2019, sputum samples from 711 patients suspected of TB in Nanshan, Shenzhen, China, were included in this prospective study. All sputum samples were examined by smear microscopy, Mycobacterium Growth Indicator Tube (MGIT) 960 culture, and Xpert MTB/RIF. The sputum remnants of Xpert MTB/RIF were used for MTBDRplus to confirm the Xpert results both for the presence of TB bacilli and for resistance to rifampicin (RIF), and also to diagnose multidrug-resistant tuberculosis (MDR-TB). Results In total, 200 (28.1%) of the 711 sputa were positive for TB by Xpert MTB/RIF, and the sputum remnants were used for MTBDRplus. The simultaneous use of Xpert MTB/RIF and MTBDRplus directly on sputum samples permitted accurate bacteriologic confirmation of TB in 64% (119/187) of cases and detection of 70% (7/10) of strains that were MDR. Conclusions The implementation of 2 rapid nucleic acid-based tests on sputum samples could facilitate the prompt and appropriate treatment of most TB cases.
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Affiliation(s)
- Chunfang Lv
- Department of Clinical Laboratory, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, Guangdong, China (mainland)
| | - Jianhong Wu
- Department of Clinical Laboratory, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, Guangdong, China (mainland)
| | | | - Liuzhu Lu
- Department of Clinical Laboratory, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, Guangdong, China (mainland)
| | - Amel Kévin Alame-Emane
- Department of Tuberculosis Prevention and Control, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, Guangdong, China (mainland)
| | - Howard Takiff
- Department of Tuberculosis Prevention and Control, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, Guangdong, China (mainland)
| | - Yangfeng Xu
- Department of Clinical Laboratory, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, Guangdong, China (mainland)
| | - Jian Wang
- Department of Tuberculosis Prevention and Control, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, Guangdong, China (mainland)
| | - Brigitte Gicquel
- Department of Tuberculosis Prevention and Control, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, Guangdong, China (mainland)
| | - Shengyuan Liu
- Department of Tuberculosis Prevention and Control, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, Guangdong, China (mainland)
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15
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Martinello M, Bajis S, Dore GJ. Progress Toward Hepatitis C Virus Elimination: Therapy and Implementation. Gastroenterol Clin North Am 2020; 49:253-277. [PMID: 32389362 DOI: 10.1016/j.gtc.2020.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The World Health Organization has called for the elimination of hepatitis C virus (HCV) as a public health threat by 2030. Highly effective direct-acting antiviral agents provide the therapeutic tools required for elimination. In the absence of a vaccine, HCV elimination will require enhanced primary prevention and an increase in the proportions of people diagnosed and treated. Given that globally only 20% of people with chronic HCV are diagnosed, and around 5% have initiated HCV treatment, the task ahead is enormous. But, global public health needs optimism, and countries currently on track for HCV elimination provide a pathway forward.
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Affiliation(s)
- Marianne Martinello
- Viral Hepatitis Clinical Research Program, The Kirby Institute, UNSW Sydney, Sydney, Australia.
| | - Sahar Bajis
- Viral Hepatitis Clinical Research Program, The Kirby Institute, UNSW Sydney, Sydney, Australia
| | - Gregory J Dore
- Viral Hepatitis Clinical Research Program, The Kirby Institute, UNSW Sydney, Sydney, Australia
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16
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Dooley KE, Miyahara S, von Groote-Bidlingmaier F, Sun X, Hafner R, Rosenkranz SL, Ignatius EH, Nuermberger EL, Moran L, Donahue K, Swindells S, Vanker N. Early Bactericidal Activity of Different Isoniazid Doses for Drug-Resistant Tuberculosis (INHindsight): A Randomized, Open-Label Clinical Trial. Am J Respir Crit Care Med 2020; 201:1416-1424. [PMID: 31945300 PMCID: PMC7258626 DOI: 10.1164/rccm.201910-1960oc] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/15/2020] [Indexed: 11/16/2022] Open
Abstract
Rationale: High-dose isoniazid is recommended in short-course regimens for multidrug-resistant tuberculosis (TB). The optimal dose of isoniazid and its individual contribution to efficacy against TB strains with inhA or katG mutations are unknown.Objectives: To define the optimal dose of isoniazid for patients with isoniazid-resistant TB mediated by inhA mutations.Methods: AIDS Clinical Trials Group A5312 is a phase 2A, open-label trial in which individuals with smear-positive pulmonary TB with isoniazid resistance mediated by an inhA mutation were randomized to receive isoniazid 5, 10, or 15 mg/kg daily for 7 days (inhA group), and control subjects with drug-sensitive TB received the standard dose (5 mg/kg/d). Overnight sputum cultures were collected daily. The 7-day early bactericidal activity (EBA) of isoniazid was estimated as the average daily change in log10 cfu on solid media (EBAcfu0-7) or as time to positivity (TTP) in liquid media in hours (EBATTP0-7) using nonlinear mixed-effects models.Measurements and Main Results: Fifty-nine participants (88% with cavitary disease, 20% HIV-positive, 16 with isoniazid-sensitive TB, and 43 with isoniazid-monoresistant or multidrug-resistant TB) were enrolled at one site in South Africa. The mean EBAcfu0-7 at doses of 5, 10, and 15 mg/kg in the inhA group was 0.07, 0.17, and 0.22 log10 cfu/ml/d, respectively, and 0.16 log10 cfu/ml/d in control subjects. EBATTP0-7 patterns were similar. There were no drug-related grade ≥3 adverse events.Conclusions: Isoniazid 10-15 mg/kg daily had activity against TB strains with inhA mutations similar to that of 5 mg/kg against drug-sensitive strains. The activity of high-dose isoniazid against strains with katG mutations will be explored next.Clinical trial registered with www.clinicaltrials.gov (NCT01936831).
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Affiliation(s)
- Kelly E. Dooley
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sachiko Miyahara
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | | | - Xin Sun
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Richard Hafner
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Susan L. Rosenkranz
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Frontier Science and Technology Research Foundation, Amherst, New York
| | - Elisa H. Ignatius
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric L. Nuermberger
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Laura Moran
- Social & Scientific Systems, Inc., Silver Spring, Maryland; and
| | - Kathleen Donahue
- Frontier Science and Technology Research Foundation, Amherst, New York
| | - Susan Swindells
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Naadira Vanker
- TASK Applied Science and Stellenbosch University, Cape Town, South Africa
| | - on behalf of the A5312 Study Team
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- TASK Applied Science and Stellenbosch University, Cape Town, South Africa
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
- Frontier Science and Technology Research Foundation, Amherst, New York
- Social & Scientific Systems, Inc., Silver Spring, Maryland; and
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
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17
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Bracchi M, van Halsema C, Post F, Awosusi F, Barbour A, Bradley S, Coyne K, Dixon-Williams E, Freedman A, Jelliman P, Khoo S, Leen C, Lipman M, Lucas S, Miller R, Seden K, Pozniak A. British HIV Association guidelines for the management of tuberculosis in adults living with HIV 2019. HIV Med 2020; 20 Suppl 6:s2-s83. [PMID: 31152481 DOI: 10.1111/hiv.12748] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
| | - Clare van Halsema
- North Manchester General Hospital, Liverpool School of Tropical Medicine
| | - Frank Post
- King's College Hospital NHS Foundation Trust
| | | | | | | | | | | | | | - Pauline Jelliman
- Royal Liverpool and Broadgreen University Hospital Trust, NHIVNA
| | | | | | | | | | | | | | - Anton Pozniak
- Chelsea and Westminster Hospital NHS Foundation Trust, London School of Hygiene and Tropical Medicine
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18
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Garrido-Cardenas JA, de Lamo-Sevilla C, Cabezas-Fernández MT, Manzano-Agugliaro F, Martínez-Lirola M. Global tuberculosis research and its future prospects. Tuberculosis (Edinb) 2020; 121:101917. [PMID: 32279873 DOI: 10.1016/j.tube.2020.101917] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 02/02/2020] [Accepted: 02/20/2020] [Indexed: 12/18/2022]
Abstract
Tuberculosis is the infectious disease that causes the most deaths each year in the world. Around 25% of the population is estimated to be infected with, Mycobacterium tuberculosis, the bacteria that gives rise to the disease, and more than one and a half million people die each year from this cause. A rigorous bibliometric analysis has been developed around tuberculosis disease, and the most remarkable results are presented in this paper. It is observed that interest in tuberculosis is growing, and the control of its spread has become one of the main health priorities in the world, with the United States, the United Kingdom, and India, leading the research in this area. On the other hand, it has been observed that there are two main health concerns around the tuberculosis: drug-resistant tuberculosis and co-infection with HIV. Finally, conclusions are offered, playing a frontline role in science policy decisions and research performance evaluations.
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Affiliation(s)
- J A Garrido-Cardenas
- Department of Biology and Geology, University of Almeria, 04120, Almeria, Spain.
| | - C de Lamo-Sevilla
- Complejo Hospitalario Torrecardenas de Almeria, Almeria, UGC, Spain.
| | - M T Cabezas-Fernández
- UGC Biotecnología, Complejo Hospitalario Torrecárdenas, Servicio Andaluz de Salud, Almería, Spain.
