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Gaensbauer JT, Dash N, Verma S, Hall DJ, Adler-Shohet FC, Li G, Lee G, Dinnes L, Wendorf K. Multidrug-resistant tuberculosis in children: A practical update on epidemiology, diagnosis, treatment and prevention. J Clin Tuberc Other Mycobact Dis 2024; 36:100449. [PMID: 38757115 PMCID: PMC11096739 DOI: 10.1016/j.jctube.2024.100449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024] Open
Abstract
Pediatric multidrug-resistant tuberculosis (MDR-TB) remains a significant global problem, and there are numerous barriers preventing children with MDR-TB from being identified, confirmed with microbiologic tests, and treated with a safe, practical, and effective regimen. However, several recent advances in diagnostics and treatment regimens have the promise to improve outcomes for children with MDR-TB. We introduce this review with two cases that exemplify both the challenges in management of MDR-TB in children, but also the potential to achieve a positive outcome. More than 30,000 cases of MDR-TB per year are believed to occur in children but less than 5% are confirmed microbiologically, contributing to poorer outcomes and excess mortality. Rapid molecular-based testing that provides information on rifampin susceptibility is increasingly globally available and recommended for all children suspected of TB disease--but remains limited by challenges obtaining appropriate samples and the paucibacillary nature of most pediatric TB. More complex assays allowing better characterization of drug-resistant isolates are emerging. For children diagnosed with MDR-TB, treatment regimens have traditionally been long and utilize multiple drugs associated with significant side effects, particularly injectable agents. Several new or repurposed drugs including bedaquiline, delamanid, clofazimine and linezolid now allow most treatment regimens to be shorter and all-oral. Yet data to support short, all-oral, novel regimens for young children containing pretomanid remain insufficient at present, and there is a compelling need to conduct pediatric trials of promising therapeutics and MDR-TB treatment regimens.
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Affiliation(s)
- James T. Gaensbauer
- Mayo Clinic Center for Tuberculosis, Mayo Clinic, Rochester, MN, USA
- Division of Pediatric Infectious Diseases, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nabaneeta Dash
- Department of Telemedicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Verma
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - DJ Hall
- Division of Pediatric Hospital Medicine, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Felice C. Adler-Shohet
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Guyu Li
- Division of Pediatric Infectious Diseases, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Grace Lee
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Laura Dinnes
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Kristen Wendorf
- Department of Pediatrics, University of California San Francisco Benioff Children’s Hospital, Oakland, CA, USA
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Noor AM, Ghazali SM, Bakar ZA, Ruzan IN. Diagnostic performance of Xpert MTB/RIF ultra in detecting Mycobacterium tuberculosis and Rifampicin Resistance in AFB Smear-negative Pulmonary and Extrapulmonary Tuberculosis samples in Malaysia. Diagn Microbiol Infect Dis 2024; 109:116230. [PMID: 38507965 DOI: 10.1016/j.diagmicrobio.2024.116230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 01/19/2024] [Accepted: 02/21/2024] [Indexed: 03/22/2024]
Abstract
Rapid and highly accurate diagnostic tools are critically needed to diagnose Mycobacterium tuberculosis and rifampicin resistance in AFB smear-negative samples. In this study, we evaluated the diagnostic performance of Xpert MTB/RIF Ultra (Ultra) as a rapid test to diagnose tuberculosis in smear-negative cases in Malaysia. A retrospective study of 1960 smear-negative pulmonary and extrapulmonary samples obtained from patients was conducted. Culture was used as the reference standard for the study. The overall sensitivity and specificity of Ultra on the tested samples were 88.7 % and 77.2 %, respectively, while the PPV was 32.3 % and the NPV was 98.2 %. Ultra showed slightly higher sensitivity in pulmonary (89.9 %) compared to extrapulmonary samples (86.1 %). The overall accuracy of Ultra was 78.5 % (kappa=0.37; 95 %CI: 0.32,0.42). Ultra showed good diagnostic accuracy for detecting MTB and rifampicin resistance in various AFB smear-negative samples. Ultra also had excellent capability in rifampicin resistance detection.
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Affiliation(s)
- Azura Mohd Noor
- Infectious Disease Research Center, Institute for Medical Research, National Institutes of Health, Ministry of Health, Malaysia 40170, Setia Alam, Shah Alam, Selangor, Malaysia.
| | - Sumarni Mohd Ghazali
- Biomedical Epidemiology Unit, Special Resource Center, Institute for Medical Research, National Institutes of Health, Ministry of Health, Malaysia 40170, Setia Alam, Shah Alam, Selangor, Malaysia
| | - Zamzurina Abu Bakar
- Institute of Respiratory Medicine, Jalan Pahang 50590, Kuala Lumpur, Malaysia
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Diallo AB, Edem VF, Fiogbe A, Osman KA, Tolofoudie M, Somboro A, Diarra B, Ogunbosi B, Abok I, Ebonyi AO, Goka B, Affolabi D, Oladokun R, Kehinde AO, Mohammed N, Togun T. Diagnostic accuracy of Xpert MTB/RIF Ultra for childhood tuberculosis in West Africa - a multicenter pragmatic study. Int J Infect Dis 2024; 140:86-91. [PMID: 38244884 DOI: 10.1016/j.ijid.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 01/22/2024] Open
Abstract
OBJECTIVE To evaluate the performance of Xpert Mycobacterium Tuberculosis/rifampicin (MTB/RIF) Ultra (Ultra) for diagnosis of childhood tuberculosis (TB) within public health systems. METHODS In this cross-sectional study, children aged <15 years with presumptive pulmonary TB were consecutively recruited and evaluated for TB at tertiary-level hospitals in Benin, Mali, and Ghana. Bivariate random-effects models were used to determine the pooled sensitivity and specificity of Ultra against culture. We also estimated its diagnostic yield against a composite microbiological reference standard (cMRS) of positive culture or Ultra. RESULTS Overall, 193 children were included in the analyses with a median (interquartile range) age of 4.0 (1.1-9.2) years, 88 (45.6%) were female, and 36 (18.7%) were HIV-positive. Thirty-one (16.1%) children had confirmed TB, 39 (20.2%) had unconfirmed TB, and 123 (63.7%) had unlikely TB. The pooled sensitivity and specificity of Ultra verified by culture were 55.0% (95% confidence interval [CI]: 28.0-79.0%) and 95.0% (95% CI: 88.0-98.0%), respectively. Against the cMRS, the diagnostic yield of Ultra and culture were 67.7% (95% CI: 48.6-83.3%) and 70.9% (95% CI: 51.9-85.8%), respectively. CONCLUSION Ultra has suboptimal sensitivity in children with TB that were investigated under routine conditions in tertiary-level hospitals in three West African countries.
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Affiliation(s)
- Awa Ba Diallo
- Department of Biological Sciences, Faculty of Pharmacy, Cheikh Anta Diop University, Dakar, Senegal
| | - Victory F Edem
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Atlantic Road, Fajara, The Gambia; Department of Immunology, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
| | - Arnauld Fiogbe
- National Teaching Hospital for Tuberculosis and Respiratory Diseases, Cotonou, Republic of Benin; National Tuberculosis Program, Republic of Benin
| | - Kwabena A Osman
- Department of Paediatrics and Child Health, Korle Bu Teaching Hospital and University of Ghana Medical School, Accra, Ghana
| | - Mohamed Tolofoudie
- University Clinical Research Centre-SEREFO Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Amadou Somboro
- University Clinical Research Centre-SEREFO Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Bassirou Diarra
- University Clinical Research Centre-SEREFO Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Babatunde Ogunbosi
- Department of Paediatrics, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
| | - Ibrahim Abok
- Department of Paediatrics, Jos University Teaching Hospital and University of Jos, Plateau State, Nigeria
| | - Augustine O Ebonyi
- Department of Paediatrics, Jos University Teaching Hospital and University of Jos, Plateau State, Nigeria
| | - Bamenla Goka
- Department of Paediatrics and Child Health, Korle Bu Teaching Hospital and University of Ghana Medical School, Accra, Ghana
| | - Dissou Affolabi
- National Teaching Hospital for Tuberculosis and Respiratory Diseases, Cotonou, Republic of Benin; National Tuberculosis Program, Republic of Benin
| | - Regina Oladokun
- Department of Paediatrics, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
| | - Aderemi O Kehinde
- Department of Medical Microbiology and Parasitology, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
| | - Nuredin Mohammed
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Atlantic Road, Fajara, The Gambia
| | - Toyin Togun
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Atlantic Road, Fajara, The Gambia; Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom; TB Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Li Z, Wang B, Du B, Sun Q, Wang D, Wei R, Li C, Zhu C, Jia H, Xing A, Zhang Z, Pan L, Hou D. The incremental value of Mycobacterium tuberculosis trace nucleic acid detection in CT-guided percutaneous biopsy needle rinse solutions for the diagnosis of tuberculosis. Front Microbiol 2024; 15:1335526. [PMID: 38389532 PMCID: PMC10882560 DOI: 10.3389/fmicb.2024.1335526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/29/2024] [Indexed: 02/24/2024] Open
Abstract
Introduction Tuberculosis (TB) diagnosis still faces challenges with high proportion of bacteriologic test negative incidences worldwide. We assessed the diagnostic value of digital PCR (dPCR) analysis of ultramicro Mycobacterium tuberculosis (M.tb) nucleic acid in CT-guided percutaneous biopsy needle rinse solution (BNRS) for TB. Methods BNRS specimens were consecutively collected and total DNA was purified. The concentrations of M.tb-specific IS6110 and IS1081 were quantified using droplet dPCR. The diagnostic performances of BNRS-dPCR and its sensitivity in comparison with conventional tests were analyzed. Results A total of 106 patients were enrolled, 63 of whom were TB (48 definite and 15 clinically suspected TB) and 43 were non-TB. The sensitivity of BNRS IS6110 OR IS1081-dPCR for total, confirmed and clinically suspected TB was 66.7%, 68.8% and 60.0%, respectively, with a specificity of 97.7%. Its sensitivity was higher than that of conventional etiological tests, including smear microscopy, mycobacterial culture and Xpert using sputum and BALF samples. The positive detection rate in TB patients increased from 39.3% for biopsy AFB test alone to 73.2% when combined with BNRS-dPCR, and from 71.4% for biopsy M.tb molecular detection alone to 85.7% when combined with BNRS-dPCR. Conclusion Our results preliminarily indicated that BNRS IS6110 OR IS1081-dPCR is a feasible etiological test, which has the potential to be used as a supplementary method to augment the diagnostic yield of biopsy and improve TB diagnosis.
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Affiliation(s)
- Zihui Li
- Laboratory of Molecular Biology, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Bing Wang
- Department of Radiology, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Boping Du
- Laboratory of Molecular Biology, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Qi Sun
- Laboratory of Molecular Biology, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Dongpo Wang
- Department of Radiology, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Rongrong Wei
- Laboratory of Molecular Biology, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Chenghai Li
- Department of Radiology, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Chuanzhi Zhu
- Laboratory of Molecular Biology, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Hongyan Jia
- Laboratory of Molecular Biology, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Aiying Xing
- Laboratory of Molecular Biology, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Zongde Zhang
- Laboratory of Molecular Biology, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Liping Pan
- Laboratory of Molecular Biology, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Dailun Hou
- Department of Radiology, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
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Kaur H, Guglani V, Singhal L, Randev S, Kumar P, Gupta V. The new Xpert Mycobacterium tuberculosis/rifampicin (MTB/Rif) Ultra assay in comparison to Xpert MTB/Rif assay for diagnosis of tuberculosis in children and adolescents. J Trop Pediatr 2023; 70:fmad046. [PMID: 38116810 DOI: 10.1093/tropej/fmad046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
BACKGROUND Microbiological diagnosis of pediatric tuberculosis (TB) using conventional microbiological techniques has been challenging due to paucibacillary nature of the disease. Molecular methods using cartridge-based tests like Xpert, have immensely improved diagnosis. A novel next-generation cartridge test, Xpert Ultra, incorporates two additional molecular targets and claims to have much lower detection limit. We attempted to compare the two techniques in presumptive pediatric TB patients. OBJECTIVES The aim of this study was to compare the diagnostic performance of Xpert MTB/Rif Ultra with Xpert MTB/Rif for the detection of pediatric TB. STUDY DESIGN This is an observational comparative analytical study. METHODS Children under 15 years of age with presumptive TB were enrolled. Appropriate specimens were obtained (sputum, induced sputum or gastric aspirate for suspected pulmonary TB, cerebrospinal fluid for suspected tubercular meningitis and pleural fluid for suspected tubercular pleural effusion), subjected to smear microscopy, mycobacterial culture, Xpert and Xpert ultra tests and other appropriate diagnostic investigations. RESULTS Out of 130 enrolled patients, 70 were diagnosed with TB using a composite reference standard (CRS). The overall sensitivity of Xpert was 64.29% [95% confidence interval (CI) 51.93-75.93%] and that of Xpert Ultra was 80% (95% CI 68.73-88.61%) with 100% overall specificity for both. The sensitivity of Xpert and Xpert Ultra in pulmonary specimens (n = 112) was 66.67% and 79.37% and in extrapulmonary specimens (n = 18) was 42.86% and 85.71%, respectively. CONCLUSION Our study found Ultra to be more sensitive than Xpert for the detection of Mycobacterium tuberculosis in children. Our findings support the use of Xpert Ultra as initial rapid molecular diagnostic test in children under evaluation for TB.