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19
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Li Y, Su X, Le W, Li S, Yang Z, Chaisson C, Madico G, Gong X, Reed GW, Wang B, Rice PA. Mycoplasma genitalium in Symptomatic Male Urethritis: Macrolide Use Is Associated With Increased Resistance. Clin Infect Dis 2020; 70:805-810. [PMID: 30972419 PMCID: PMC7390511 DOI: 10.1093/cid/ciz294] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 04/04/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Mycoplasma genitalium (MG) causes symptomatic urethritis in men, and can infect alone or together with other sexually transmitted infection (STI) agents. METHODS The prevalence of MG and other STIs was determined in 1816 men with symptomatic urethritis. Resistance of MG to macrolides and fluoroquinolones was determined by sequencing; the impact of recent antimicrobial usage on the distribution of MG single or mixed infections was determined. RESULTS Overall, prevalence of MG infection was 19.7% (358/1816). Fifty-four percent (166/307) of MG infections occurred alone in the absence of other STI agents. Men with single MG infection self-administered or were prescribed antibiotics more often in the 30 days prior to enrollment than subjects with urethritis caused by MG coinfection (P < .0001). Higher rates (96.7%) of infection with macrolide resistance in MG were identified in men who had taken macrolides prior to enrollment (P < .03). Overall, 88.9% (303/341) of 23S ribosomal RNA (rRNA) genes contained mutations responsible for macrolide resistance; 89.5% (308/344) of parC and 12.4% (42/339) of gyrA genes had mutations responsible for fluoroquinolone resistance. Approximately 88% (270/308) of MG had combined mutations in 23S rRNA and parC genes; 10.4% (32/308) had mutations in all 3 genes. CONCLUSIONS MG was the single pathogen identified in 11% of men with symptomatic urethritis. Overall, nearly 90% of MG infections were resistant to macrolides and fluoroquinolones. Men who took macrolides in the 30 days prior to enrollment had higher rates (97%) of macrolide-resistant MG. Resistance was associated with numerous mutations in 23SrRNA, parC, and gyrA genes.
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Affiliation(s)
- Yang Li
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing
- Affiliated Qingdao Municipal Hospital of Qingdao University, China
| | - Xiaohong Su
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing
| | - Wenjing Le
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing
| | - Sai Li
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing
| | - Zhaoyan Yang
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health
| | - Christine Chaisson
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health
| | - Guillermo Madico
- National Emerging Infectious Diseases Laboratories, Boston University
| | - Xiangdong Gong
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing
| | - George W Reed
- Department of Medicine, Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester
- Corrona Research Foundation, Albany, New York
| | - Baoxi Wang
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing
- Department of Dermatology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peter A Rice
- Department of Medicine, Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester
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20
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Soares VM, Almeida IND, Vater MC, Alves S, Figueredo LJDA, Scherer L, Kritski AL, Carvalho WDS, Miranda SSD. Genotype®MTBDRplus and Xpert®MTB/RIF in the diagnosis of tuberculosis and resistant tuberculosis: cost analysis in a tertiary referral hospital. Rev Soc Bras Med Trop 2020; 53:e20190175. [PMID: 32049199 PMCID: PMC7083373 DOI: 10.1590/0037-8682-0175-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 01/08/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The present study sought to assess the mean and activity based cost (ABC) of the laboratory diagnosis for tuberculosis through the application of conventional and molecular techniques-Xpert®MTB/RIF and Genotype®MTBDRplus-in a tertiary referral hospital in Brazil. METHODS The mean cost and ABC formed the basis for the cost analysis of the TB laboratory diagnosis. RESULTS The mean cost and ABC were US$ 4.00 and US$ 3.24, respectively, for a bacilloscopy; US$ 6.73 and US$ 5.27 for a Lowenstein-Jensen (LJ) culture; US$ 105.42 and US$ 76.56 for a drug sensitivity test (DST)-proportions method (PM) in LJ; US$ 148.45 and US$ 136.80 for a DST-BACTECTM MGITTM 960 system; US$ 11.53 and US$ 9.89 for an Xpert®MTB/RIF; and US$ 84.21 and US$ 48.38 for a Genotype®MTBDRplus. CONCLUSIONS The mean cost and ABC proved to be good decision-making parameters in the diagnosis of TB and MDR-TB. The effective implementation of algorithms will depend on the conditions at each location.
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Affiliation(s)
- Valéria Martins Soares
- Federação Hospitalar do Estado de Minas Gerais, Hospital Júlia Kubistchek, Laboratório de Microbiologia, Belo Horizonte, MG, Brasil
| | - Isabela Neves de Almeida
- Universidade Federal de Minas Gerais, Laboratório de Pesquisa em Micobactérias, Belo Horizonte, MG, Brasil
| | - Maria Cláudia Vater
- Universidade Federal do Rio de Janeiro, Programa Acadêmico de Tuberculose, Rio de Janeiro, RJ, Brasil
| | - Suely Alves
- Universidade Federal do Rio de Janeiro, Programa Acadêmico de Tuberculose, Rio de Janeiro, RJ, Brasil
| | | | - Luciene Scherer
- Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - Afrânio Lineu Kritski
- Universidade Federal do Rio de Janeiro, Programa Acadêmico de Tuberculose, Rio de Janeiro, RJ, Brasil
| | | | - Silvana Spindola de Miranda
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Grupo de Pesquisa em Micobactérias, Belo Horizonte, MG, Brasil
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21
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Ducatman BS, Ducatman AM, Crawford JM, Laposata M, Sanfilippo F. The Value Proposition for Pathologists: A Population Health Approach. Acad Pathol 2020; 7:2374289519898857. [PMID: 31984223 PMCID: PMC6961144 DOI: 10.1177/2374289519898857] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/11/2019] [Accepted: 12/04/2019] [Indexed: 01/09/2023] Open
Abstract
The transition to a value-based payment system offers pathologists the opportunity to play an increased role in population health by improving outcomes and safety as well as reducing costs. Although laboratory testing itself accounts for a small portion of health-care spending, laboratory data have significant downstream effects in patient management as well as diagnosis. Pathologists currently are heavily engaged in precision medicine, use of laboratory and pathology test results (including autopsy data) to reduce diagnostic errors, and play leading roles in diagnostic management teams. Additionally, pathologists can use aggregate laboratory data to monitor the health of populations and improve health-care outcomes for both individual patients and populations. For the profession to thrive, pathologists will need to focus on extending their roles outside the laboratory beyond the traditional role in the analytic phase of testing. This should include leadership in ensuring correct ordering and interpretation of laboratory testing and leadership in population health programs. Pathologists in training will need to learn key concepts in informatics and data analytics, health-care economics, public health, implementation science, and health systems science. While these changes may reduce reimbursement for the traditional activities of pathologists, new opportunities arise for value creation and new compensation models. This report reviews these opportunities for pathologist leadership in utilization management, precision medicine, reducing diagnostic errors, and improving health-care outcomes.
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Affiliation(s)
- Barbara S. Ducatman
- Department of Pathology, Beaumont Health, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI,
USA
| | - Alan M. Ducatman
- Department of Occupational and Environmental Health Sciences, West Virginia
University School of Public Health, Morgantown, WV, USA
| | - James M. Crawford
- Department of Pathology and Laboratory Medicine, Donald and Barbara Zucker
School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Michael Laposata
- Department of Pathology, University of Texas Medical Branch, Galveston, TX,
USA
| | - Fred Sanfilippo
- Department of Pathology and Laboratory Medicine, Emory University School of
Medicine, Atlanta, GA, USA
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22
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Huang F, van den Hof S, Qu Y, Li Y, Zhang H, Wang L, Sun M, Lu W, Hou S, Zhang T, Huan S, Chin DP, Cobelens F. Added Value of Comprehensive Program to Provide Universal Access to Care for Sputum Smear-Negative Drug-Resistant Tuberculosis, China. Emerg Infect Dis 2019; 25:1289-1296. [PMID: 31211666 PMCID: PMC6590765 DOI: 10.3201/eid2507.181417] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The increase in drug-resistant tuberculosis in China calls for scaling up rapid diagnosis. We evaluated introduction of rapid resistance testing by line-probe assay for all patients with a diagnosis of pulmonary tuberculosis in 2 prefectures in middle and eastern China. We analyzed sputum samples for smear-positive patients and cultures for smear-negative patients. We used a before–after comparison of baseline and intervention periods (12 months each) and analyzed data for 5,222 baseline period patients and 4,364 intervention period patients. The number of patients with rifampin resistance increased from 30 in the baseline period to 97 in the intervention period for smear-positive patients and from 0 to 13 for smear-negative patients, reflecting a low proportion of positive cultures (410/2,844, 14.4%). Expanding rapid testing for drug resistance for smear-positive patients resulted in a 3-fold increase in patients with diagnoses of rifampin-resistant tuberculosis. However, testing smear-negative patients had limited added value because of a low culture-positive rate.