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Affiliation(s)
- Harveen Kaur
- Department of Pediatrics, Government Medical College and Hospital, Chandigarh 160030, India
| | - Vishal Guglani
- Department of Pediatrics, Government Medical College and Hospital, Chandigarh 160030, India
| | - Lipika Singhal
- Department of Microbiology, Government Medical College and Hospital, Chandigarh 160030, India
| | - Shivani Randev
- Department of Pediatrics, Government Medical College and Hospital, Chandigarh 160030, India
| | - Pankaj Kumar
- Department of Pediatrics, Government Medical College and Hospital, Chandigarh 160030, India
| | - Varsha Gupta
- Department of Microbiology, Government Medical College and Hospital, Chandigarh 160030, India
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Bossù G, Autore G, Bernardi L, Buonsenso D, Migliori GB, Esposito S. Treatment options for children with multi-drug resistant tuberculosis. Expert Rev Clin Pharmacol 2023; 16:5-15. [PMID: 36378271 DOI: 10.1080/17512433.2023.2148653] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION According to the latest report from the World Health Organization (WHO), approximately 10.0 million people fell ill with tuberculosis (TB) in 2020, 12% of which were children aged under 15 years. There is very few experience on treatment of multi-drug resistant (MDR)-TB in pediatrics. AREAS COVERED The aim of this review is to analyze and summarize therapeutic options available for children experiencing MDR-TB. We also focused on management of MDR-TB prophylaxis. EXPERT OPINION The therapeutic management of children with MDR-TB or MDR-TB contacts is complicated by a lack of knowledge, and the fact that many potentially useful drugs are not registered for pediatric use and there are no formulations suitable for children in the first years of life. Furthermore, most of the available drugs are burdened by major adverse events that need to be taken into account, particularly in the case of prolonged therapy. A close follow-up with a standardized timeline and a comprehensive assessment of clinical, laboratory, microbiologic and radiologic data is extremely important in these patients. Due to the complexity of their management, pediatric patients with confirmed or suspected MDR-TB should always be referred to a specialized center.
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Affiliation(s)
- Gianluca Bossù
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Giovanni Autore
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Luca Bernardi
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Battista Migliori
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri - IRCCS, Tradate, Italia
| | - Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
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Wang C, Sun L, Li Q, Lu H. Xpert MTB/RIF Ultra in the auxiliary diagnosis of tuberculosis among people living with human immunodeficiency virus. Drug Discov Ther 2022; 16:305-308. [PMID: 36529510 DOI: 10.5582/ddt.2022.01082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Clinical diagnosis of tuberculosis (TB) in people living with the human immunodeficiency virus (HIV) poses a challenge. The Xpert MTB/RIF Ultra (Ultra) has displayed greater sensitivity at diagnosing tuberculosis and rifampicin resistance compared to the Xpert MTB/RIF (Xpert). However, whether Ultra is able to facilitate an auxiliary diagnosis of TB in patients with an HIV-TB co-infection remains unclear. Accordingly, the current study evaluated the use of Ultra in patients with an HIV-TB co-infection by summarizing relevant studies. The sensitivity and specificity of Ultra and Xpert at diagnosing patients with an HIV-TB co-infection have been summarized and compared. The performance of Ultra in diagnosing extrapulmonary tuberculosis was also summarized. Although a large-cohort, multi-center study needs to be conducted to assess Ultra's ability to detect TB in AIDS patients in the future, the current evidence supports the use of Ultra for the assessment of patients with an HIV-TB co-infection.
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Affiliation(s)
- Cheng Wang
- National Clinical Research Centre for Infectious Diseases, The Third People's Hospital of Shenzhen and The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China.,School of Public Health, Bengbu Medical College, Bengbu, Anhui, China
| | - Liqin Sun
- National Clinical Research Centre for Infectious Diseases, The Third People's Hospital of Shenzhen and The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Qian Li
- National Clinical Research Centre for Infectious Diseases, The Third People's Hospital of Shenzhen and The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Hongzhou Lu
- National Clinical Research Centre for Infectious Diseases, The Third People's Hospital of Shenzhen and The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
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Kay AW, Ness T, Verkuijl SE, Viney K, Brands A, Masini T, González Fernández L, Eisenhut M, Detjen AK, Mandalakas AM, Steingart KR, Takwoingi Y. Xpert MTB/RIF Ultra assay for tuberculosis disease and rifampicin resistance in children. Cochrane Database Syst Rev 2022; 9:CD013359. [PMID: 36065889 PMCID: PMC9446385 DOI: 10.1002/14651858.cd013359.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Every year, an estimated one million children and young adolescents become ill with tuberculosis, and around 226,000 of those children die. Xpert MTB/RIF Ultra (Xpert Ultra) is a molecular World Health Organization (WHO)-recommended rapid diagnostic test that simultaneously detects Mycobacterium tuberculosis complex and rifampicin resistance. We previously published a Cochrane Review 'Xpert MTB/RIF and Xpert MTB/RIF Ultra assays for tuberculosis disease and rifampicin resistance in children'. The current review updates evidence on the diagnostic accuracy of Xpert Ultra in children presumed to have tuberculosis disease. Parts of this review update informed the 2022 WHO updated guidance on management of tuberculosis in children and adolescents. OBJECTIVES To assess the diagnostic accuracy of Xpert Ultra for detecting: pulmonary tuberculosis, tuberculous meningitis, lymph node tuberculosis, and rifampicin resistance, in children with presumed tuberculosis. Secondary objectives To investigate potential sources of heterogeneity in accuracy estimates. For detection of tuberculosis, we considered age, comorbidity (HIV, severe pneumonia, and severe malnutrition), and specimen type as potential sources. To summarize the frequency of Xpert Ultra trace results. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, three other databases, and three trial registers without language restrictions to 9 March 2021. SELECTION CRITERIA Cross-sectional and cohort studies and randomized trials that evaluated Xpert Ultra in HIV-positive and HIV-negative children under 15 years of age. We included ongoing studies that helped us address the review objectives. We included studies evaluating sputum, gastric, stool, or nasopharyngeal specimens (pulmonary tuberculosis), cerebrospinal fluid (tuberculous meningitis), and fine needle aspirate or surgical biopsy tissue (lymph node tuberculosis). For detecting tuberculosis, reference standards were microbiological (culture) or composite reference standard; for stool, we also included Xpert Ultra performed on a routine respiratory specimen. For detecting rifampicin resistance, reference standards were drug susceptibility testing or MTBDRplus. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and, using QUADAS-2, assessed methodological quality judging risk of bias separately for each target condition and reference standard. For each target condition, we used the bivariate model to estimate summary sensitivity and specificity with 95% confidence intervals (CIs). We stratified all analyses by type of reference standard. We summarized the frequency of Xpert Ultra trace results; trace represents detection of a very low quantity of Mycobacterium tuberculosis DNA. We assessed certainty of evidence using GRADE. MAIN RESULTS We identified 14 studies (11 new studies since the previous review). For detection of pulmonary tuberculosis, 335 data sets (25,937 participants) were available for analysis. We did not identify any studies that evaluated Xpert Ultra accuracy for tuberculous meningitis or lymph node tuberculosis. Three studies evaluated Xpert Ultra for detection of rifampicin resistance. Ten studies (71%) took place in countries with a high tuberculosis burden based on WHO classification. Overall, risk of bias was low. Detection of pulmonary tuberculosis Sputum, 5 studies Xpert Ultra summary sensitivity verified by culture was 75.3% (95% CI 64.3 to 83.8; 127 participants; high-certainty evidence), and specificity was 97.1% (95% CI 94.7 to 98.5; 1054 participants; high-certainty evidence). Gastric aspirate, 7 studies Xpert Ultra summary sensitivity verified by culture was 70.4% (95% CI 53.9 to 82.9; 120 participants; moderate-certainty evidence), and specificity was 94.1% (95% CI 84.8 to 97.8; 870 participants; moderate-certainty evidence). Stool, 6 studies Xpert Ultra summary sensitivity verified by culture was 56.1% (95% CI 39.1 to 71.7; 200 participants; moderate-certainty evidence), and specificity was 98.0% (95% CI 93.3 to 99.4; 1232 participants; high certainty-evidence). Nasopharyngeal aspirate, 4 studies Xpert Ultra summary sensitivity verified by culture was 43.7% (95% CI 26.7 to 62.2; 46 participants; very low-certainty evidence), and specificity was 97.5% (95% CI 93.6 to 99.0; 489 participants; high-certainty evidence). Xpert Ultra sensitivity was lower against a composite than a culture reference standard for all specimen types other than nasopharyngeal aspirate, while specificity was similar against both reference standards. Interpretation of results In theory, for a population of 1000 children: • where 100 have pulmonary tuberculosis in sputum (by culture): - 101 would be Xpert Ultra-positive, and of these, 26 (26%) would not have pulmonary tuberculosis (false positive); and - 899 would be Xpert Ultra-negative, and of these, 25 (3%) would have tuberculosis (false negative). • where 100 have pulmonary tuberculosis in gastric aspirate (by culture): - 123 would be Xpert Ultra-positive, and of these, 53 (43%) would not have pulmonary tuberculosis (false positive); and - 877 would be Xpert Ultra-negative, and of these, 30 (3%) would have tuberculosis (false negative). • where 100 have pulmonary tuberculosis in stool (by culture): - 74 would be Xpert Ultra-positive, and of these, 18 (24%) would not have pulmonary tuberculosis (false positive); and - 926 would be Xpert Ultra-negative, and of these, 44 (5%) would have tuberculosis (false negative). • where 100 have pulmonary tuberculosis in nasopharyngeal aspirate (by culture): - 66 would be Xpert Ultra-positive, and of these, 22 (33%) would not have pulmonary tuberculosis (false positive); and - 934 would be Xpert Ultra-negative, and of these, 56 (6%) would have tuberculosis (false negative). Detection of rifampicin resistance Xpert Ultra sensitivity was 100% (3 studies, 3 participants; very low-certainty evidence), and specificity range was 97% to 100% (3 studies, 128 participants; low-certainty evidence). Trace results Xpert Ultra trace results, regarded as positive in children by WHO standards, were common. Xpert Ultra specificity remained high in children, despite the frequency of trace results. AUTHORS' CONCLUSIONS We found Xpert Ultra sensitivity to vary by specimen type, with sputum having the highest sensitivity, followed by gastric aspirate and stool. Nasopharyngeal aspirate had the lowest sensitivity. Xpert Ultra specificity was high against both microbiological and composite reference standards. However, the evidence base is still limited, and findings may be imprecise and vary by study setting. Although we found Xpert Ultra accurate for detection of rifampicin resistance, results were based on a very small number of studies that included only three children with rifampicin resistance. Therefore, findings should be interpreted with caution. Our findings provide support for the use of Xpert Ultra as an initial rapid molecular diagnostic in children being evaluated for tuberculosis.
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Affiliation(s)
- Alexander W Kay
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Tara Ness
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | | - Kerri Viney
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Annemieke Brands
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Tiziana Masini
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Lucia González Fernández
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Michael Eisenhut
- Paediatric Department, Luton & Dunstable University Hospital NHS Foundation Trust, Luton, UK
| | | | - Anna M Mandalakas
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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9
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Aguilera-Alonso D, Solís-García G, Noguera-Julian A, González-Martín J, Román Cobeña A, Baquero-Artigao F, Toro Rueda C, Rodríguez-Molino P, Bloise Sánchez I, Vallmanya T, Bernet-Sánchez A, Minguell Domingo L, Rubio A, Saavedra-Lozano J, Ruiz-Serrano MJ, Blázquez-Gamero D, López-Roa P, Gomez-Pastrana D, López Prieto MD, López Medina EM, Gil-Brusola A, Martín Nalda A, Soriano-Arandes A, Tórtola T, Falcon-Neyra L, González Galán V, Tebruegge M, Santiago-García B. Accuracy of Xpert Ultra for the diagnosis of paediatric tuberculosis in a low TB burden country: a prospective multicentre study. Thorax 2022; 77:1023-1029. [PMID: 36357344 DOI: 10.1136/thorax-2021-218378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 07/28/2022] [Indexed: 11/04/2022]
Abstract
IntroductionChildhood pulmonary tuberculosis (TB) remains a diagnostic challenge. This study aimed to evaluate the performance of Xpert Ultra for the diagnosis of pulmonary TB in children in a low TB prevalence setting.MethodsProspective, multicentre, diagnostic accuracy study. Children with clinical or radiological suspicion of pulmonary TB were recruited at 11 paediatric units in Spain. Up to three gastric or sputum specimens were taken on 3 consecutive days, and analysed by Xpert MTB/RIF, Xpert Ultra and culture in parallel.Results86 children were included (median age 4.9 years, IQR 2.0–10.0; 51.2% male). The final diagnosis was pulmonary TB in 75 patients (87.2%); 33 (44.0%) were microbiologically confirmed. A total of 219 specimens, comprising gastric aspirates (n=194; 88.6%) and sputum specimens (n=25; 11.4%), were analysed. Using culture as reference standard and comparing individual specimens, the sensitivity was 37.8% (14/37) for Xpert MTB/RIF and 81.1% (30/37) for Xpert Ultra (p<0.001); specificity was 98.4% (179/182) and 93.4% (170/182), respectively (p=0.02). In the per-patient analysis, considering positive results on any specimen, the sensitivity was 42.9% (9/21) for Xpert MTB/RIF and 81.0% for Xpert Ultra (17/21, p=0.01); specificity was 96.9% (63/65) and 87.7% (57/65, p=0.07), respectively.ConclusionsIn children with pulmonary TB in a low burden setting, Xpert Ultra has significantly higher sensitivity than the previous generation of Xpert assay and only marginally lower specificity. Therefore, in children undergoing evaluation for suspected pulmonary TB, Xpert Ultra should be used in preference to Xpert MTB/RIF whenever possible.