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23
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Dara M, Ehsani S, Mozalevskis A, Vovc E, Simões D, Avellon Calvo A, Casabona I Barbarà J, Chokoshvili O, Felker I, Hoffner S, Kalmambetova G, Noroc E, Shubladze N, Skrahina A, Tahirli R, Tsertsvadze T, Drobniewski F. Tuberculosis, HIV, and viral hepatitis diagnostics in eastern Europe and central Asia: high time for integrated and people-centred services. THE LANCET. INFECTIOUS DISEASES 2019; 20:e47-e53. [PMID: 31740252 DOI: 10.1016/s1473-3099(19)30524-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 08/12/2019] [Accepted: 08/20/2019] [Indexed: 12/21/2022]
Abstract
Globally, high rates (and in the WHO European region an increasing prevalence) of co-infection with tuberculosis and HIV and HIV and hepatitis C virus exist. In eastern European and central Asian countries, the tuberculosis, HIV, and viral hepatitis programmes, including diagnostic services, are separate vertical structures. In this Personal View, we consider underlying reasons for the poor integration for these diseases, particularly in the WHO European region, and how to address this with an initial focus on diagnostic services. In part, this low integration has reflected different diagnostic development histories, global funding sources, and sample types used for diagnosis (eg, typically sputum for tuberculosis and blood for HIV and hepatitis C). Cooperation between services improved as patients with tuberculosis needed routine testing for HIV and vice versa, but financial, infection control, and logistical barriers remain. Multidisease diagnostic platforms exist, but to be used optimally, appropriate staff training and sensible understanding of different laboratory and infection control risks needs rapid implementation. Technically these ideas are all feasible. Poor coordination between these vertical systems remains unhelpful. There is a need to increase political and operational integration of diagnostic and treatment services and bring them closer to patients.
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Affiliation(s)
- Masoud Dara
- Communicable Diseases Department, Division of Health Emergencies and Communicable Diseases, Regional Office for Europe, World Health Organization, Copenhagen, Denmark.
| | - Soudeh Ehsani
- Joint Tuberculosis, HIV and Viral Hepatitis Programme, Regional Office for Europe, World Health Organization, Copenhagen, Denmark
| | - Antons Mozalevskis
- Joint Tuberculosis, HIV and Viral Hepatitis Programme, Regional Office for Europe, World Health Organization, Copenhagen, Denmark
| | - Elena Vovc
- Joint Tuberculosis, HIV and Viral Hepatitis Programme, Regional Office for Europe, World Health Organization, Copenhagen, Denmark
| | - Daniel Simões
- EPI Unit, Institute of Public Health, University of Porto, Porto, Portugal
| | - Ana Avellon Calvo
- Hepatitis Unit, National Center of Microbiology, Carlos III Institute of Health, Majadahonda, Madrid, Spain
| | - Jordi Casabona I Barbarà
- Center for Epidemiological Studies on STI and AIDS in Catalonia and Research Network on Biomedical Research, Epidemiology and Public Health, Catalan Agency of Public Health, Badalona, Spain
| | - Otar Chokoshvili
- Infectious diseases and Clinical Immunology Research Center, Tbilisi, Georgia
| | - Irina Felker
- Scientific department, Novosibirsk Tuberculosis Research Institute, Novosibirsk, Russia
| | - Sven Hoffner
- Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | | | - Ecatarina Noroc
- National AIDS Programme, Dermatology and Communicable Diseases Hospital, Chisinau, Moldova
| | - Natalia Shubladze
- National Reference Laboratory, National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Alena Skrahina
- Clinical department, Republican Scientific and Practical Centre for Pulmonology and Tuberculosis, Minsk, Belarus
| | - Rasim Tahirli
- Laboratory for Medical Service, Specialized Treatment Institution, Main Medical Department, Ministry of Justice, Baku, Azerbaijan
| | - Tengiz Tsertsvadze
- Infectious Diseases and Clinical Immunology Research Center, Tbilisi State University, Tbilisi, Georgia
| | - Francis Drobniewski
- Global Health and Tuberculosis, Imperial College London, London, UK; WHO European Laboratory Initiative on Tuberculosis, HIV and Viral hepatitis, WHO Regional Office of Europe, Copenhagen, Denmark
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24
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Aricha SA, Kingwara L, Mwirigi NW, Chaba L, Kiptai T, Wahogo J, Otwabe JS, Onyango PO, Karanja M, Ayieko C, Matu SW. Comparison of GeneXpert and line probe assay for detection of Mycobacterium tuberculosis and rifampicin-mono resistance at the National Tuberculosis Reference Laboratory, Kenya. BMC Infect Dis 2019; 19:852. [PMID: 31615537 PMCID: PMC6794895 DOI: 10.1186/s12879-019-4470-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 09/13/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The dual challenge of low diagnostic sensitivity of microscopy test and technical challenge of performing a TB culture test poses a problem for case detection and initiation of Tuberculosis (TB) second-line treatment. There is thus need for a rapid, reliable and easily accessible assay. This comparative analysis was performed to assess diagnostic performance characteristics of GeneXpert MTB/RIF and Line Probe Assay (LPA). METHODS Three hundred twenty nine sputum samples of patients across the 47 counties in Kenya suspected to have drug resistant TB were picked and subjected to GeneXpert, LPA and Culture MGIT at the National TB Reference Laboratory. Sensitivity, specificity and predictive values were then determined to assess the performance characteristics of the various assays. RESULTS Against culture MGIT as the gold standard for TB diagnosis, GeneXpert had a sensitivity, specificity, positive predictive value, and negative predictive value of 78.5, 64.9, 59.4 and 82.2% respectively while LPA had 98.4, 66.0, 65.4 and 98.4%. For diagnosis of rifampicin mono-resistance GeneXpert had a moderate agreement (Kappa 0.59, P < 0.01) (sensitivity 62.50%, specificity 96.50%) while LPA that had almost perfect agreement (Kappa = 0.89, p < 0.01) with a (sensitivity 90.0% and specificity 99.1%). CONCLUSION LPA has a better performance characteristic to GeneXpert and an alternative to culture with regards to detection of RIF's mono-resistance.
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Affiliation(s)
- S. A. Aricha
- School of Physical and Biological Sciences, Maseno University, Kisumu, Kenya
- National Public Health Laboratories, Nairobi, Kenya
| | - L. Kingwara
- National Public Health Laboratories, Nairobi, Kenya
| | | | - L. Chaba
- Strathmore University, Nairobi, Kenya
| | | | - J. Wahogo
- National Public Health Laboratories, Nairobi, Kenya
| | - J. S. Otwabe
- Kisii teaching and Referral Hospital, Nairobi, Kenya
| | - P. O. Onyango
- School of Physical and Biological Sciences, Maseno University, Kisumu, Kenya
| | - M. Karanja
- National AIDS and STI Control Program, Nairobi, Kenya
| | - C. Ayieko
- School of Physical and Biological Sciences, Maseno University, Kisumu, Kenya
| | - S. W. Matu
- Kenya Medical Research Institute, Nairobi, Kenya
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25
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Stagg HR, Bothamley GH, Davidson JA, Kunst H, Lalor MK, Lipman MC, Loutet MG, Lozewicz S, Mohiyuddin T, Abbara A, Alexander E, Booth H, Creer DD, Harris RJ, Kon OM, Loebinger MR, McHugh TD, Milburn HJ, Palchaudhuri P, Phillips PPJ, Schmok E, Taylor L, Abubakar I. Fluoroquinolones and isoniazid-resistant tuberculosis: implications for the 2018 WHO guidance. Eur Respir J 2019; 54:13993003.00982-2019. [PMID: 31371444 PMCID: PMC6785706 DOI: 10.1183/13993003.00982-2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 07/01/2019] [Indexed: 01/15/2023]
Abstract
Introduction 2018 World Health Organization (WHO) guidelines for the treatment of isoniazid (H)-resistant (Hr) tuberculosis recommend a four-drug regimen: rifampicin (R), ethambutol (E), pyrazinamide (Z) and levofloxacin (Lfx), with or without H ([H]RZE-Lfx). This is used once Hr is known, such that patients complete 6 months of Lfx (≥6[H]RZE-6Lfx). This cohort study assessed the impact of fluoroquinolones (Fq) on treatment effectiveness, accounting for Hr mutations and degree of phenotypic resistance. Methods This was a retrospective cohort study of 626 Hr tuberculosis patients notified in London, 2009–2013. Regimens were described and logistic regression undertaken of the association between regimen and negative regimen-specific outcomes (broadly, death due to tuberculosis, treatment failure or disease recurrence). Results Of 594 individuals with regimen information, 330 (55.6%) were treated with (H)RfZE (Rf=rifamycins) and 211 (35.5%) with (H)RfZE-Fq. The median overall treatment period was 11.9 months and median Z duration 2.1 months. In a univariable logistic regression model comparing (H)RfZE with and without Fqs, there was no difference in the odds of a negative regimen-specific outcome (baseline (H)RfZE, cluster-specific odds ratio 1.05 (95% CI 0.60–1.82), p=0.87; cluster NHS trust). Results varied minimally in a multivariable model. This odds ratio dropped (0.57, 95% CI 0.14–2.28) when Hr genotype was included, but this analysis lacked power (p=0.42). Conclusions In a high-income setting, we found a 12-month (H)RfZE regimen with a short Z duration to be similarly effective for Hr tuberculosis with or without a Fq. This regimen may result in fewer adverse events than the WHO recommendations. WHO has assessed regimen recommendations for isoniazid-resistant TB to be of very low certainty. The addition of fluoroquinolones to a 12-month (isoniazid, rifamycin, ethambutol, short-duration pyrazinamide) regimen may be unnecessary in certain settings.http://bit.ly/2XoTgNL
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Affiliation(s)
- Helen R Stagg
- Institute for Global Health, University College London, London, UK .,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Graham H Bothamley
- Respiratory Medicine, Homerton University Hospital, London, UK.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Jennifer A Davidson
- Tuberculosis Unit, National Infection Service, Public Health England, London, UK.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Heinke Kunst
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Maeve K Lalor
- Institute for Global Health, University College London, London, UK.,Tuberculosis Unit, National Infection Service, Public Health England, London, UK.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Marc C Lipman
- Respiratory Medicine, Royal Free Hospital, London, UK.,UCL Respiratory, Division of Medicine, University College London.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Miranda G Loutet
- Tuberculosis Unit, National Infection Service, Public Health England, London, UK.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Stefan Lozewicz
- Respiratory Medicine, North Middlesex University Hospital, London, UK.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Tehreem Mohiyuddin
- Tuberculosis Unit, National Infection Service, Public Health England, London, UK.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Aula Abbara
- Infectious Diseases, London North West University Healthcare NHS Trust, London, UK.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Eliza Alexander
- National Mycobacterial Reference Service South, Public Health England, London, UK.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Helen Booth
- Tuberculosis Service, University College London Hospitals/Whittington Health, London, UK.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Dean D Creer
- Respiratory Medicine, Barnet General Hospital, Royal Free London NHS Foundation Trust, London, UK.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Ross J Harris
- Statistics, Modelling and Economics Department, Public Health England, London, UK.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Onn Min Kon
- TB Service, Imperial College Healthcare, London, UK.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Michael R Loebinger
- Respiratory Medicine, Chelsea and Westminster Hospital, London, UK.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Timothy D McHugh
- Centre for Clinical Microbiology, University College London, London, UK.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Heather J Milburn
- Respiratory Medicine, Guy's and St Thomas' Hospital, London, UK.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Paramita Palchaudhuri
- Respiratory Services, Queen Elizabeth Hospital, London, UK.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Patrick P J Phillips
- Dept of Medicine and Dept of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Erik Schmok
- Respiratory Medicine, Homerton University Hospital, London, UK.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Lucy Taylor
- National Mycobacterial Reference Service South, Public Health England, London, UK.,These authors contributed equally to this manuscript and are presented alphabetically
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK
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Is latent tuberculosis infection challenging in Iranian health care workers? A systematic review and meta-analysis. PLoS One 2019; 14:e0223335. [PMID: 31581258 PMCID: PMC6776393 DOI: 10.1371/journal.pone.0223335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 09/18/2019] [Indexed: 01/23/2023] Open
Abstract
Background The high chances of getting latent tuberculosis infection (LTBI) among health care workers (HCWs) will an enormous problem in low and upper-middle-income countries. Method Search strategies were done through both national and international databases include SID, Barakat knowledge network system, Irandoc, Magiran, Iranian national library, web of science, Scopus, PubMed/MEDLINE, OVID, EMBASE, the Cochrane library, and Google Scholar search engine. The Persian and the English languages were used as the filter in national and international databases, respectively. Medical Subject Headings (MeSH) terms was used to controlling comprehensive vocabulary. The search terms were conducted without time limitation till January 01, 2019. Results The prevalence of LTBI in Iranian’s HCWs, based on the PPD test was 27.13% [CI95%: 18.64–37.7]. The highest prevalence of LTBI in Iranian’s HCWs were estimated 41.4% [CI95%: 25.4–59.5] in the north, and 33.8% [CI95%: 21.1–49.3] in the west. The lowest prevalence of LTBI was evaluated 18.2% [CI95%: 3.4–58.2] in the south of Iran. The prevalence of LTBI in Iranian’s HCWs who had work-experience more than 20 years old were estimated 20.49% [CI95%: 11–34.97]. In the PPD test, the prevalence of LTBI in Iranian’s HCWs who had received the Bacille Calmette–Guérin (BCG) was estimated 15% [CI95%: 3.6–47.73]. While, in the QFT, the prevalence of LTBI in Iranian’s HCWs in non-vaccinated was estimated 25.71% [CI95%: 13.96–42.49]. Conclusions This meta-analysis shows the highest prevalence of LTBI in Iranian’s HCWs in the north and the west probably due to neighboring countries like Azerbaijan and Iraq, respectively. It seems that Iranian’s HCWs have not received the necessary training to prevent of TB. We also found that BCG was not able to protect Iranian’s HCWs from TB infections, completely.
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Mathys V, Roycroft E, Raftery P, Groenheit R, Folkvardsen DB, Homorodean D, Vasiliauskiene E, Vasiliauskaite L, Kodmon C, van der Werf MJ, Drobniewski F, Nikolayevskyy V. Time-and-motion tool for the assessment of working time in tuberculosis laboratories: a multicentre study. Int J Tuberc Lung Dis 2019; 22:444-451. [PMID: 29562994 PMCID: PMC5868372 DOI: 10.5588/ijtld.17.0564] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Implementation of novel diagnostic assays in tuberculosis (TB) laboratory diagnosis requires effective management of time and resources. OBJECTIVE To further develop and assess at multiple centres a time-and-motion (T&M) tool as an objective means for recording the actual time spent on running laboratory assays. DESIGN Multicentre prospective study conducted in six European Union (EU) reference TB laboratories. RESULTS A total of 1060 specimens were tested using four laboratory assays. The number of specimens per batch varied from one to 60; a total of 64 recordings were performed. Theoretical hands-on times per specimen (TTPS) in h:min:s for Xpert® MTB/RIF, mycobacterial interspersed repetitive unit-variable number of tandem repeats genotyping, Ziehl-Neelsen staining and manual fluorescence microscopy were respectively 00:33:02 ± 00:12:32, 00:13:34 ± 00:03:11, 00:09:54 ± 00:00:53 and 00:06:23 ± 00:01:36. Variations between laboratories were predominantly linked to the time spent on reporting and administrative procedures. Processing specimens in batches could help save time in highly automated assays (e.g., line-probe) (TTPS 00:14:00 vs. 00:09:45 for batches comprising 7 and 31 specimens, respectively). CONCLUSIONS The T&M tool can be considered a universal and objective methodology contributing to workload assessment in TB diagnostic laboratories. Comparison of workload between laboratories could help laboratory managers justify their resource and personnel needs for the implementation of novel, time-saving, cost-effective technologies, as well as identify areas for improvement.
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Affiliation(s)
- V Mathys
- Scientific Institute of Public Health (WIV-ISP), Brussels, Belgium
| | - E Roycroft
- Irish Mycobacteria Reference Laboratory, St James' Hospital, Dublin, Ireland
| | - P Raftery
- Irish Mycobacteria Reference Laboratory, St James' Hospital, Dublin, Ireland
| | - R Groenheit
- Public Health Agency of Sweden, Stockholm, Sweden
| | - D B Folkvardsen
- International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark
| | - D Homorodean
- Clinical Hospital of Pneumology, Cluj-Napoca, Romania
| | - E Vasiliauskiene
- Centre of Laboratory Medicine, Tuberculosis Laboratory, Vilnius University Hospital Santaros Klinikos, Vilnius, Institute of Biomedical Sciences, Department of Physiology, Biochemistry, Microbiology and Laboratory Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - L Vasiliauskaite
- Centre of Laboratory Medicine, Tuberculosis Laboratory, Vilnius University Hospital Santaros Klinikos, Vilnius, Institute of Biomedical Sciences, Department of Physiology, Biochemistry, Microbiology and Laboratory Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - C Kodmon
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - M J van der Werf
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | | | - V Nikolayevskyy
- Imperial College, London, Public Health England, National Mycobacterium Reference Service South, London, UK
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28
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Kendall EA, Sahu S, Pai M, Fox GJ, Varaine F, Cox H, Cegielski JP, Mabote L, Vassall A, Dowdy DW. What will it take to eliminate drug-resistant tuberculosis? Int J Tuberc Lung Dis 2019; 23:535-546. [PMID: 31097060 PMCID: PMC6600801 DOI: 10.5588/ijtld.18.0217] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Drug-resistant tuberculosis (DR-TB) is challenging to diagnose, treat, and prevent, but this situation is slowly changing. If the world is to drastically reduce the incidence of DR-TB, we must stop creating new DR-TB as an essential first step. The DR-TB epidemic that is ongoing should also be directly addressed. First-line drug resistance must be rapidly detected using universal molecular testing for resistance to at least rifampin and, preferably, other key drugs at initial TB diagnosis. DR-TB treatment outcomes must also improve dramatically. Effective use of currently available, new, and repurposed drugs, combined with patient-centered treatment that aids adherence and reduces catastrophic costs, are essential. Innovations within sight, such as short, highly effective, broadly indicated regimens, paired with point-of-care drug susceptibility testing, could accelerate progress in treatment outcomes. Preventing or containing resistance to second-line and novel drugs is also critical and will require high-quality systems for diagnosis, regimen selection, and treatment monitoring. Finally, earlier detection and/or prevention of DR-TB is necessary, with particular attention to airborne infection control, case finding, and preventive therapy for contacts of patients with DR-TB. Implementing these strategies can overcome the barrier that DR-TB represents for global TB elimination efforts, and could ultimately make global elimination of DR-TB (fewer than one annual case per million population worldwide) attainable. There is a strong cost-effectiveness case to support pursuing DR-TB elimination; however, achieving this goal will require substantial global investment plus political and societal commitment at national and local levels.