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10
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Sabi I, Olomi W, Nkereuwem E, Togun T, Gomez MP, Sylla M, Diarra B, Sanogo M, Sichone E, Mahiga H, Njeleka F, Ebonyi AO, Egere U, Ntinginya NE, Hoelscher M, Heinrich N, Kampmann B. Diagnosis of paediatric TB using Xpert ® MTB/RIF Ultra on fresh respiratory samples. Int J Tuberc Lung Dis 2022; 26:862-868. [PMID: 35996291 PMCID: PMC9423021 DOI: 10.5588/ijtld.22.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE: To evaluate the diagnostic accuracy of Xpert® MTB/RIF Ultra (Ultra) on fresh respiratory samples for the diagnosis of pulmonary TB (PTB) in children.METHODS: Between July 2017 and December 2019, children with presumed TB were prospectively enrolled at clinical sites in three African countries. Children were assessed using history, physical examination and chest X-ray. Sputum or gastric aspirate samples were analysed using Ultra and culture. The diagnostic accuracy of Ultra was calculated against culture as the reference standard.RESULTS: In total, 547children were included. The median age was 4.7 years, 77 (14.1%) were HIV infected and 77 (14.1%) had bacteriologically confirmed TB. Ultra detected an additional 20 cases in the group of children with negative culture results. The sensitivity of Ultra was 66.3% (95% CI 47-82), and the specificity was 95.4% (95% CI 89-99) when assessed against culture as the reference standard.CONCLUSION: Despite the improved performance of Ultra as compared to Xpert as was previously reported, its sensitivity remains sub-optimal for the detection of TB in children. Ultra detected additional 20 cases which otherwise could not have been detected by culture alone, suggesting that the latter is an imperfect reference standard.
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Affiliation(s)
- I Sabi
- National Institute for Medical Research, Mbeya Medical Research Center, Mbeya, Tanzania, Center for International Health, University Hospital, Ludwig Maximilian University (LMU) Munich, Germany
| | - W Olomi
- National Institute for Medical Research, Mbeya Medical Research Center, Mbeya, Tanzania
| | - E Nkereuwem
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - T Togun
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - M P Gomez
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - M Sylla
- Paediatrics Department, University Teaching Hospital Gabriel Toure, Bamako, Mali
| | - B Diarra
- University Clinical Research Centre, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - M Sanogo
- University Clinical Research Centre, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - E Sichone
- National Institute for Medical Research, Mbeya Medical Research Center, Mbeya, Tanzania
| | - H Mahiga
- National Institute for Medical Research, Mbeya Medical Research Center, Mbeya, Tanzania
| | - F Njeleka
- National Institute for Medical Research, Mbeya Medical Research Center, Mbeya, Tanzania
| | - A O Ebonyi
- Department of Paediatrics, Jos University Teaching Hospital, Jos, Nigeria
| | - U Egere
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - N E Ntinginya
- National Institute for Medical Research, Mbeya Medical Research Center, Mbeya, Tanzania
| | - M Hoelscher
- Center for International Health, University Hospital, Ludwig Maximilian University (LMU) Munich, Germany, German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany, Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU Munich, Germany
| | - N Heinrich
- Center for International Health, University Hospital, Ludwig Maximilian University (LMU) Munich, Germany, German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany, Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU Munich, Germany
| | - B Kampmann
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
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11
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Wang G, Huang M, Jing H, Jia J, Dong L, Zhao L, Wang F, Xue Y, Deng Y, Jiang G, Huang H. The Practical Value of Xpert MTB/RIF Ultra for Diagnosis of Pulmonary Tuberculosis in a High Tuberculosis Burden Setting: a Prospective Multicenter Diagnostic Accuracy Study. Microbiol Spectr 2022; 10:e0094922. [PMID: 35876568 PMCID: PMC9430854 DOI: 10.1128/spectrum.00949-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/01/2022] [Indexed: 12/03/2022] Open
Abstract
Due to the probability of decreased specificity, the practical value of performing the Xpert MTB/RIF Ultra (Xpert Ultra) assay over the Xpert assay for diagnosing pulmonary tuberculosis (TB) and rifampicin (RIF) resistance in a high TB burden setting was evaluated. Participants were recruited consecutively in three tertiary hospitals in China and allocated to the TB case detection and/or rifampicin (RIF) resistance detection group. Each sputum specimen was subjected to smear, MGIT960 liquid culture, and Xpert, and Xpert Ultra assay in parallel. Drug susceptibility testing was conducted for all recovered isolates in the RIF resistance detection group. In total, 1,079 patients were recruited to the case detection group and 450 to the RIF resistance detection group. Xpert Ultra had higher sensitivity than Xpert (92.26%, 322/349 versus 89.40%, 312/349; P = 0.006), whereas the most prominent increase was identified in the smear-negative patients (83.70% versus 78.52%; P = 0.039). The specificity of Xpert Ultra was slightly lower than that of Xpert (96.30%, 495/514 versus 98.25%, 505/514; P = 0.055). Reclassifying trace results as negative resulted in a 4.01% loss of sensitivity (from 92.26% to 88.25%) accompanied by a 1.37% gain in specificity (from 96.30% to 97.67%). Both the sensitivity (97.64% versus 99.21%, P = 0.313) and specificity (96.90% versus 97.21%, P = 0.816) of Xpert Ultra and Xpert for detection RIF resistance were comparable. In conclusion, Xpert Ultra could improve the diagnosis of smear-negative pulmonary TB in contrast to the Xpert assay. A high percentage of TB history did not significantly decrease the specificity of the test, which supports the potential role of Xpert Ultra as an initial diagnostic tool for TB. IMPORTANCE Xpert Ultra is more sensitive than Xpert, especially in smear-negative TB. A high percentage of TB history in the non-TB population did not significantly affect the reliability of the assay, which supports the potential role of Xpert Ultra as an initial diagnostic tool for TB.
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Affiliation(s)
- Guirong Wang
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, People’s Republic of China
| | - Mingxiang Huang
- Fuzhou Pulmonary Hospital of Fujian, Fuzhou, People’s Republic of China
| | - Hui Jing
- Katharine Hsu International Research Center of Human Infectious Diseases, Shandong Public Health Clinical Center, Jinan, Shandong, People’s Republic of China
| | - Junnan Jia
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, People’s Republic of China
| | - Lingling Dong
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, People’s Republic of China
| | - Liping Zhao
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, People’s Republic of China
| | - Fen Wang
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, People’s Republic of China
| | - Yi Xue
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, People’s Republic of China
| | - Yunfeng Deng
- Katharine Hsu International Research Center of Human Infectious Diseases, Shandong Public Health Clinical Center, Jinan, Shandong, People’s Republic of China
| | - Guanglu Jiang
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, People’s Republic of China
| | - Hairong Huang
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, People’s Republic of China
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12
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Nandlal L, Perumal R, Naidoo K. Rapid Molecular Assays for the Diagnosis of Drug-Resistant Tuberculosis. Infect Drug Resist 2022; 15:4971-4984. [PMID: 36060232 PMCID: PMC9438776 DOI: 10.2147/idr.s381643] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/20/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Louansha Nandlal
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), South African Medical Research Council (SAMRC)-CAPRISA-TB-HIV Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
| | - Rubeshan Perumal
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), South African Medical Research Council (SAMRC)-CAPRISA-TB-HIV Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
- Correspondence: Rubeshan Perumal, Centre for the AIDS Programme of Research in South Africa (CAPRISA), South African Medical Research Council (SAMRC)-CAPRISA-TB-HIV Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa, Email
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), South African Medical Research Council (SAMRC)-CAPRISA-TB-HIV Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
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13
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Abstract
Rapid detection of Mycobacterium tuberculosis complex and determination of drug resistance are essential for early diagnosis and treatment of tuberculosis (TB). Xpert MTB/RIF Ultra (Xpert Ultra), a molecular test that can simultaneously identify M. tuberculosis complex and resistance to rifampicin directly on clinical samples, is currently used. Xpert Ultra represents a helpful tool for rapid pulmonary TB diagnosis, especially in patients with paucibacillary infection. The aim of this review is to provide an overview of the diagnostic performance of Xpert Ultra in detection of extra-pulmonary tuberculosis.
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Affiliation(s)
- Laura Rindi
- Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia, Università di Pisa, Pisa, Italy
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14
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Sharma V, Singh A, Gaur M, Rawat D, Yadav A, Rajan, Kumar C, Varma-Basil M, Lohiya S, Khanna V, Khanna A, Chaudhry A, Singh Y, Misra R. Evaluating the efficacy of stool sample on Xpert MTB/RIF Ultra and its comparison with other sample types by meta-analysis for TB diagnostics. Eur J Clin Microbiol Infect Dis 2022; 41:893-906. [PMID: 35508741 DOI: 10.1007/s10096-022-04449-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/19/2022] [Indexed: 11/03/2022]
Abstract
Precise and timely detection of tuberculosis (TB) is crucial to reduce transmission. This study aims to assess the accuracy of Xpert MTB/RIF Ultra on stool samples and systematically review the performance of Xpert MTB/RIF Ultra with different sample types by meta-analysis. Stool samples of smear-negative pulmonary TB (PTB), cervical lymph node TB, and abdominal TB patients were tested on the Xpert MTB/RIF Ultra system. Meta-analysis was performed on a set of 44 studies. Data were grouped by sample type, and the pooled sensitivity and specificity of Xpert MTB/RIF Ultra were calculated. The sensitivity of Xpert MTB/RIF Ultra with stool samples was 100% for smear-negative PTB, 27.27% for cervical lymph node TB, and 50% for abdominal TB patients, with 100% specificity for all included TB groups. The summary estimate for all PTB samples showed 84.2% sensitivity and 94.5% specificity, and EPTB samples showed 88.6% sensitivity and 96.4% specificity. Among all sample types included in our meta-analysis, urine showed the best performance for EPTB diagnosis. This pilot study supports the use of stool as an alternative non-invasive sample on Xpert MTB/RIF Ultra for rapid testing, suitable for both PTB and EPTB diagnosis.
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Affiliation(s)
- Vishal Sharma
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Anoop Singh
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Mohita Gaur
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Deepti Rawat
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Anjali Yadav
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Rajan
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Chanchal Kumar
- Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, 110007, India
| | - Mandira Varma-Basil
- Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, 110007, India
| | - Sheelu Lohiya
- Chest Clinic, Lok Nayak Hospital, Delhi, 110002, India
| | - Vishal Khanna
- Chest Clinic, Lok Nayak Hospital, Delhi, 110002, India
| | - Ashwani Khanna
- State TB Officer & In-Charge, Chest Clinic, Lok Nayak Hospital, Delhi, 110002, India
| | - Anil Chaudhry
- Rajan Babu Institute of Pulmonary Medicine and Tuberculosis, Kingsway Camp, Delhi, 110009, India
| | - Yogendra Singh
- Department of Zoology, University of Delhi, Delhi, 110007, India.
| | - Richa Misra
- Department of Zoology, University of Delhi, Delhi, 110007, India. .,Department of Zoology, Sri Venkateswara College, University of Delhi, Delhi, 110021, India.
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15
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Signorino C, Votto M, De Filippo M, Marseglia GL, Galli L, Chiappini E. Diagnostic accuracy of Xpert ultra for childhood tuberculosis: A preliminary systematic review and meta-analysis. Pediatr Allergy Immunol 2022; 33 Suppl 27:80-82. [PMID: 35080295 PMCID: PMC9306500 DOI: 10.1111/pai.13637] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/28/2021] [Accepted: 08/06/2021] [Indexed: 01/07/2023]
Abstract
Diagnosis of childhood tuberculosis (TB) is challenging. Xpert MTB/RIF and the new version Xpert MTB/RIF Ultra (Ultra) are molecular tests currently used to rapidly identify the infection. We reviewed the literature for the accuracy of Ultra assay in the diagnosis of tuberculosis and rifampicin resistance in children. We conducted a full search in PubMed, Web of Science (WOS), Embase, and Scopus, up to April 2021. A bivariate random-effects model was used to determine the pooled sensitivity and specificity of Ultra, with a 95% confidence interval (CI), compared with culturing and the composite reference standard (CRS). In the ten included studies (2,427 participants), the pooled Ultra sensitivity and specificity, in diagnosing pulmonary tuberculosis (PTB), were 78% (95% CI, 73-82) and 92% (95% CI, 91-94), respectively, against culture. Since a high heterogeneity was found between studies, we created subgroups based on different samples and ages. Ultra-pooled sensitivity was consistently lower against CRS (95% CI, 35%, 32-38). Compared to Xpert MTB/RIF, Ultra sensitivity tended toward higher values (Ultra: 73%, 67%-78% vs. Xpert MTB/RIF: 66%, 60%-72%), but specificity was lower (Ultra: 95%, 94%-96% vs. Xpert MTB/RIF: 99%, 98%-99%). Ultra has improved the definitive diagnosis of PTB, particularly in subjects with paucibacillary TB, including children. The lower specificity could be due to the fact that culture is an imperfect reference standard. Further studies are needed to evaluate the accuracy of Ultra in the diagnosis of childhood TB.
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Affiliation(s)
- Claudia Signorino
- Post-graduate School of Pediatrics, Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Martina Votto
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Maria De Filippo
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Gian Luigi Marseglia
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Luisa Galli
- Division of Pediatric Infectious Disease, Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Elena Chiappini
- Division of Pediatric Infectious Disease, Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
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16
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Sun L, Liu Y, Fang M, Chen Y, Zhu Y, Xia C, Jia J, Quan S, Wang Y, Tian X, Shi Y, Duan L, Shi X, Liao Q, Wan C, Shen A. Use of Xpert MTB/RIF Ultra assay on stool and gastric aspirate samples to diagnose pulmonary tuberculosis in children in a high-tuberculosis burden but resource-limited area of China: Diagnosis of Childhood TB using Stool. Int J Infect Dis 2021; 114:236-243. [PMID: 34774781 DOI: 10.1016/j.ijid.2021.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/03/2021] [Accepted: 11/05/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES We analyzed the performance of Xpert MTB/RIF Ultra (Ultra) on stool and gastric aspirate (GA) samples for the diagnosis of pediatric pulmonary tuberculosis (TB) caused by Mycobacterium tuberculosis in a high burden area in China. METHODS Children with presumptive TB were enrolled in two hospitals in Sichuan Province (July 2019-Oct 2020). Because of the unavailable sputum for etiological tests, GA samples were aspirated and tested by bacterial culture, acid-fast bacillus microscopy and Ultra. Stool samples were tested simultaneously using Ultra and Xpert. RESULTS Finally, 141 children with active TB and 34 with non-TB respiratory tract infections were enrolled. Ultra-stool (60.3%, 85/141) and Ultra-GA (52.5%, 74/141) were similarly sensitive (P=0.187). Among the subset of 48 children with confirmed TB, Ultra testing was equally sensitive on stool and GA samples (85.4%, 41/48). The agreement between Ultra-stool and Ultra-GA was moderate in children with active TB (kappa value = 0.527). After integrating Ultra-GA and Ultra-stool outcomes, 70.9% (100/141) of the children were considered to have confirmed TB. The specificities of Ultra-stool and Ultra-GA were 97.1% (33/34) and 100% (34/34), respectively (P=0.314). CONCLUSIONS In children, stools can be used as alternative samples to GAs for Ultra tests. Stool- and GA-based Ultra are appropriate tests for bacteriological TB confirmation.
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Affiliation(s)
- Lin Sun
- Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics (Capital Medical University), Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yang Liu
- West China Second Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Min Fang
- The No. 1 People's Hospital of Liangshan Yizu Autonomous Prefecture, Liangshan, Sichuan, China
| | - Yu Chen
- Shenyang Tenth People's Hospital (Shenyang Chest Hospital), Shenyang, Liaoning, China
| | - Yu Zhu
- West China Second Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Cheng Xia
- Ganzi Tibetan Autonomous Prefecture People's Hospital, Ganzi, Sichuan, China
| | - Jihang Jia
- West China Second Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Shuting Quan
- Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics (Capital Medical University), Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yacui Wang
- Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics (Capital Medical University), Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xue Tian
- Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics (Capital Medical University), Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yan Shi
- The No. 1 People's Hospital of Liangshan Yizu Autonomous Prefecture, Liangshan, Sichuan, China
| | - Li Duan
- The No. 1 People's Hospital of Liangshan Yizu Autonomous Prefecture, Liangshan, Sichuan, China
| | - Xiaomei Shi
- The No. 1 People's Hospital of Liangshan Yizu Autonomous Prefecture, Liangshan, Sichuan, China
| | - Qiong Liao
- West China Second Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chaomin Wan
- West China Second Hospital, Sichuan University, Chengdu, Sichuan, China.
| | - Adong Shen
- Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics (Capital Medical University), Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, Henan, China.
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17
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Peng X, Liao Q, Fang M, Zhu Y, Shi Y, Quan S, Wang Y, Duan L, Shi X, Liu Y, Wang M, Wei Q, Zhou H, Wang Y, Wu X, Yao Y, Sun L, Shen A, Wan C. Detection of pulmonary tuberculosis in children using the Xpert MTB/RIF Ultra assay on sputum: a multicenter study. Eur J Clin Microbiol Infect Dis 2021; 41:235-243. [PMID: 34734347 DOI: 10.1007/s10096-021-04340-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/23/2021] [Indexed: 11/25/2022]
Abstract
Microbiological confirmation is rare in children with active tuberculosis; therefore, a more accurate test is needed to detect pulmonary tuberculosis in children. In this multicenter study, we evaluated the utility of the Xpert MTB/RIF Ultra (Ultra) on sputum, an assay recommended by the World Health Organization to test for childhood tuberculosis in high-burden settings. Children with symptoms suggestive of tuberculosis were enrolled at three hospitals in China and categorized as having active tuberculosis or nontuberculosis. The sensitivity and specificity of Ultra were 42.1% (48/114) and 99.0% (208/210), respectively. Using three MTB culture results as the reference, the sensitivity of Ultra in the subset of 38 children with culture-positive and 76 children with culture-negative was 68.4% (26/38) and 28.9% (22/76), respectively(p < 0.001). A single MTB culture combined with a single Ultra could detect 54 (54/114,47.4%) cases with active TB, while repeated MTB culture combined with a single Ultra detected 60 (60/114, 52.6%) cases with active TB(p = 0.427). Among 155 children (58 with TB and 97 with RTIs) simultaneously tested with the Ultra and Xpert MTB/RIF (Xpert), the sensitivity of the Xpert (24.1%, 14/58) was lower than that of the Ultra (41.4%, 24/58; p = 0.048). Eight children were found to have rifampin-resistant MTB strains. The Xpert MTB/RIF Ultra assay should be implemented to test for pulmonary tuberculosis in children to achieve higher confirmation rates.
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Affiliation(s)
- Xiaoshan Peng
- Department of Pediatrics Infectious Diseases, West China Second Hospital, Sichuan University, No.20, 3Rd Section of Renmin South Road, Chengdu, 610041, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, No.20, 3Rd Section of Renmin South Road, Chengdu, 610041, China
| | - Qiong Liao
- Department of Pediatrics Infectious Diseases, West China Second Hospital, Sichuan University, No.20, 3Rd Section of Renmin South Road, Chengdu, 610041, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, No.20, 3Rd Section of Renmin South Road, Chengdu, 610041, China
| | - Min Fang
- Department of Pediatrics Infectious Diseases, The No. 1 People's Hospital of Liangshan Yizu Autonomous Prefecture, Liangshan, China
| | - Yu Zhu
- Department of Pediatrics Infectious Diseases, West China Second Hospital, Sichuan University, No.20, 3Rd Section of Renmin South Road, Chengdu, 610041, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, No.20, 3Rd Section of Renmin South Road, Chengdu, 610041, China
| | - Yan Shi
- Department of Pediatrics Infectious Diseases, The No. 1 People's Hospital of Liangshan Yizu Autonomous Prefecture, Liangshan, China
| | - Shuting Quan
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China.,Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China.,Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China
| | - Yacui Wang
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China.,Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China.,Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China
| | - Li Duan
- Department of Pediatrics Infectious Diseases, The No. 1 People's Hospital of Liangshan Yizu Autonomous Prefecture, Liangshan, China
| | - Xiaomei Shi
- Department of Pediatrics Infectious Diseases, The No. 1 People's Hospital of Liangshan Yizu Autonomous Prefecture, Liangshan, China
| | - Yang Liu
- Department of Pediatrics Infectious Diseases, West China Second Hospital, Sichuan University, No.20, 3Rd Section of Renmin South Road, Chengdu, 610041, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, No.20, 3Rd Section of Renmin South Road, Chengdu, 610041, China
| | - Manzhi Wang
- Changsha Central Hospital, University of South China, Changsha, China
| | - Qingsong Wei
- Changsha Central Hospital, University of South China, Changsha, China
| | - Haiyi Zhou
- Changsha Central Hospital, University of South China, Changsha, China
| | - Yanchun Wang
- Department of Infections, Kunming Children's Hospital, Kunming, China
| | - Xirong Wu
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China.,Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China.,Department of Respiratory, Beijing Children's Hospital, Beijing, China
| | - Yao Yao
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China.,Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China.,Department of Respiratory, Beijing Children's Hospital, Beijing, China
| | - Lin Sun
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China. .,Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China. .,Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China.
| | - Adong Shen
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China. .,Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China. .,Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China. .,Children's Hospital Affiliated To Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, China.
| | - Chaomin Wan
- Department of Pediatrics Infectious Diseases, West China Second Hospital, Sichuan University, No.20, 3Rd Section of Renmin South Road, Chengdu, 610041, China. .,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, No.20, 3Rd Section of Renmin South Road, Chengdu, 610041, China.
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18
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Dowling WB, Whitelaw A, Nel P. Tracing TB: Are there predictors for active TB disease in patients with Xpert Ultra trace results? Int J Infect Dis 2021; 114:115-123. [PMID: 34740802 DOI: 10.1016/j.ijid.2021.10.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 10/07/2021] [Accepted: 10/28/2021] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES The Xpert MTB/Rif Ultra (Xpert Ultra; Cepheid, USA) has increased sensitivity compared with its predecessor (Gene Xpert), due to the addition of multicopy amplification targets and a novel trace call. The World Health Organization suggests that tuberculosis (TB) treatment should be initiated in HIV, paediatric, and extra-pulmonary TB patients with trace results. However, other factors such as previous TB disease may complicate the interpretation of trace results in high-burden TB settings. This study aimed to clarify the positive predictors for active TB disease in patients with trace results and to investigate if previous TB disease influences TB culture positivity. METHODS A retrospective descriptive study was performed on 290 patients with trace results, to determine what the positive predictors for active TB are by comparing clinical factors to TB culture. RESULTS The key findings of this study were that extra-pulmonary TB samples (OR, 2.7; p=0.012), no previous TB disease (OR, 4.5; p=0.001) and symptoms suggestive of TB (OR, 6.4; p<0.001) are independent predictors for active TB disease. CONCLUSION This study found readily available clinical predictors that can aid clinicians with TB management decisions in patients with trace results.
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Affiliation(s)
- Wentzel Bruce Dowling
- Division of Medical Microbiology and Immunology, University of Stellenbosch, Cape Town, South Africa; National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa.
| | - Andrew Whitelaw
- Division of Medical Microbiology and Immunology, University of Stellenbosch, Cape Town, South Africa; National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa.
| | - Pieter Nel
- Division of Medical Microbiology and Immunology, University of Stellenbosch, Cape Town, South Africa; National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa.
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19
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Zhang P, Liu H, Wang H, Wu Y, Sun L, Rao M, Jia X, Song Y, Deng G, Li T, Ye F, Zhou Y, Liao Y. Performance of Xpert MTB/RIF Ultra for the Diagnosis of Pulmonary Tuberculosis Using Bronchoalveolar Lavage Samples in People Living with HIV/AIDS (PLWHA) in China: A Prospective Study. HIV AIDS (Auckl) 2021; 13:905-916. [PMID: 34531689 PMCID: PMC8439626 DOI: 10.2147/hiv.s319117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/23/2021] [Indexed: 11/24/2022]
Abstract
Background Sputum is commonly used for the diagnostic testing of pulmonary tuberculosis (PTB), but people living with HIV/AIDS (PLWHA) usually have little sputum. Moreover, the automated molecular test, Xpert MTB/RIF assay (Xpert), has a low sensitivity in PLWHA. We aimed to estimate the performance of Xpert Ultra on the detection of Mycobacterium tuberculosis (MTB) using bronchoalveolar lavage (BAL). Methods From February 5, 2018 to March 30, 2019, a total of 99 PLWHA with suspected PTB at the Third People’s Hospital of Shenzhen, China, were recruited. The information on demographics and medical history, blood MTB antigen-specific interferon gamma enzyme-linked immunospot assay (T-SPOT.TB), T lymphocyte subsets, and plasma HIV RNA load were collected. Computed tomography (CT) and flexible bronchoscopy were performed, and BAL and blood samples were collected. Testing of acid-fast bacilli (AFB), tuberculosis real-time fluorescence quantitative PCR (TBDNA), Ultra, Xpert, and MTB culture were conducted. Results Compared to BAL MTB culture for tuberculosis diagnosis, Ultra, Xpert, T-SPOT.TB, TBDNA and AFB smear had the sensitivity of 0.96 (24/25), 0.80 (20/25), 0.84 (21/25), 0.44 (11/25), and 0.12 (3/25), respectively; and the specificity of 0.92 (68/74), 0.96 (71/74), 0.93 (69/74), 0.96 (71/74), and 0.99 (73/74), respectively. Our study found that the sensitivity of Ultra was higher than that of culture and Xpert (AUC 0.92, 0.86 and 0.84, respectively). The results also indicated that PLWHA with CD4 <200 cells/mm3 had reduced both sensitivity (from 1.00 and 0.86 to 0.94 and 0.78, respectively) and specificity (from 0.96 and 1.00 to 0.90 and 0.41, respectively) of Ultra and Xpert for the diagnosis of PTB. Discussion Our data supported an increased sensitivity of Ultra compared to that of Xpert on BAL samples of PLWHA, regardless of the CD4 counts and reference diagnosis standards.