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Affiliation(s)
- E A Kendall
- Johns Hopkins University, Baltimore, Maryland, USA
| | - S Sahu
- Stop TB Partnership, Geneva, Switzerland
| | - M Pai
- McGill International TB Center, McGill University, Montreal, Quebec, Canada
| | - G J Fox
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - F Varaine
- Médecins Sans Frontières, Paris, France
| | - H Cox
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; **Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - L Mabote
- AIDS and Rights Alliance for Southern Africa, Cape Town, South Africa
| | - A Vassall
- London School of Hygiene & Tropical Medicine, London, UK
| | - D W Dowdy
- Johns Hopkins University, Baltimore, Maryland, USA
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29
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Ming D, Rawson T, Sangkaew S, Rodriguez-Manzano J, Georgiou P, Holmes A. Connectivity of rapid-testing diagnostics and surveillance of infectious diseases. Bull World Health Organ 2019; 97:242-244. [PMID: 30992638 PMCID: PMC6453318 DOI: 10.2471/blt.18.219691] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 11/30/2018] [Accepted: 12/25/2018] [Indexed: 11/27/2022] Open
Affiliation(s)
- Damien Ming
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Hospital Campus, London W12 0NN, England
| | - Timothy Rawson
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Hospital Campus, London W12 0NN, England
| | - Sorawat Sangkaew
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Hospital Campus, London W12 0NN, England
| | | | - Pantelis Georgiou
- Department of Electrical and Electronic Engineering, Imperial College, London, England
| | - Alison Holmes
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Hospital Campus, London W12 0NN, England
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30
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DNA markers for tuberculosis diagnosis. Tuberculosis (Edinb) 2018; 113:139-152. [PMID: 30514496 DOI: 10.1016/j.tube.2018.09.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 09/23/2018] [Accepted: 09/27/2018] [Indexed: 02/07/2023]
Abstract
Tuberculosis (TB), caused by Mycobacterium tuberculosis complex (MTBC), is an infectious disease with more than 10.4 million cases and 1.7 million deaths reported worldwide in 2016. The classical methods for detection and differentiation of mycobacteria are: acid-fast microscopy (Ziehl-Neelsen staining), culture, and biochemical methods. However, the microbial phenotypic characterization is time-consuming and laborious. Thus, fast, easy, and sensitive nucleic acid amplification tests (NAATs) have been developed based on specific DNA markers, which are commercially available for TB diagnosis. Despite these developments, the disease remains uncontrollable. The identification and differentiation among MTBC members with the use of NAATs remains challenging due, among other factors, to the high degree of homology within the members and mutations, which hinders the identification of specific target sequences in the genome with potential impact in the diagnosis and treatment outcomes. In silico methods provide predictive identification of many new target genes/fragments/regions that can specifically be used to identify species/strains, which have not been fully explored. This review focused on DNA markers useful for MTBC detection, species identification and antibiotic resistance determination. The use of DNA targets with new technological approaches will help to develop NAATs applicable to all levels of the health system, mainly in low resource areas, which urgently need customized methods to their specific conditions.
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31
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Shenoy VP, Kumar A, Chawla K. Rapid detection of multidrug resistant tuberculosis in respiratory specimens at a tertiary care centre in south coastal Karnataka using Genotype MTBDR plus assay. IRANIAN JOURNAL OF MICROBIOLOGY 2018; 10:275-280. [PMID: 30675322 PMCID: PMC6339998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVES Despite high prevalence of MDR-TB in India very limited information about MDR-TB and mutation patterns in rpoB, inhA and katG genes among MDR-isolates of Mycobacterium tuberculosis in south coastal Karnataka region is available; thus present study is an attempt to explore the extent of MDR-TB and mutation patterns prevalent among clinical isolates in this region using GenoType MTBDR plus assay. MATERIALS AND METHODS A total of 256 sputum samples from Pulmonary TB patients suspected of MDR-TB were tested by GenoType MTBDR plus as per manufacturer's guidelines for detection of mutations conferring resistance to rifampicin and isoniazid. The results of GenoType MTBDR plus were recorded and analysed using SPSS version 22. For all analyses, a p value <0.05 was considered statistically significant. RESULTS Fifty (19.53%) isolates were found MDR, 32 (12.50%) isolates were found mono-resistant to isoniazid and 15 (5.86%) isolates were found mono-resistant to rifampicin. Eleven isolates (4.3%) were found NTM. Mutation in codon S531L, S315T1 and C15T were most common in rpoB, katG and inhA genes respectively. Unknown mutations were found in 50.77% (33/65), 3.66% (3/82) and 26.83% (22/82) isolates for rpoB, katG and inhA genes respectively. Hetero-resistance in MDR, rifampicin monoresistant and isoniazid monoresistant isolates was found to be 26% (13/50), 20% (3/15) and 34.37% (11/32) respectively. CONCLUSION Mutation in codon S531L, S315T1 and C15T were most common mutations associated with MDR-TB. Further high number of isolates showed mutations in unknown regions and hetero-resistance thus more elaborate studies based on sequencing are desirable in this region.
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Affiliation(s)
- Vishnu Prasad Shenoy
- Corresponding author: Vishnu Prasad Shenoy, Ph.D, Department of Microbiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India. Tel: +919886616197,
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Validation of Novel Mycobacterium tuberculosis Isoniazid Resistance Mutations Not Detectable by Common Molecular Tests. Antimicrob Agents Chemother 2018; 62:AAC.00974-18. [PMID: 30082293 DOI: 10.1128/aac.00974-18] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 08/03/2018] [Indexed: 01/20/2023] Open
Abstract
Resistance to the first-line antituberculosis (TB) drug isoniazid (INH) is widespread, and the mechanism of resistance is unknown in approximately 15% of INH-resistant (INH-R) strains. To improve molecular detection of INH-R TB, we used whole-genome sequencing (WGS) to analyze 52 phenotypically INH-R Mycobacterium tuberculosis complex (MTBC) clinical isolates that lacked the common katG S315T or inhA promoter mutations. Approximately 94% (49/52) of strains had mutations at known INH-associated loci that were likely to confer INH resistance. All such mutations would be detectable by sequencing more DNA adjacent to existing target regions. Use of WGS minimized the chances of missing infrequent INH resistance mutations outside commonly targeted hotspots. We used recombineering to generate 12 observed clinical katG mutations in the pansusceptible H37Rv reference strain and determined their impact on INH resistance. Our functional genetic experiments have confirmed the role of seven suspected INH resistance mutations and discovered five novel INH resistance mutations. All recombineered katG mutations conferred resistance to INH at a MIC of ≥0.25 μg/ml and should be added to the list of INH resistance determinants targeted by molecular diagnostic assays. We conclude that WGS is a useful tool for detecting uncommon INH resistance mutations that would otherwise be missed by current targeted molecular testing methods and suggest that its use (or use of expanded conventional or next-generation-based targeted sequencing) may provide earlier diagnosis of INH-R TB.
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Miotto P, Zhang Y, Cirillo DM, Yam WC. Drug resistance mechanisms and drug susceptibility testing for tuberculosis. Respirology 2018; 23:1098-1113. [PMID: 30189463 DOI: 10.1111/resp.13393] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 08/03/2018] [Accepted: 08/12/2018] [Indexed: 12/12/2022]
Abstract
Tuberculosis (TB) caused by Mycobacterium tuberculosis (MTB) is the deadliest infectious disease and the associated global threat has worsened with the emergence of drug resistance, in particular multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB). Although the World Health Organization (WHO) End-TB Strategy advocates for universal access to antimicrobial susceptibility testing, this is not widely available and/or it is still underused. The majority of drug resistance in clinical MTB strains is attributed to chromosomal mutations. Resistance-related mutations could also exert certain fitness cost to the drug-resistant MTB strains and growth fitness could be restored by the presence of compensatory mutations. Understanding these underlying mechanisms could provide an important insight into TB pathogenesis and predict the future trend of MDR-TB global pandemic. This review covers the mechanisms of resistance in MTB and provides a comprehensive overview of current phenotypic and molecular approaches for drug susceptibility testing, with particular attention to the methods endorsed and recommended by the WHO.