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Affiliation(s)
- Peize Zhang
- Department of Lung Disease, The Third People's Hospital of Shenzhen, Shenzhen City, Guangdong Province, People's Republic of China
| | - HouMing Liu
- Department of Clinical Laboratory, The Third People's Hospital of Shenzhen, Shenzhen City, Guangdong Province, People's Republic of China
| | - Hui Wang
- Department of Infectious Disease No.1, The Third People's Hospital of Shenzhen, Shenzhen City, Guangdong Province, People's Republic of China
| | - Yanbo Wu
- Department of Infectious Disease, Shenzhen Longhua New District Central Hospital, Shenzhen City, Guangdong Province, People's Republic of China
| | - Liqin Sun
- Department of Infectious Disease No.1, The Third People's Hospital of Shenzhen, Shenzhen City, Guangdong Province, People's Republic of China
| | - Man Rao
- Department of Infectious Disease No.1, The Third People's Hospital of Shenzhen, Shenzhen City, Guangdong Province, People's Republic of China
| | - Xinyun Jia
- Department of Infectious Disease No.1, The Third People's Hospital of Shenzhen, Shenzhen City, Guangdong Province, People's Republic of China
| | - Ying Song
- Department of Infectious Disease No.1, The Third People's Hospital of Shenzhen, Shenzhen City, Guangdong Province, People's Republic of China
| | - Guofang Deng
- Department of Lung Disease, The Third People's Hospital of Shenzhen, Shenzhen City, Guangdong Province, People's Republic of China
| | - Tianpin Li
- Department of Clinical Laboratory, The Third People's Hospital of Shenzhen, Shenzhen City, Guangdong Province, People's Republic of China
| | - Feidi Ye
- Department of Clinical Laboratory, The Third People's Hospital of Shenzhen, Shenzhen City, Guangdong Province, People's Republic of China
| | - Yang Zhou
- Department of Infectious Disease No.1, The Third People's Hospital of Shenzhen, Shenzhen City, Guangdong Province, People's Republic of China
| | - Yi Liao
- Department of Primary Health Promotion, Shenzhen Center for Disease Control and Prevention, Shenzhen City, Guangdong Province, People's Republic of China
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20
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Mao L, LaCourse SM, Kim S, Liu C, Ning B, Bao D, Fan J, Lyon CJ, Sun Z, Nachman S, Mitchell CD, Hu TY. Evaluation of a serum-based antigen test for tuberculosis in HIV-exposed infants: a diagnostic accuracy study. BMC Med 2021; 19:113. [PMID: 34001096 PMCID: PMC8130139 DOI: 10.1186/s12916-021-01983-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 04/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Non-sputum methods are urgently needed to improve tuberculosis diagnosis and treatment monitoring in children. This study evaluated the ability of a serum assay quantifying a species-specific peptide of the Mycobacterium tuberculosis CFP-10 virulence factor via nanotechnology and matrix-assisted laser desorption ionization time-of-flight mass spectrometry to diagnose tuberculosis in HIV-infected and HIV-uninfected infants. METHODS Serum CFP-10 peptide signal was blinded evaluated in cryopreserved sera of 519 BCG-immunized, HIV-exposed infants (284 HIV-infected, 235 HIV-uninfected) from a multi-center randomized placebo-controlled isoniazid prophylaxis trial conducted in southern Africa between 2004 and 2008, who were followed up to 192 weeks for Mtb infection and TB. Children were classified as confirmed, unconfirmed, or unlikely tuberculosis cases using 2015 NIH diagnostic criteria for pediatric TB. RESULTS In HIV-infected infants, CFP-10 signal had 100% sensitivity for confirmed TB (5/5, 95% CI, 47.8-100) and 83.7% sensitivity for unconfirmed TB (36/43, 95% CI 69.3-93.2), with 93.1% specificity (203/218, 95% CI 88.9-96.1). In HIV-uninfected infants, CFP-10 signal detected the single confirmed TB case and 75.0% of unconfirmed TB cases (15/20; 95% CI 50.9-91.3), with 96.2% specificity (177/184, 95% CI, 92.3-98.5). Serum CFP-10 achieved 77% diagnostic sensitivity for confirmed and unconfirmed TB (13/17, 95% CI, 50-93%) at ≤ 24 weeks pre-diagnosis, and both CFP-10-positivity and concentration declined following anti-TB therapy initiation. CONCLUSIONS Serum CFP-10 signal exhibited high diagnostic sensitivity and specificity for tuberculosis in HIV-infected and HIV-uninfected infants and potential utility for early TB detection and monitoring of anti-TB treatment responses.
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Affiliation(s)
- Liyan Mao
- Center for Cellular and Molecular Diagnostics, Biochemistry and Molecular Biology, Tulane University School of Medicine, Room 474, 333 S. Liberty Street, New Orleans, LA 70112 USA
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 China
| | - Sylvia M. LaCourse
- Departments of Medicine and Global Health, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA 98104 USA
| | - Soyeon Kim
- Frontier Science Foundation, Brookline, MA 02115 USA
| | - Chang Liu
- Department of Chemical Engineering, Biomedical Engineering Program, University of South Carolina, Columbia, SC 29208 USA
| | - Bo Ning
- Center for Cellular and Molecular Diagnostics, Biochemistry and Molecular Biology, Tulane University School of Medicine, Room 474, 333 S. Liberty Street, New Orleans, LA 70112 USA
| | - Duran Bao
- Center for Cellular and Molecular Diagnostics, Biochemistry and Molecular Biology, Tulane University School of Medicine, Room 474, 333 S. Liberty Street, New Orleans, LA 70112 USA
| | - Jia Fan
- Center for Cellular and Molecular Diagnostics, Biochemistry and Molecular Biology, Tulane University School of Medicine, Room 474, 333 S. Liberty Street, New Orleans, LA 70112 USA
| | - Christopher J. Lyon
- Center for Cellular and Molecular Diagnostics, Biochemistry and Molecular Biology, Tulane University School of Medicine, Room 474, 333 S. Liberty Street, New Orleans, LA 70112 USA
| | - Ziyong Sun
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 China
| | - Sharon Nachman
- Department of Pediatrics, State University of New York at Stony Brook, Stony Brook, NY 11794 USA
| | - Charles D. Mitchell
- Department of Pediatrics, Division of Infectious Diseases and Immunology, University of Miami Miller School of Medicine, Batchelor Children’s Research Institute, Room 286, 1580 NW 10th Avenue, Miami, FL 33136 USA
| | - Tony Y. Hu
- Center for Cellular and Molecular Diagnostics, Biochemistry and Molecular Biology, Tulane University School of Medicine, Room 474, 333 S. Liberty Street, New Orleans, LA 70112 USA
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21
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Mekkaoui L, Hallin M, Mouchet F, Payen MC, Maillart E, Clevenbergh P, Georgala A, Van den Wijngaert S. Performance of Xpert MTB/RIF Ultra for diagnosis of pulmonary and extra-pulmonary tuberculosis, one year of use in a multi-centric hospital laboratory in Brussels, Belgium. PLoS One 2021; 16:e0249734. [PMID: 33831077 DOI: 10.1371/journal.pone.0249734] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/23/2021] [Indexed: 02/07/2023] Open
Abstract
Among the challenges in controlling tuberculosis, a rapid and accurate diagnostic test for the detection of Mycobacterium tuberculosis complex (MTBc) and its resistance to first line therapies is crucial. We evaluated the performance of the Xpert MTB/RIF Ultra assay (Xpert Ultra) for the rapid detection of MTBc and rifampicin resistance (RR) in 1120 pulmonary and 461 extra-pulmonary clinical specimens and compared it with conventional phenotypic techniques. The Xpert Ultra assay detected MTBc in 223 (14.1%) samples with an overall sensitivity and specificity, using culture as the "gold standard", of 91.1% (95% CI, 85.6-95.1) and 94.5% (95% CI, 93.1-95.6), respectively. The sensitivity of the Xpert Ultra test for smear-negative extra-pulmonary specimens was high (87.1%), even higher than with smear-negative pulmonary specimens (81.8%). But this enhanced sensitivity came with a low overall specificity of smear-negative extra-pulmonary specimens (66.7%). For 73 patients, 79/1423 (3.4%) negative mycobacterial culture samples were found to be positive with Xpert Ultra. Clinical data was necessary to correctly interpret potential false-positive results, especially trace-positive results. Sensitivity of the Xpert Ultra to detect RR compared to drug susceptibility testing was 100% (95% CI, 29.2-100) and specificity was 99.2% (95% CI, 95.8-100). We concluded that the Xpert Ultra test is able to provide a reliable TB diagnosis within a significantly shorter turnaround time than culture. This is especially true for paucibacillary samples such as smear-negative pulmonary specimens and extra-pulmonary specimens.
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22
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Nkereuwem E, Togun T, Gomez MP, Székely R, Macé A, Jobe D, Schumacher SG, Kampmann B, Denkinger CM. Comparing accuracy of lipoarabinomannan urine tests for diagnosis of pulmonary tuberculosis in children from four African countries: a cross-sectional study. Lancet Infect Dis 2021; 21:376-384. [PMID: 33316214 DOI: 10.1016/s1473-3099(20)30598-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/01/2020] [Accepted: 06/24/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND A sensitive and specific non-sputum-based test would be groundbreaking for the diagnosis of childhood tuberculosis. We assessed side by side the diagnostic accuracy of the urine-based lipoarabinomannan assays Fujifilm SILVAMP TB LAM (FujiLAM) and Alere Determine TB LAM Ag (AlereLAM) for detection of childhood tuberculosis. METHODS In this cross-sectional study, we tested urine samples from children younger than 15 years with presumed pulmonary tuberculosis. Children were consecutively recruited from four dedicated outpatient childhood tuberculosis clinics in The Gambia, Mali, Nigeria, and Tanzania. Biobanked urine samples were thawed and tested using FujiLAM and AlereLAM assays. We measured diagnostic performance against a microbiological reference standard (confirmed tuberculosis) and a composite reference standard (confirmed and unconfirmed tuberculosis). Sensitivity and specificity were estimated with bivariate random-effects meta-analyses. FINDINGS Between July 1, 2017, and Dec 1, 2018, we obtained and stored urine samples from 415 children. 63 (15%) children had confirmed tuberculosis, 113 (27%) had unconfirmed tuberculosis, and 239 (58%) were unlikely to have tuberculosis. 61 children were HIV-positive (prevalence 15%). Using the microbiological reference standard, the sensitivity of FujiLAM was 64·9% (95% CI 43·7-85·2; positive in 40 of 63 confirmed samples) and the sensitivity of AlereLAM was 30·7% (8·6-61·6; 19 of 63). The specificity of FujiLAM was 83·8% (95% CI 76·5-89·4; negative in 297 of 352 unconfirmed and unlikely samples) and the specificity of AlereLAM was 87·8% (79·0-93·7; 312 of 352). Against the composite reference standard, both assays had decreased sensitivity; the sensitivity of FujiLAM was 32·9% (95% CI 24·6-41·9; positive in 58 of 176 confirmed and unconfirmed samples) and the sensitivity of AlereLAM was 20·2% (12·3-29·4; 36 of 176). The specificity of FujiLAM was 83·3% (95% CI 71·8-91·7; negative in 202 of 239 unlikely samples) and the specificity of AlereLAM was 90·0% (81·6-95·6; 216 of 239). INTERPRETATION By comparison with AlereLAM, FujiLAM showed higher sensitivity and similar specificity. FujiLAM could potentially add value to the rapid diagnosis of tuberculosis in children. FUNDING German Federal Ministry of Education and Research, the Global Health Innovative Technology Fund, the UK Research and Innovation Global Challenges Research Fund, and the UK Medical Research Council.
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Affiliation(s)
- Esin Nkereuwem
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Toyin Togun
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Banjul, The Gambia; Faculty of Infectious and Tropical Diseases, London, UK
| | - Marie P Gomez
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Rita Székely
- FIND (Foundation for Innovative New Diagnostics), Geneva, Switzerland
| | - Aurélien Macé
- FIND (Foundation for Innovative New Diagnostics), Geneva, Switzerland
| | - Dawda Jobe
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | | | - Beate Kampmann
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Banjul, The Gambia; The Vaccine Centre, London School of Hygiene & Tropical Medicine, London, UK.
| | - Claudia M Denkinger
- FIND (Foundation for Innovative New Diagnostics), Geneva, Switzerland; Division of Tropical Medicine, Centre of Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany
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23
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He Y, Lyon CJ, Nguyen DT, Liu C, Sha W, Graviss EA, Hu TY. Serum-Based Diagnosis of Pediatric Tuberculosis by Assay of Mycobacterium tuberculosis Factors: a Retrospective Cohort Study. J Clin Microbiol 2021; 59:e01756-20. [PMID: 33239373 DOI: 10.1128/JCM.01756-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 11/18/2020] [Indexed: 11/20/2022] Open
Abstract
Diagnosis of pediatric tuberculosis (TB) is often complicated by its nonspecific symptoms, paucibacillary nature, and the need for invasive specimen collection techniques. However, a recently reported assay that detects Mycobacterium tuberculosis virulence factors in serum can diagnose various TB manifestations, including paucibacillary TB cases, in adults with good sensitivity and specificity. Diagnosis of pediatric tuberculosis (TB) is often complicated by its nonspecific symptoms, paucibacillary nature, and the need for invasive specimen collection techniques. However, a recently reported assay that detects Mycobacterium tuberculosis virulence factors in serum can diagnose various TB manifestations, including paucibacillary TB cases, in adults with good sensitivity and specificity. The current study examined the ability of this M. tuberculosis biomarker assay to diagnose pediatric TB using archived cryopreserved serum samples drawn from children ≤18 years of age who were screened for suspected TB as part of a prospective population-based active surveillance study. In this analysis, any detectable level of either of the M. tuberculosis virulence factors CFP-10 and ESAT-6 was considered direct evidence of TB. Serum samples from 105 children evaluated for TB (55 TB cases and 50 close contacts without TB) were analyzed. The results of this analysis yielded sensitivity of 85.5% (95% confidence interval [CI], 73.3 to 93.5). Similar diagnostic sensitivities were observed for culture-positive (87.5%; 95% CI, 67.6 to 97.3) and culture-negative (83.9%; 95% CI, 66.3 to 94.5) TB cases and for culture negative pulmonary (77.8%; 95% CI, 40.0 to 97.2) and extrapulmonary (86.4%; 95% CI, 65.1 to 97.1) TB cases. These results suggest that serum biomarker analysis holds significant promise for rapid and sensitive diagnosis of pediatric TB cases, including extrapulmonary or paucibacillary TB cases. The ability to use frozen samples for this analysis should also permit assays to be performed at central sites, without a requirement for strict timelines for sample analysis.
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24
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Jaganath D, Wambi P, Reza TF, Nakafeero J, Aben EO, Kiconco E, Nannyonga G, Nsereko M, Sekadde MP, Mudiope M, Kato-Maeda M, Starke J, Andama A, Mohanty S, Wobudeya E, Cattamanchi A. A Prospective Evaluation of Xpert MTB/RIF Ultra for Childhood Pulmonary Tuberculosis in Uganda. J Pediatric Infect Dis Soc 2021; 10:586-592. [PMID: 33416072 PMCID: PMC8163061 DOI: 10.1093/jpids/piaa159] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/01/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Xpert MTB/RIF Ultra (Xpert Ultra) has improved the sensitivity to detect pulmonary tuberculosis (TB) in adults. However, there have been limited prospective evaluations of its diagnostic accuracy in children. METHODS We enrolled children undergoing assessment for pulmonary TB in Kampala, Uganda, over a 12-month period. Children received a complete TB evaluation and were classified as Confirmed, Unconfirmed, or Unlikely TB. We calculated the sensitivity and specificity of Xpert Ultra among children with Confirmed vs Unlikely TB. We also determined the diagnostic accuracy with clinical, microbiological, and extended microbiological reference standards (MRSs). RESULTS Of the 213 children included, 23 (10.8%) had Confirmed TB, 88 (41.3%) had Unconfirmed TB, and 102 (47.9%) had Unlikely TB. The median age was 3.9 years, 13% were HIV-positive, and 61.5% were underweight. Xpert Ultra sensitivity was 69.6% (95% confidence interval [CI]: 47.1-86.8) among children with Confirmed TB and decreased to 23.4% (95% CI: 15.9-32.4) with the clinical reference standard. Specificity was 100% (95% CI: 96.4-100) among children with Unlikely TB and decreased to 94.7% (95% CI: 90.5-97.4) with a MRS. Sensitivity was 52.9% (95% CI: 35.1-70.2) and specificity 95.5% (95% CI: 91.4-98.1) with the extended MRS. Of the 26 positive Xpert Ultra results, 6 (23.1%) were "Trace-positive," with most (5/6) occurring in children with Unconfirmed TB. CONCLUSIONS Xpert Ultra is a useful tool for diagnosing pulmonary TB in children, but there remains a need for more sensitive tests to detect culture-negative TB.
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Affiliation(s)
- Devan Jaganath
- Division of Pediatric Infectious Diseases, University of California–San Francisco, San Francisco, California, USA,Division of Pulmonary and Critical Care Medicine, University of California–San Francisco, San Francisco, California, USA,Center for Tuberculosis, University of California–San Francisco, San Francisco, California, USA,Corresponding Author: Devan Jaganath, MD, MPH, Division of Pediatric Infectious Diseases, University of California, 550 16th St., 4th Floor, San Francisco, CA, USA. E-mail:
| | - Peter Wambi
- Mulago National Referral Hospital, Kampala, Uganda
| | - Tania F Reza
- Division of Pulmonary and Critical Care Medicine, University of California–San Francisco, San Francisco, California, USA,Center for Tuberculosis, University of California–San Francisco, San Francisco, California, USA
| | | | | | - Emma Kiconco
- Mulago National Referral Hospital, Kampala, Uganda
| | | | | | - Moorine P Sekadde
- National TB and Leprosy Program, Ministry of Health, Kampala, Uganda
| | | | - Midori Kato-Maeda
- Division of Pulmonary and Critical Care Medicine, University of California–San Francisco, San Francisco, California, USA,Center for Tuberculosis, University of California–San Francisco, San Francisco, California, USA
| | - Jeffrey Starke
- Division of Pediatric Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Alfred Andama
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Swomitra Mohanty
- Departments of Chemical Engineering and Materials Science Engineering, University of Utah, Salt Lake City, Utah, USA
| | | | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, University of California–San Francisco, San Francisco, California, USA,Center for Tuberculosis, University of California–San Francisco, San Francisco, California, USA,Department of Medicine, Center for Vulnerable Populations, University of California–San Francisco, San Francisco, California, USA
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25
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Liu XH, Xia L, Song B, Wang H, Qian XQ, Wei JH, Li T, Xi XH, Song YL, Li SQ, Lowrie DB, Fan XY, Lu SH. Stool-based Xpert MTB/RIF Ultra assay as a tool for detecting pulmonary tuberculosis in children with abnormal chest imaging: A prospective cohort study. J Infect 2020; 82:84-89. [PMID: 33275958 DOI: 10.1016/j.jinf.2020.10.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/01/2020] [Accepted: 10/03/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To evaluate the diagnostic efficacy of stool-based Xpert MTB/RIF Ultra assay versus other assays for the detection of paediatric pulmonary tuberculosis (PTB). METHODS A prospective head-to-head comparative study was conducted from Dec 2017 to May 2019 in Shanghai Public Health Clinical Centre. Samples were collected from children (< 15 years) with abnormal chest imaging (X-ray or CT scan) results for the following tests: Ultra on stool sample (Ultra-Stool), Ultra on respiratory tract sample (Ultra-RTS), Xpert MTB/RIF assay (Xpert) on RTS (Xpert-RTS), acid-fast bacilli smear on RTS (AFB-RTS), and Mycobacterium tuberculosis (Mtb) culture on RTS (Culture-RTS). The results were compared with a composite reference standard. RESULTS A total of 126 cases with paired results were analysed. Against a composite reference standard, Ultra-RTS demonstrated the highest sensitivity (52%) and specificity (100%). Ultra-Stool showed 84.1% concordance with Ultra-RTS, demonstrating 45.5% sensitivity and 94.7% specificity (kappa = 0.65, 95% CI= 0.51-0.79). The sensitivity of Ultra-Stool was similar to Mtb culture (45.5%, p = 1.000) and higher than AFB-RTS (27.3%, p < 0.05). Assay positivity was associated with age and infiltration range in chest imaging. CONCLUSIONS When RTS is difficult to obtain, stool sample-based Ultra is a comparable alternative.
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Affiliation(s)
- Xu-Hui Liu
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China; Shanghai Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lu Xia
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Bin Song
- Wuhan Jinyintan Hospital, Wuhan, China
| | - Heng Wang
- Guiyang Pulmonary Hospital, Guiyang, China
| | - Xue-Qin Qian
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Jian-Hao Wei
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Tao Li
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Xiu-Hong Xi
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Yuan-Lin Song
- Shanghai Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shan-Qun Li
- Shanghai Zhongshan Hospital, Fudan University, Shanghai, China
| | - Douglas B Lowrie
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Xiao-Yong Fan
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China; Wenzhou Medical University, Wenzhou, China; TB Center, Shanghai Emerging and Re-emerging Institute, 2901, Caolang Rd, Jinshan, Shanghai 201508, China.
| | - Shui-Hua Lu
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China; Wenzhou Medical University, Wenzhou, China; TB Center, Shanghai Emerging and Re-emerging Institute, 2901, Caolang Rd, Jinshan, Shanghai 201508, China.
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26
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Yadav R, Vaidya P, Mathew JL, Singh S, Khaneja R, Agarwal P, Singh M, Sethi S. Diagnostic accuracy of Xpert MTB/RIF ultra for detection of Mycobacterium tuberculosis in children: a prospective cohort study. Lett Appl Microbiol 2020; 72:225-230. [PMID: 33090531 DOI: 10.1111/lam.13402] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 09/29/2020] [Accepted: 09/29/2020] [Indexed: 12/11/2022]
Abstract
The Xpert MTB/RIF Ultra is a recent advancement in molecular diagnostics of tuberculosis (TB) with higher sensitivity compared to its predecessor, the Xpert MTB/RIF assay. Prospective studies evaluating the performance of Xpert MTB/RIF Ultra in children with suspected TB are lacking. In this study, we evaluated the Xpert MTB/RIF Ultra for detection of Mycobacterium tuberculosis in samples from 156 children, of which one was excluded from the analysis. Of the remaining 155 samples, 6·5% (10/155), 21·3% (33/155), 20% (31/155) and 21·9% (34/155) were positive by smear examination, MGIT culture, Xpert MTB/RIF and Xpert MTB/RIF Ultra, respectively. The Xpert MTB/RIF and Xpert MTB/RIF Ultra had a similar overall sensitivity of 81·8% (95% CI: 64·5-93) and 84·8% (95% CI: 68·1-94·9), respectively. In suspected pediatric TB patients, the Xpert MTB/RIF Ultra had higher sensitivity compared to the Xpert MTB/RIF (72·7 vs 63·6). The AUC (area under the curve) of 0·905 for the Xpert MTB/RIF and 0·893 for the Xpert MTB/RIF Ultra indicate similar and good overall performance. Both Xpert assays were found to be equally efficient, however Xpert MTB/RIF Ultra showed better detection rate in suspected TB cases.
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Affiliation(s)
- R Yadav
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - P Vaidya
- Pediatric Medicine, Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - J L Mathew
- Pediatric Medicine, Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S Singh
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - P Agarwal
- WHO Country Office for India, New Delhi, India
| | - M Singh
- Pediatric Medicine, Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S Sethi
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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27
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Abstract
Major challenges still exist in the accurate diagnosis of tuberculosis in children. Algorithms based on clinical and radiological features remain in widespread use despite poor performance. Newer molecular diagnostics allow for rapid identification of TB and detection of drug-resistance in a subset of children, but lack sensitivity. Molecular testing of multiple specimens, including non-traditional specimen types, such as nasopharyngeal aspirates and stool and urine, may improve sensitivity, but the optimal combination of specimens requires further research. Novel tests under development or evaluation include a urine lipoarabinomannan test with improved sensitivity and a range of biomarkers measured from stimulated or unstimulated peripheral blood.