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Affiliation(s)
- Paolo Miotto
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Ying Zhang
- Department of Molecular Microbiology and Immunology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Daniela Maria Cirillo
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Wing Cheong Yam
- Department of Microbiology, Queen Mary Hospital Compound, The University of Hong Kong, Hong Kong, China
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Padmasawitri TIA, Frederix GW, Alisjahbana B, Klungel O, Hövels AM. Disparities in model-based cost-effectiveness analyses of tuberculosis diagnosis: A systematic review. PLoS One 2018; 13:e0193293. [PMID: 29742106 PMCID: PMC5942841 DOI: 10.1371/journal.pone.0193293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 01/30/2018] [Indexed: 01/17/2023] Open
Abstract
Background Structural approach disparities were minimally addressed in past systematic reviews of model-based cost-effectiveness analyses addressing Tuberculosis management strategies. This review aimed to identify the structural approach disparities in model-based cost-effectiveness analysis studies addressing Tuberculosis diagnosis and describe potential hazards caused by those disparities. Methods A systematic search to identify studies published before October 2015 was performed in five electronic databases. After removal of duplication, studies’ titles and abstracts were screened based on predetermined criteria. The full texts of potentially relevant studies were subsequently screened and excluded when they did not address active pulmonary Tuberculosis diagnosis. Quality of the studies was assessed using the “Philips’ checklist.” Various data regarding general information, cost-effectiveness results, and disease modeling were extracted using standardized data extraction forms. Data pertaining to models’ structural approaches were compared and analyzed qualitatively for their applicability in various study settings, as well as their potential influence on main outcomes and cost-effectiveness conclusion. Results A total of 27 studies were included in the review. Most studies utilized a static model, which could underestimate the cost-effectiveness of the diagnostic tools strategies, due to the omission of indirect diagnosis effects, i.e. transmission reduction. A few structural assumption disparities were found in the dynamic models. Extensive disparities were found in the static models, consisting of varying structural assumptions regarding treatment outcomes, clinical diagnosis and empirical treatment, inpatient discharge decision, and re-diagnosis of false negative patients. Conclusion In cost-effectiveness analysis studies addressing active pulmonary Tuberculosis diagnosis, models showed numerous disparities in their structural approaches. Several structural approaches could be inapplicable in certain settings. Furthermore, they could contribute to under- or overestimation of the cost-effectiveness of the diagnosis tools or strategies. They could thus lead to ambiguities and difficulties when interpreting a study result. A set of recommendations is proposed to manage issues related to these structural disparities.
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Affiliation(s)
- T. I. Armina Padmasawitri
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Pharmacology and Clinical Pharmacy Research Group, School of Pharmacy, Institut Teknologi Bandung, Bandung, Indonesia
| | - Gerardus W. Frederix
- Julius Centre for Health Sciences and Primary Care, University Medical Centre, Utrecht, The Netherlands
| | - Bachti Alisjahbana
- TB-HIV Research Centre, Medical Faculty, Padjadjaran University, Hasan Sadikin Hospital, Bandung, Indonesia
| | - Olaf Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Anke M. Hövels
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- * E-mail:
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Erkose Genc G, Satana D, Yildirim E, Erturan Z, Yegenoglu Y, Uzun M. Evaluation of FluoroType MTB for direct detection of Mycobacterium tuberculosis complex and GenoType MTBDRplus for determining rifampicin and isoniazid resistance. BIOTECHNOL BIOTEC EQ 2018. [DOI: 10.1080/13102818.2018.1466662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
- Gonca Erkose Genc
- Department of Medical Microbiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Dilek Satana
- Department of Medical Microbiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Esra Yildirim
- Department of Food Engineering, Faculty of Engineering and Natural Sciences, Istanbul Sabahattin Zaim University, Istanbul, Turkey
| | - Zayre Erturan
- Department of Medical Microbiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Yildiz Yegenoglu
- Department of Medical Microbiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Meltem Uzun
- Department of Medical Microbiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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36
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Broda A, Nikolayevskyy V, Casali N, Khan H, Bowker R, Blackwell G, Patel B, Hume J, Hussain W, Drobniewski F. Experimental platform utilising melting curve technology for detection of mutations in Mycobacterium tuberculosis isolates. Eur J Clin Microbiol Infect Dis 2018; 37:1273-1279. [PMID: 29675789 PMCID: PMC6015100 DOI: 10.1007/s10096-018-3246-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/28/2018] [Indexed: 11/26/2022]
Abstract
Tuberculosis (TB) remains one of the most deadly infections with approximately a quarter of cases not being identified and/or treated mainly due to a lack of resources. Rapid detection of TB or drug-resistant TB enables timely adequate treatment and is a cornerstone of effective TB management. We evaluated the analytical performance of a single-tube assay for multidrug-resistant TB (MDR-TB) on an experimental platform utilising RT-PCR and melting curve analysis that could potentially be operated as a point-of-care (PoC) test in resource-constrained settings with a high burden of TB. Firstly, we developed and evaluated the prototype MDR-TB assay using specimens extracted from well-characterised TB isolates with a variety of distinct rifampicin and isoniazid resistance conferring mutations and nontuberculous Mycobacteria (NTM) strains. Secondly, we validated the experimental platform using 98 clinical sputum samples from pulmonary TB patients collected in high MDR-TB settings. The sensitivity of the platform for TB detection in clinical specimens was 75% for smear-negative and 92.6% for smear-positive sputum samples. The sensitivity of detection for rifampicin and isoniazid resistance was 88.9 and 96.0% and specificity was 87.5 and 100%, respectively. Observed limitations in sensitivity and specificity could be resolved by adjusting the sample preparation methodology and melting curve recognition algorithm. Overall technology could be considered a promising PoC methodology especially in resource-constrained settings based on its combined accuracy, convenience, simplicity, speed, and cost characteristics.
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Affiliation(s)
- Agnieszka Broda
- Infectious Diseases, Department of Medicine, Imperial College London, London, UK
| | - Vlad Nikolayevskyy
- Infectious Diseases, Department of Medicine, Imperial College London, London, UK
| | - Nicki Casali
- Infectious Diseases, Department of Medicine, Imperial College London, London, UK
| | - Huma Khan
- Enigma Diagnostics Ltd, Salisbury, UK
| | | | | | | | | | | | - Francis Drobniewski
- Infectious Diseases, Department of Medicine, Imperial College London, London, UK.
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37
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Mugwagwa T, Stagg HR, Abubakar I, White PJ. Comparing different technologies for active TB case-finding among the homeless: a transmission-dynamic modelling study. Sci Rep 2018; 8:1433. [PMID: 29362378 PMCID: PMC5780390 DOI: 10.1038/s41598-018-19757-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 12/13/2017] [Indexed: 01/06/2023] Open
Abstract
Homeless persons have elevated risk of tuberculosis (TB) and are under-served by conventional health services. Approaches to active case-finding (ACF) and treatment tailored to their needs are required. A transmission-dynamic model was developed to assess the effectiveness and efficiency of screening with mobile Chest X-ray, GeneXpert, or both. Effectiveness of ACF depends upon the prevalence of infection in the population (which determines screening 'yield'), patient willingness to wait for GeneXpert results, and treatment adherence. ACF is efficient when TB prevalence exceeds 78/100,000 and 46% of drug sensitive TB cases and 33% of multi-drug resistant TB cases complete treatment. This threshold increases to 92/100,000 if additional post-ACF enhanced case management (ECM) increases treatment completion to 85%. Generally, the most efficient option is one-step screening of all patients with GeneXpert, but if too many patients (>27% without ECM, >19% with ECM) are unwilling to wait the 90 minutes required then two-step screening using chest X-ray (which is rapid) followed by GeneXpert for confirmation of TB is the most efficient option. Targeted ACF and support services benefit health through early successful treatment and averting TB transmission and disease. The optimal strategy is setting-specific, requiring careful consideration of patients' needs regarding testing and treatment.
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Affiliation(s)
- Tendai Mugwagwa
- Modelling and Economics Unit, National Infection Service, Public Health England, London, UK.
- MRC Centre for Outbreak Analysis and Modelling, and NIHR Health Protection Research Unit in Modelling Methodology, Department of Infectious Disease Epidemiology, Imperial College London, London, UK.
| | - Helen R Stagg
- Institute for Global Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Ibrahim Abubakar
- Institute for Global Health, Faculty of Population Health Sciences, University College London, London, UK
- Medical Directorate, Public Health England, London, UK
| | - Peter J White
- Modelling and Economics Unit, National Infection Service, Public Health England, London, UK
- MRC Centre for Outbreak Analysis and Modelling, and NIHR Health Protection Research Unit in Modelling Methodology, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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Lee SM, Kim KJ, Chang CL. Detection of Rifampicin Resistance in Mycobacterium tuberculosis by Using Middlebrook 7H9 Broth Medium with 2,3-Diphenyl-5-Thienyl-(2)-Tetrazolium Chloride. ANNALS OF CLINICAL MICROBIOLOGY 2018. [DOI: 10.5145/acm.2018.21.3.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Sun Min Lee
- Department of Laboratory Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Kyung Jun Kim
- Department of Laboratory Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Chulhun L. Chang
- Department of Laboratory Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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39
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Grebely J, Applegate TL, Cunningham P, Feld JJ. Hepatitis C point-of-care diagnostics: in search of a single visit diagnosis. Expert Rev Mol Diagn 2017; 17:1109-1115. [DOI: 10.1080/14737159.2017.1400385] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Jason Grebely
- Viral Hepatitis Clinical Research Program, The Kirby Institute, UNSW Sydney, Sydney, Australia
| | - Tanya L. Applegate
- Viral Hepatitis Clinical Research Program, The Kirby Institute, UNSW Sydney, Sydney, Australia
| | - Philip Cunningham
- St Vincent’s Centre for Applied Medical Research, Darlinghurst, Sydney, Australia
| | - Jordan J. Feld
- Toronto Centre for Liver Disease, Sandra Rotman Centre for Global Health, University of Toronto, Toronto, Canada
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Should all suspected tuberculosis cases in high income countries be tested with GeneXpert? Tuberculosis (Edinb) 2017; 110:112-120. [PMID: 29779766 DOI: 10.1016/j.tube.2017.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Revised: 10/14/2017] [Accepted: 10/17/2017] [Indexed: 11/24/2022]
Abstract
In countries with a low incidence of multidrug-resistant tuberculosis (MDR-TB), universal testing with GeneXpert might not be always cost-effective. This study provides hospital managers in low MDR-TB incidence countries with criteria on when decentralised universal GeneXpert testing would make sense. The alternatives taken into consideration include: universal microbiological culture and drug susceptibility testing (DST) only (comparator); as above but with concurrent centralized GeneXpert in a referral laboratory vs a decentralized GeneXpert system in every hospital to test smear-positive cases only; as above but testing all samples with GeneXpert regardless of smear status. The parameters were from the national TB statistics for England and from a systematic review. Decentralised GeneXpert to test any suspected TB case was the most cost-effective option when 6% or more TB patients belonged to the high-risk group, defined as previous TB diagnosis and or being born in countries with a high MDR-TB incidence. Hospital managers in England and other low MDR-TB incidence countries could use these findings to decide when to invest in GeneXpert or other molecular diagnostics with similar performance criteria for TB diagnostics.