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Affiliation(s)
- Mark P Nicol
- Division of Infection and Immunity, School of Biomedical Sciences, University of Western Australia, Perth, Australia.
| | - Heather J Zar
- Department of Paediatrics and Child Health, and SA-MRC Unit on Child & Adolescent Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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28
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Lounnas M, Diack A, Nicol MP, Eyangoh S, Wobudeya E, Marcy O, Godreuil S, Bonnet M. Laboratory development of a simple stool sample processing method diagnosis of pediatric tuberculosis using Xpert Ultra. Tuberculosis (Edinb) 2020; 125:102002. [PMID: 33049437 DOI: 10.1016/j.tube.2020.102002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/28/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022]
Abstract
Stool samples are alternatives to respiratory samples for bacteriological confirmation of childhood tuberculosis but require intensive laboratory processing before molecular testing to remove PCR inhibitors and debris. We aimed to develop a centrifuge-free processing method for use in resource-limited settings based on a sucrose-flotation method that showed good sensitivity for childhood tuberculosis diagnosis. In an in vitro study using Xpert MTB/RIF Ultra on stool samples spiked with defined bacterial concentrations of Mycobacterium tuberculosis (MTB), we compared different simplification parameters to the reference sucrose-flotation method. Best methods were selected based on the rate of invalid/error results and on sensitivity, compared to the reference method on stools spiked at 103 colony forming units (CFU)/g MTB. For final selection, we tested the best parameter combinations at 102 CFU/g. Out of 13 different parameter combinations, three were tested at 102 CFU/g. The best combination used 0.5 g stool, manual shaking, no filtration, 30-min sedimentation, and a 1:3.6 dilution ratio. This method gave 10% invalid/error results and a sensitivity of 70% vs 63% at 103 CFU/g and 53% vs 58% at 102 CFU/g compared to the reference method. This pre-clinical study was able to develop a centrifuge-free processing method to facilitate stool Xpert Ultra testing.
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Affiliation(s)
- Manon Lounnas
- UMR MIVEGEC Univ Montpellier-IRD-CNRS, IRD, Montpellier, France; Département de Bactériologie, Centre Hospitalier Universitaire de Montpellier, Université de Montpellier, Montpellier, France.
| | - Abibatou Diack
- UMR MIVEGEC Univ Montpellier-IRD-CNRS, IRD, Montpellier, France; Département de Bactériologie, Centre Hospitalier Universitaire de Montpellier, Université de Montpellier, Montpellier, France
| | - Mark P Nicol
- Division of Medical Microbiology and Institute for Infectious Diseases and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; School of Biomedical Sciences, University of Western Australia, Perth, Australia
| | - Sara Eyangoh
- Service de Mycobactériologie, Centre Pasteur du Cameroun, Réseau International des Instituts Pasteur, Yaounde, Cameroon
| | - Eric Wobudeya
- Mulago National Referral Hospital, Directorate of Paediatrics & Child Health, Kampala, Uganda
| | - Olivier Marcy
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), UMR, 1219, Bordeaux, France
| | - Sylvain Godreuil
- UMR MIVEGEC Univ Montpellier-IRD-CNRS, IRD, Montpellier, France; Département de Bactériologie, Centre Hospitalier Universitaire de Montpellier, Université de Montpellier, Montpellier, France
| | - Maryline Bonnet
- IRD UMI 233 TransVIHMI- UM-INSERM U1175, Montpellier, France.
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29
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Lyu C, Shi H, Cui Y, Li M, Yan Z, Yan L, Jiang Y. CRISPR-based biosensing is prospective for rapid and sensitive diagnosis of pediatric tuberculosis. Int J Infect Dis 2020; 101:183-187. [PMID: 32987180 DOI: 10.1016/j.ijid.2020.09.1428] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/12/2020] [Accepted: 09/15/2020] [Indexed: 12/27/2022] Open
Abstract
Pediatric tuberculosis (TB) is an important part of global TB prevention and control. Diagnosis of childhood TB still remains challenging when using conventional tests, due to the non-specific clinical manifestations and paucibacillary nature of the specimens. Thus, a sensitive, rapid and low-cost diagnostic test is of great demand. Benefiting from specific and rapid Cas-protein-based catalytic activities, CRISPR-based biosensing platforms (CRISPR platforms) are showing superiority in detecting pathogen nucleic acid traces in clinical samples. Based on their excellent sensitivity, and time and cost saved in existing research, this study aimed to highlight the potential of CRISPR platforms as a tool for diagnosing pediatric TB, and advocate for studies to evaluate its performance in specimens collected from children, especially noninvasive specimens. These platforms are also promising in identifying drug resistance and genotyping. All of the above will help early diagnosis of pediatric TB, thus guide reasonable treatment, and be significant in achieving the World Health Organization End-TB strategy.
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Affiliation(s)
- Chunyang Lyu
- Department of Laboratory Medicine, West China Second Hospital, Sichuan University, Chengdu, Sichuan, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Hua Shi
- Department of Laboratory Medicine, West China Second Hospital, Sichuan University, Chengdu, Sichuan, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Yali Cui
- Department of Laboratory Medicine, West China Second Hospital, Sichuan University, Chengdu, Sichuan, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Mingyuan Li
- Department of Laboratory Medicine, West China Second Hospital, Sichuan University, Chengdu, Sichuan, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Ziyi Yan
- Department of Laboratory Medicine, West China Second Hospital, Sichuan University, Chengdu, Sichuan, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Lingyi Yan
- Department of Laboratory Medicine, West China Second Hospital, Sichuan University, Chengdu, Sichuan, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Yongmei Jiang
- Department of Laboratory Medicine, West China Second Hospital, Sichuan University, Chengdu, Sichuan, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China.
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30
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Kay AW, González Fernández L, Takwoingi Y, Eisenhut M, Detjen AK, Steingart KR, Mandalakas AM. Xpert MTB/RIF and Xpert MTB/RIF Ultra assays for active tuberculosis and rifampicin resistance in children. Cochrane Database Syst Rev 2020; 8:CD013359. [PMID: 32853411 PMCID: PMC8078611 DOI: 10.1002/14651858.cd013359.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Every year, at least one million children become ill with tuberculosis and around 200,000 children die. Xpert MTB/RIF and Xpert Ultra are World Health Organization (WHO)-recommended rapid molecular tests that simultaneously detect tuberculosis and rifampicin resistance in adults and children with signs and symptoms of tuberculosis, at lower health system levels. To inform updated WHO guidelines on molecular assays, we performed a systematic review on the diagnostic accuracy of these tests in children presumed to have active tuberculosis. OBJECTIVES Primary objectives • To determine the diagnostic accuracy of Xpert MTB/RIF and Xpert Ultra for (a) pulmonary tuberculosis in children presumed to have tuberculosis; (b) tuberculous meningitis in children presumed to have tuberculosis; (c) lymph node tuberculosis in children presumed to have tuberculosis; and (d) rifampicin resistance in children presumed to have tuberculosis - For tuberculosis detection, index tests were used as the initial test, replacing standard practice (i.e. smear microscopy or culture) - For detection of rifampicin resistance, index tests replaced culture-based drug susceptibility testing as the initial test Secondary objectives • To compare the accuracy of Xpert MTB/RIF and Xpert Ultra for each of the four target conditions • To investigate potential sources of heterogeneity in accuracy estimates - For tuberculosis detection, we considered age, disease severity, smear-test status, HIV status, clinical setting, specimen type, high tuberculosis burden, and high tuberculosis/HIV burden - For detection of rifampicin resistance, we considered multi-drug-resistant tuberculosis burden • To compare multiple Xpert MTB/RIF or Xpert Ultra results (repeated testing) with the initial Xpert MTB/RIF or Xpert Ultra result SEARCH METHODS: We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, Science Citation Index, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and the International Standard Randomized Controlled Trials Number (ISRCTN) Registry up to 29 April 2019, without language restrictions. SELECTION CRITERIA Randomized trials, cross-sectional trials, and cohort studies evaluating Xpert MTB/RIF or Xpert Ultra in HIV-positive and HIV-negative children younger than 15 years. Reference standards comprised culture or a composite reference standard for tuberculosis and drug susceptibility testing or MTBDRplus (molecular assay for detection of Mycobacterium tuberculosis and drug resistance) for rifampicin resistance. We included studies evaluating sputum, gastric aspirate, stool, nasopharyngeal or bronchial lavage specimens (pulmonary tuberculosis), cerebrospinal fluid (tuberculous meningitis), fine needle aspirates, or surgical biopsy tissue (lymph node tuberculosis). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality using the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2). For each target condition, we used the bivariate model to estimate pooled sensitivity and specificity with 95% confidence intervals (CIs). We stratified all analyses by type of reference standard. We assessed certainty of evidence using the GRADE approach. MAIN RESULTS For pulmonary tuberculosis, 299 data sets (68,544 participants) were available for analysis; for tuberculous meningitis, 10 data sets (423 participants) were available; for lymph node tuberculosis, 10 data sets (318 participants) were available; and for rifampicin resistance, 14 data sets (326 participants) were available. Thirty-nine studies (80%) took place in countries with high tuberculosis burden. Risk of bias was low except for the reference standard domain, for which risk of bias was unclear because many studies collected only one specimen for culture. Detection of pulmonary tuberculosis For sputum specimens, Xpert MTB/RIF pooled sensitivity (95% CI) and specificity (95% CI) verified by culture were 64.6% (55.3% to 72.9%) (23 studies, 493 participants; moderate-certainty evidence) and 99.0% (98.1% to 99.5%) (23 studies, 6119 participants; moderate-certainty evidence). For other specimen types (nasopharyngeal aspirate, 4 studies; gastric aspirate, 14 studies; stool, 11 studies), Xpert MTB/RIF pooled sensitivity ranged between 45.7% and 73.0%, and pooled specificity ranged between 98.1% and 99.6%. For sputum specimens, Xpert Ultra pooled sensitivity (95% CI) and specificity (95% CI) verified by culture were 72.8% (64.7% to 79.6%) (3 studies, 136 participants; low-certainty evidence) and 97.5% (95.8% to 98.5%) (3 studies, 551 participants; high-certainty evidence). For nasopharyngeal specimens, Xpert Ultra sensitivity (95% CI) and specificity (95% CI) were 45.7% (28.9% to 63.3%) and 97.5% (93.7% to 99.3%) (1 study, 195 participants). For all specimen types, Xpert MTB/RIF and Xpert Ultra sensitivity were lower against a composite reference standard than against culture. Detection of tuberculous meningitis For cerebrospinal fluid, Xpert MTB/RIF pooled sensitivity and specificity, verified by culture, were 54.0% (95% CI 27.8% to 78.2%) (6 studies, 28 participants; very low-certainty evidence) and 93.8% (95% CI 84.5% to 97.6%) (6 studies, 213 participants; low-certainty evidence). Detection of lymph node tuberculosis For lymph node aspirates or biopsies, Xpert MTB/RIF pooled sensitivity and specificity, verified by culture, were 90.4% (95% CI 55.7% to 98.6%) (6 studies, 68 participants; very low-certainty evidence) and 89.8% (95% CI 71.5% to 96.8%) (6 studies, 142 participants; low-certainty evidence). Detection of rifampicin resistance Xpert MTB/RIF pooled sensitivity and specificity were 90.0% (67.6% to 97.5%) (6 studies, 20 participants; low-certainty evidence) and 98.3% (87.7% to 99.8%) (6 studies, 203 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS We found Xpert MTB/RIF sensitivity to vary by specimen type, with gastric aspirate specimens having the highest sensitivity followed by sputum and stool, and nasopharyngeal specimens the lowest; specificity in all specimens was > 98%. Compared with Xpert MTB/RIF, Xpert Ultra sensitivity in sputum was higher and specificity slightly lower. Xpert MTB/RIF was accurate for detection of rifampicin resistance. Xpert MTB/RIF was sensitive for diagnosing lymph node tuberculosis. For children with presumed tuberculous meningitis, treatment decisions should be based on the entirety of clinical information and treatment should not be withheld based solely on an Xpert MTB/RIF result. The small numbers of studies and participants, particularly for Xpert Ultra, limits our confidence in the precision of these estimates.