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41
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Kitai I, Morris SK, Kordy F, Lam R. Diagnosis and management of pediatric tuberculosis in Canada. CMAJ 2017; 189:E11-E16. [PMID: 28246254 DOI: 10.1503/cmaj.151212] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Ian Kitai
- Division of Infectious Diseases (Kitai, Morris, Kordy, Lam); Centre for Global Child Health (Morris), Hospital for Sick Children; Department of Pediatrics (Kitai, Morris); Faculty of Nursing (Lam), University of Toronto, Toronto, Ont.
| | - Shaun K Morris
- Division of Infectious Diseases (Kitai, Morris, Kordy, Lam); Centre for Global Child Health (Morris), Hospital for Sick Children; Department of Pediatrics (Kitai, Morris); Faculty of Nursing (Lam), University of Toronto, Toronto, Ont
| | - Faisal Kordy
- Division of Infectious Diseases (Kitai, Morris, Kordy, Lam); Centre for Global Child Health (Morris), Hospital for Sick Children; Department of Pediatrics (Kitai, Morris); Faculty of Nursing (Lam), University of Toronto, Toronto, Ont
| | - Ray Lam
- Division of Infectious Diseases (Kitai, Morris, Kordy, Lam); Centre for Global Child Health (Morris), Hospital for Sick Children; Department of Pediatrics (Kitai, Morris); Faculty of Nursing (Lam), University of Toronto, Toronto, Ont
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42
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Evaluation of GenoType MTBDR plus by Use of Extracted DNA from Formalin-Fixed Paraffin-Embedded Specimens. J Clin Microbiol 2017; 55:3300-3302. [PMID: 28878006 DOI: 10.1128/jcm.01410-17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Chatterjee A, Nilgiriwala K, Saranath D, Rodrigues C, Mistry N. Whole genome sequencing of clinical strains of Mycobacterium tuberculosis from Mumbai, India: A potential tool for determining drug-resistance and strain lineage. Tuberculosis (Edinb) 2017; 107:63-72. [PMID: 29050774 DOI: 10.1016/j.tube.2017.08.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 08/04/2017] [Accepted: 08/07/2017] [Indexed: 12/22/2022]
Abstract
Amplification of drug resistance in Mycobacterium tuberculosis (M.tb) and its transmission are significant barriers in controlling tuberculosis (TB) globally. Diagnostic inaccuracies and delays impede appropriate drug administration, which exacerbates primary and secondary drug resistance. Increasing affordability of whole genome sequencing (WGS) and exhaustive cataloguing of drug resistance mutations is poised to revolutionise TB diagnostics and facilitate personalized drug therapy. However, application of WGS for diagnostics in high endemic areas is yet to be demonstrated. We report WGS of 74 clinical TB isolates from Mumbai, India, characterising genotypic drug resistance to first- and second-line anti-TB drugs. A concordance analysis between phenotypic and genotypic drug susceptibility of a subset of 29 isolates and the sensitivity of resistance prediction to the 4 drugs was calculated, viz. isoniazid-100%, rifampicin-100%, ethambutol-100% and streptomycin-85%. The whole genome based phylogeny showed almost equal proportion of East Asian (27/74) and Central Asian (25/74) strains. Interestingly we also found a clonal group of 9 isolates, of which 7 patients were found to be from the same geographical location and accessed the same health post. This provides the first evidence of epidemiological linkage for tracking TB transmission in India, an approach which has the potential to significantly improve chances of End-TB goals. Finally, the use of Mykrobe Predictor, as a standalone drug resistance and strain typing tool, requiring just few minutes to analyse raw WGS data into tabulated results, implies the rapid clinical applicability of WGS based TB diagnosis.
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Affiliation(s)
- Anirvan Chatterjee
- The Foundation for Medical Research, 84-A, R. G. Thadani Marg, Worli, Mumbai 400 018, India
| | - Kayzad Nilgiriwala
- The Foundation for Medical Research, 84-A, R. G. Thadani Marg, Worli, Mumbai 400 018, India
| | - Dhananjaya Saranath
- The Foundation for Medical Research, 84-A, R. G. Thadani Marg, Worli, Mumbai 400 018, India; Sunandan Divatia School of Science, NMIMS (deemed-to-be) University, V. L. Mehta Road, Mumbai 400 056, India
| | - Camilla Rodrigues
- P. D. Hinduja Hospital, Veer Savarkar Marg, Mahim, Mumbai 400 016, India
| | - Nerges Mistry
- The Foundation for Medical Research, 84-A, R. G. Thadani Marg, Worli, Mumbai 400 018, India.
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Current Nucleic Acid Extraction Methods and Their Implications to Point-of-Care Diagnostics. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9306564. [PMID: 28785592 PMCID: PMC5529626 DOI: 10.1155/2017/9306564] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 06/05/2017] [Indexed: 12/12/2022]
Abstract
Nucleic acid extraction (NAE) plays a vital role in molecular biology as the primary step for many downstream applications. Many modifications have been introduced to the original 1869 method. Modern processes are categorized into chemical or mechanical, each with peculiarities that influence their use, especially in point-of-care diagnostics (POC-Dx). POC-Dx is a new approach aiming to replace sophisticated analytical machinery with microanalytical systems, able to be used near the patient, at the point of care or point of need. Although notable efforts have been made, a simple and effective extraction method is still a major challenge for widespread use of POC-Dx. In this review, we dissected the working principle of each of the most common NAE methods, overviewing their advantages and disadvantages, as well their potential for integration in POC-Dx systems. At present, it seems difficult, if not impossible, to establish a procedure which can be universally applied to POC-Dx. We also discuss the effects of the NAE chemicals upon the main plastic polymers used to mass produce POC-Dx systems. We end our review discussing the limitations and challenges that should guide the quest for an efficient extraction method that can be integrated in a POC-Dx system.
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Wikman-Jorgensen PE, Llenas-García J, Pérez-Porcuna TM, Hobbins M, Ehmer J, Mussa MA, Ascaso C. Microscopic observation drug-susceptibility assay vs. Xpert ® MTB/RIF for the diagnosis of tuberculosis in a rural African setting: a cost-utility analysis. Trop Med Int Health 2017; 22:734-743. [PMID: 28380276 DOI: 10.1111/tmi.12879] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the cost-utility of microscopic observation drug-susceptibility assay (MODS) and Xpert® MTB/RIF implementation for tuberculosis (TB) diagnosis in rural northern Mozambique. METHODS Stochastic transmission compartmental TB model from the healthcare provider perspective with parameter input from direct measurements, systematic literature reviews and expert opinion. MODS and Xpert® MTB/RIF were evaluated as replacement test of smear microscopy (SM) or as an add-on test after a negative SM. Costs were calculated in 2013 USD, effects in disability-adjusted life years (DALY). Willingness to pay threshold (WPT) was established at once the per capita Gross National Income of Mozambique. RESULTS MODS as an add-on test to negative SM produced an incremental cost-effectiveness ratio (ICER) of 5647.89USD/DALY averted. MODS as a substitute for SM yielded an ICER of 5374.58USD/DALY averted. Xpert® MTB/RIF as an add-on test to negative SM yielded ICER of 345.71USD/DALY averted. Xpert® MTB/RIF as a substitute for SM obtained an ICER of 122.13USD/DALY averted. TB prevalence and risk of infection were the main factors impacting MODS and Xpert® MTB/RIF ICER in the one-way sensitivity analysis. In the probabilistic sensitivity analysis, Xpert® MTB/RIF was most likely to have an ICER below the WPT, whereas MODS was not. CONCLUSION Our cost-utility analysis favours the implementation of Xpert® MTB/RIF as a replacement of SM for all TB suspects in this rural high TB/HIV prevalence African setting.
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Affiliation(s)
- Philip E Wikman-Jorgensen
- Department of Public Health, University of Barcelona, Barcelona, Spain.,SolidarMed Mozambique, Ancuabe, Mozambique
| | - Jara Llenas-García
- SolidarMed Mozambique, Ancuabe, Mozambique.,Infectious Diseases Unit, Hospital General Universitario de Elche, Alicante, Spain
| | - Tomàs M Pérez-Porcuna
- Department of Public Health, University of Barcelona, Barcelona, Spain.,Research Unit, Paediatrics Department, CAP Valldoreix, Mutua Terrassa Foundation, Mutua Terrassa University Hospital, Terrassa, Catalunya, Spain
| | | | | | - Manuel A Mussa
- Provincial Health Directorate, Operational Research Nucleus of Pemba, Pemba, Mozambique
| | - Carlos Ascaso
- Department of Public Health, University of Barcelona, Barcelona, Spain
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Shinkins B, Yang Y, Abel L, Fanshawe TR. Evidence synthesis to inform model-based cost-effectiveness evaluations of diagnostic tests: a methodological review of health technology assessments. BMC Med Res Methodol 2017; 17:56. [PMID: 28410588 PMCID: PMC5391551 DOI: 10.1186/s12874-017-0331-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 03/27/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Evaluations of diagnostic tests are challenging because of the indirect nature of their impact on patient outcomes. Model-based health economic evaluations of tests allow different types of evidence from various sources to be incorporated and enable cost-effectiveness estimates to be made beyond the duration of available study data. To parameterize a health-economic model fully, all the ways a test impacts on patient health must be quantified, including but not limited to diagnostic test accuracy. METHODS We assessed all UK NIHR HTA reports published May 2009-July 2015. Reports were included if they evaluated a diagnostic test, included a model-based health economic evaluation and included a systematic review and meta-analysis of test accuracy. From each eligible report we extracted information on the following topics: 1) what evidence aside from test accuracy was searched for and synthesised, 2) which methods were used to synthesise test accuracy evidence and how did the results inform the economic model, 3) how/whether threshold effects were explored, 4) how the potential dependency between multiple tests in a pathway was accounted for, and 5) for evaluations of tests targeted at the primary care setting, how evidence from differing healthcare settings was incorporated. RESULTS The bivariate or HSROC model was implemented in 20/22 reports that met all inclusion criteria. Test accuracy data for health economic modelling was obtained from meta-analyses completely in four reports, partially in fourteen reports and not at all in four reports. Only 2/7 reports that used a quantitative test gave clear threshold recommendations. All 22 reports explored the effect of uncertainty in accuracy parameters but most of those that used multiple tests did not allow for dependence between test results. 7/22 tests were potentially suitable for primary care but the majority found limited evidence on test accuracy in primary care settings. CONCLUSIONS The uptake of appropriate meta-analysis methods for synthesising evidence on diagnostic test accuracy in UK NIHR HTAs has improved in recent years. Future research should focus on other evidence requirements for cost-effectiveness assessment, threshold effects for quantitative tests and the impact of multiple diagnostic tests.
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Affiliation(s)
- Bethany Shinkins
- Test Evaluation Group, Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Worsely Building, Clarendon Way, Leeds, LS2 9LJ, UK.
| | - Yaling Yang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Lucy Abel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Thomas R Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
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Huaman MA, Brawley R, Ashkin D. Multidrug-resistant tuberculosis in transplant recipients: Case report and review of the literature. Transpl Infect Dis 2017; 19. [DOI: 10.1111/tid.12672] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 09/27/2016] [Accepted: 10/23/2016] [Indexed: 12/17/2022]
Affiliation(s)
- Moises A. Huaman
- Division of Infectious Diseases; University of Kentucky College of Medicine; Lexington KY USA
| | | | - David Ashkin
- Southeastern National Tuberculosis Center; Gainesville FL USA
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Shrivastava K, Garima K, Narang A, Bhattacharyya K, Vishnoi E, Singh RK, Chaudhry A, Prasad R, Bose M, Varma-Basil M. Rv1458c: a new diagnostic marker for identification of Mycobacterium tuberculosis complex in a novel duplex PCR assay. J Med Microbiol 2017; 66:371-376. [PMID: 28126044 DOI: 10.1099/jmm.0.000440] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Kamal Shrivastava
- Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Kushal Garima
- Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Anshika Narang
- Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Kausik Bhattacharyya
- Dr B R Ambedkar Centre for Biomedical Research (ACBR), University of Delhi, Delhi, India
| | - Ekta Vishnoi
- Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Roshan Kumar Singh
- Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Anil Chaudhry
- Department of Pulmonary Medicine, Rajan Babu Institute of Pulmonary Medicine and Tuberculosis, Delhi, India
| | - Rajendra Prasad
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Mridula Bose
- Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Mandira Varma-Basil
- Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
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Liyoyo AA, Heysell SK, Kisonga RM, Lyimo JJ, Mleoh LJ, Mutayoba BK, Lekule IA, Mmbaga BT, Kibiki GS, Mpagama SG. Gridlock from Diagnosis to Treatment of Multidrug-Resistant Tuberculosis (MDR-TB) in Tanzania: Illuminating Potential Factors for Possible Intervention. East Afr Health Res J 2017; 1:31-39. [PMID: 34308156 PMCID: PMC8279266 DOI: 10.24248/eahrj-d-16-00330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 02/01/2017] [Indexed: 11/20/2022] Open
Abstract
Settings Kibong'oto Infectious Diseases Hospital, Kilimanjaro, Tanzania. Objective Characterise multidrug-resistant tuberculosis (MDR-TB)-treated cases during the scaling up of molecular diagnostics using Xpert MTB/RIF and GenoType MTBDRplus. Design Retrospective cohort study. Results A total of 223 MDR-TB patients were referred to the Kibong'oto Infectious Disease Hospital from January 2013 through December 2014. Four cities-Dar es Salaam, Mbeya, Mwanza, and Tanga-contributed 144 (65%) of referrals. Of the total referred patients, HIV coinfection was found in 92 (41%) and 180 (81%) had history of previous TB treatment. Molecular drug susceptibility testing (DST) contributed 201 (91%) of referrals and resulted in a shorter time from diagnosis to start of treatment, 30 days (95% confidence interval [CI], 26-37), compared to conventional phenotypic DST, 212 days (95% CI, 151-272; P<.001). Molecular DST found higher proportions of MDR-TB children and people living with HIV without prior treatment, 5 (12%) and 24 (56%), respectively, compared to those with previous treatment for TB, 4 (2%) and 68 (38%), respectively. The median CD4 count correspondingly was 131 cells/μl (IQR, 109-131) and 200 cells/μl (IQR, 94-337) for MDR-TB diagnosed by phenotypic and molecular diagnostics (P=.70). Despite the more rapid time to treatment initiation among patients diagnosed by molecular DST, treatment outcomes, including time to sputum culture conversion, did not differ compared to those diagnosed with conventional phenotypic DST. Regardless of the method of diagnosis, MDR-TB/HIV coinfected patients who died had lower CD4 counts (mean 86 ± 87 cells/μl) than survivors (mean 274 ± 224 cells/μl; P=.02). Conclusion Molecular diagnostics appear to speedup the time to treatment initiation, but may not improve other treatment outcomes.
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Affiliation(s)
- Alphonce A Liyoyo
- Kilimanjaro Christian Medical University College, Moshi, Tanzania.,Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Scott K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | | | - Johnson J Lyimo
- National TB and Leprosy Programme, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | - Liberate J Mleoh
- National TB and Leprosy Programme, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | - Beatrice K Mutayoba
- National TB and Leprosy Programme, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | - Isaack A Lekule
- Kibong'oto Infectious Disease Hospital, Kilimanjaro, Tanzania
| | - Blandina T Mmbaga
- Kilimanjaro Christian Medical University College, Moshi, Tanzania.,Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Gibson S Kibiki
- Kilimanjaro Christian Medical University College, Moshi, Tanzania.,Kilimanjaro Clinical Research Institute, Moshi, Tanzania.,East African Health Research Commission, Bujumbura, Burundi
| | - Stellah G Mpagama
- Kilimanjaro Christian Medical University College, Moshi, Tanzania.,Kibong'oto Infectious Disease Hospital, Kilimanjaro, Tanzania
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Evolution of Phenotypic and Molecular Drug Susceptibility Testing. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 1019:221-246. [PMID: 29116638 DOI: 10.1007/978-3-319-64371-7_12] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Drug Resistant Tuberculosis (DRTB) is an emerging problem world-wide. In order to control the disease and decrease the number of cases overtime a prompt diagnosis followed by an appropriate treatment should be provided to patients. Phenotypic DST based on liquid automated culture has greatly reduced the time needed to generate reliable data but has the drawback to be expensive and prone to contamination in the absence of appropriate infrastructures. In the past 10 years molecular biology tools have been developed. Those tools target the main mutations responsible for DRTB and are now globally accessible in term of cost and infrastructures needed for the implementation. The dissemination of the Xpert MTB/rif has radically increased the capacity to perform the detection of rifampicin resistant TB cases. One of the main challenges for the large scale implementation of molecular based tests is the emergence of conflicting results between phenotypic and genotypic tests. This mines the confidence of clinicians in the molecular tests and delays the initiation of an appropriate treatment. A new technique is revolutionizing the genotypic approach to DST: the WGS by Next-Generation Sequencing technologies. This methodology promises to become the solution for a rapid access to universal DST, able indeed to overcome the limitations of the current phenotypic and genotypic assays. Today the use of the generated information is still challenging in decentralized facilities due to the lack of automation for sample processing and standardization in the analysis.The growing knowledge of the molecular mechanisms at the basis of drug resistance and the introduction of high-performing user-friendly tools at peripheral level should allow the very much needed accurate diagnosis of DRTB in the near future.
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