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MESH Headings
- Adolescent
- Antibiotics, Antitubercular/therapeutic use
- Bias
- Child
- Feces/microbiology
- Gastrointestinal Contents/microbiology
- Humans
- Molecular Typing/methods
- Molecular Typing/standards
- Mycobacterium tuberculosis/drug effects
- Mycobacterium tuberculosis/isolation & purification
- Rifampin/therapeutic use
- Sensitivity and Specificity
- Sputum/microbiology
- Tuberculosis, Lymph Node/diagnosis
- Tuberculosis, Lymph Node/drug therapy
- Tuberculosis, Lymph Node/microbiology
- Tuberculosis, Meningeal/cerebrospinal fluid
- Tuberculosis, Meningeal/diagnosis
- Tuberculosis, Meningeal/drug therapy
- Tuberculosis, Meningeal/microbiology
- Tuberculosis, Multidrug-Resistant/diagnosis
- Tuberculosis, Multidrug-Resistant/drug therapy
- Tuberculosis, Multidrug-Resistant/microbiology
- Tuberculosis, Pulmonary/diagnosis
- Tuberculosis, Pulmonary/drug therapy
- Tuberculosis, Pulmonary/microbiology
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Affiliation(s)
- Alexander W Kay
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Michael Eisenhut
- Paediatric Department, Luton & Dunstable University Hospital NHS Foundation Trust, Luton, UK
| | | | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Anna M Mandalakas
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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31
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Ssengooba W, Iragena JD, Nakiyingi L, Mujumbi S, Wobudeya E, Mboizi R, Boulware D, Meya DB, Choo L, Crook AM, Lebeau K, Joloba M, Demers AM, Cresswell FV, Gibb DM. Accuracy of Xpert Ultra in Diagnosis of Pulmonary Tuberculosis among Children in Uganda: a Substudy from the SHINE Trial. J Clin Microbiol 2020; 58:e00410-20. [PMID: 32493780 DOI: 10.1128/JCM.00410-20] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/22/2020] [Indexed: 12/18/2022] Open
Abstract
Childhood tuberculosis (TB) presents significant diagnostic challenges associated with paucibacillary disease and requires a more sensitive test. We evaluated the diagnostic accuracy of Xpert MTB/RIF Ultra (Ultra) compared to other microbiological tests using respiratory samples from Ugandan children in the SHINE trial. SHINE is a randomized trial evaluating shorter treatment in 1,204 children with minimal TB disease in Africa and India. Among 352 samples and one cervical lymph node fine needle aspirate, one sample was randomly selected per patient and tested with the Xpert MTB/RIF assay (Xpert) and with Lowenstein-Jensen medium (LJ) and liquid mycobacterial growth indicator tube (MGIT) cultures. We selected only uncontaminated stored sample pellets for Ultra testing. We estimated the sensitivity of Xpert and Ultra against culture and a composite microbiological reference standard (any positive result). Of 398 children, 353 (89%) had culture, Xpert, and Ultra results. The median age was 2.8 years (interquartile range [IQR], 1.3 to 5.3); 8.5% (30/353) were HIV infected, and 54.4% (192/353) were male. Of the 353, 31 (9%) were positive by LJ and/or MGIT culture, 36 (10%) by Ultra, and 16 (5%) by Xpert. Sensitivities (95% confidence intervals [CI]) were 58% (39 to 65% [18/31]) for Ultra and 45% (27 to 64% [14/31]) for Xpert against any culture-positive result, with false positives of <1% and 5.5% for Xpert and Ultra. Against a composite microbiological reference, sensitivities were 72% (58 to 84% [36/50]) for Ultra and 32% (20 to 47% [16/50]) for Xpert. However, there were 17 samples that were positive only with Ultra (majority trace). Among children screened for minimal TB in Uganda, Ultra has higher sensitivity than Xpert. This represents an important advance for a condition which has posed a diagnostic challenge for decades.
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32
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Sun L, Zhu Y, Fang M, Shi Y, Peng X, Liao Q, Wang X, Quan S, Wang Y, Duan L, Shi X, Zhao Z, Chen L, Xu Y, Zhang T, Cui X, Wan C, Shen A. Evaluation of Xpert MTB/RIF Ultra Assay for Diagnosis of Childhood Tuberculosis: a Multicenter Accuracy Study. J Clin Microbiol 2020; 58:e00702-20. [PMID: 32522831 DOI: 10.1128/JCM.00702-20] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/04/2020] [Indexed: 02/07/2023] Open
Abstract
A multicenter study was performed to evaluate the value of testing gastric aspirate (GA) with Xpert MTB/RIF Ultra assay (Ultra) for childhood tuberculosis (TB) detection in China. In total, 129 children with active TB and 173 children without TB were enrolled. The sensitivity of Ultra in bacteriologically confirmed TB and probable TB cases was 87.5% (42/48) and 44.4% (36/81), respectively. The specificity of Ultra was high (99.4%, 172/173). When Ultra, culture, and acid-fast bacilli outcomes were integrated as a composite reference standard, the percentage of children with definite TB increased from 37. A multicenter study was performed to evaluate the value of testing gastric aspirate (GA) with Xpert MTB/RIF Ultra assay (Ultra) for childhood tuberculosis (TB) detection in China. In total, 129 children with active TB and 173 children without TB were enrolled. The sensitivity of Ultra in bacteriologically confirmed TB and probable TB cases was 87.5% (42/48) and 44.4% (36/81), respectively. The specificity of Ultra was high (99.4%, 172/173). When Ultra, culture, and acid-fast bacilli outcomes were integrated as a composite reference standard, the percentage of children with definite TB increased from 37.2% (48/129) to 67.4% (87/129). The sensitivity of Ultra is 80.0% (40/50) in children aged <4 years, which is significantly higher than that in older children (48.1%, 38/79) (P < 0.001). Ultra conducted using GA samples can provide faster results, allowing an early and accurate TB diagnosis, especially in younger children with difficulty producing sputum.
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33
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Togun T, Hoggart CJ, Agbla SC, Gomez MP, Egere U, Sillah AK, Saidy B, Mendy F, Pai M, Kampmann B. A three-marker protein biosignature distinguishes tuberculosis from other respiratory diseases in Gambian children. EBioMedicine 2020; 58:102909. [PMID: 32711253 PMCID: PMC7381493 DOI: 10.1016/j.ebiom.2020.102909] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/02/2020] [Accepted: 07/08/2020] [Indexed: 01/30/2023] Open
Abstract
Background Our study aimed to identify a host cytokine biosignature that could distinguish childhood tuberculosis (TB) from other respiratory diseases (OD). Methods Cytokine responses in prospectively recruited children with symptoms suggestive of TB were measured in whole blood assay supernatants, harvested after overnight incubation, using a Luminex platform. We used logistic regression models with Least Absolute Shrinkage and Selection Operator (LASSO) penalty to identify the optimal biosignature associated with confirmed TB disease in the training set. We subsequently assessed its performance in the test set. Findings Of the 431 children included in the study, 44 had bacteriologically confirmed TB, 60 had clinically diagnosed TB while 327 had OD. All children were HIV-negative. Application of LASSO regression models to the training set (n = 260) resulted in the combination of IL-1ra, IL-7 and IP-10 from unstimulated samples as the optimally discriminant cytokine biosignature associated with bacteriologically confirmed TB. In the test set (n = 171), this biosignature distinguished children diagnosed with TB disease, irrespective of microbiological confirmation, from OD with area under the receiver operator characteristic curve (AUC) of 0•74 (95% CI: 0•67, 0•81), and demonstrated sensitivity and specificity of 72•2% (95% CI: 60•4, 82•1%) and 75•0% (95% CI: 64•9, 83•4%) respectively, with its performance independent of their age group and their age- and sex-adjusted nutritional status. Interpretation This novel biosignature of childhood TB derived from unstimulated supernatants is promising. Independent validation with further optimisation will improve its performance and translational potential. Funding Steinberg Fellowship (McGill University); Grand Challenges Canada; MRC Program Grant.
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Affiliation(s)
- Toyin Togun
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Atlantic Boulevard, Fajara, The Gambia; The Vaccine Centre, and Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom.
| | - Clive J Hoggart
- Section of Paediatrics, Imperial College London, St Mary's Campus, London, United Kingdom; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Schadrac C Agbla
- Department of Health Data Sciences, University of Liverpool, Liverpool, United Kingdom; Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom
| | - Marie P Gomez
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Atlantic Boulevard, Fajara, The Gambia
| | - Uzochukwu Egere
- Community Health Systems Group, Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Abdou K Sillah
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Atlantic Boulevard, Fajara, The Gambia
| | - Binta Saidy
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Atlantic Boulevard, Fajara, The Gambia
| | - Francis Mendy
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Atlantic Boulevard, Fajara, The Gambia
| | - Madhukar Pai
- McGill International TB Centre, and Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Quebec, Canada; Manipal-McGill Centre for Infectious Diseases, Manipal University, Manipal, India
| | - Beate Kampmann
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Atlantic Boulevard, Fajara, The Gambia; The Vaccine Centre, and Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom.
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Jiang J, Yang J, Shi Y, Jin Y, Tang S, Zhang N, Lu Y, Sun G. Head-to-head comparison of the diagnostic accuracy of Xpert MTB/RIF and Xpert MTB/RIF Ultra for tuberculosis: a meta-analysis. Infect Dis (Lond) 2020; 52:763-775. [PMID: 32619114 DOI: 10.1080/23744235.2020.1788222] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) diagnosis has significantly improved since the introduction of the automated molecular test Xpert MTB/RIF (Xpert) and the new version Xpert MTB/RIF Ultra (Ultra) that detect Mycobacterium tuberculosis. Due to the rapidly widespread use of Xpert and Ultra, we conducted a meta-analysis to compare the performances of Xpert and Ultra in diagnosing TB and discuss the advantages and limitations of these two tests. METHODS Web of Science, Medline (via PubMed), Embase (via OvidSP), the Cochrane Central Register of Controlled Trials and Google Scholar (up to April 2020) were searched for relevant studies. The diagnostic performance of Xpert and Ultra for TB was determined using a bivariate random-effects regression model. The sources of heterogeneity were explored via meta-regression and subgroup analyses. RESULTS Of 19 studies that examined a total of 5855 samples, the pooled sensitivity and specificity of Xpert in TB diagnosis were 0.69 (95% CI: 0.57-0.78) and 0.99 (95% CI: 0.98-0.99), respectively. However, the pooled sensitivity and specificity of Ultra in TB diagnosis were 0.84 (95% CI: 0.76-0.90) and 0.97 (95% CI: 0.96-0.98), respectively. Regardless of whether the comparisons were indirect or direct, Ultra was consistently found to be more sensitive, but with slightly lower specificity than Xpert in diagnosing TB. CONCLUSIONS Compared with Xpert, Ultra had higher sensitivity but slightly lower specificity for the diagnosis of TB disease. The excellent upgrade in sensitivity of the Ultra test was particularly relevant in subjects with paucibacillary TB including tuberculous pleurisy, tuberculous meningitis and paediatric TB.
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Affiliation(s)
- Jianjun Jiang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jin Yang
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yining Shi
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yongmei Jin
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Sihui Tang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Na Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Youjin Lu
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Gengyun Sun
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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Zar HJ. Reply to Jain et al.: Utility of Xpert Ultra on Different Respiratory Specimens in Children. Am J Respir Crit Care Med 2020; 201:1452-1453. [PMID: 32176518 PMCID: PMC7258642 DOI: 10.1164/rccm.202003-0506le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
PURPOSE OF REVIEW The present review focuses on recent advances and current challenges in screening, diagnosis and management of tuberculosis (TB) in children, encompassing TB infection and TB disease, and public health priorities for screening and family engagement. RECENT FINDINGS Although awareness has improved in recent years that children in TB endemic areas suffer a huge disease burden, translation into better prevention and care remains challenging. Recent WHO guidelines have incorporated screening of all household contacts of pulmonary TB cases, but implementation in high incidence settings remains limited. Improved tests using noninvasive samples, such as the lateral flow urinary lipoarabinomannan assay and the new Xpert Ultra assay applied to induced sputum or stool in young children, are showing promise and further assessment is eagerly awaited. From a treatment perspective, child-friendly dispersible fixed dose combination tablets are now widely available with excellent acceptability and tolerance reported in young children. SUMMARY High-level government commitment to TB control as a public health priority and feasible strategies to achieve this are required to contain the global epidemic, whereas strong engagement of local TB clinics and affected families in TB prevention is essential to limit secondary cases and protect exposed children.
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Affiliation(s)
| | - Ben J Marais
- Department of Infectious Diseases & Microbiology, The Children's Hospital at Westmead, Westmead.,Discipline of Child and Adolescent Health.,Marie Bashir Institute for Infectious Diseases & Biosecurity, University of Sydney, Sydney, New South Wales, Australia
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Sarınoğlu RC, Duman N, Ünlü N, Yıldızeli SO, Yagci AK. Xpert MTB/Ultra assay: Handle with care. J Infect 2020; 80:350-71. [DOI: 10.1016/j.jinf.2019.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 11/08/2019] [Indexed: 11/20/2022]
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Wang G, Wang S, Yang X, Sun Q, Jiang G, Huang M, Huo F, Ma Y, Chen X, Huang H. Accuracy of Xpert MTB/RIF Ultra for the Diagnosis of Pleural TB in a Multicenter Cohort Study. Chest 2020; 157:268-275. [DOI: 10.1016/j.chest.2019.07.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 06/20/2019] [Accepted: 07/27/2019] [Indexed: 10/26/2022] Open
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Zar HJ, Workman LJ, Prins M, Bateman LJ, Mbhele SP, Whitman CB, Denkinger CM, Nicol MP. Tuberculosis Diagnosis in Children Using Xpert Ultra on Different Respiratory Specimens. Am J Respir Crit Care Med 2019; 200:1531-1538. [PMID: 31381861 PMCID: PMC6909828 DOI: 10.1164/rccm.201904-0772oc] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 08/05/2019] [Indexed: 11/16/2022] Open
Abstract
Rationale: Microbiological confirmation of pulmonary tuberculosis in children is desirable.Objectives: To investigate the diagnostic accuracy and incremental yield of Xpert MTB/RIF Ultra (Ultra; Cepheid), a new rapid test, on repeated induced sputum, nasopharyngeal aspirates, and combinations of specimens.Methods: Consecutive South African children hospitalized with suspected pulmonary tuberculosis were enrolled.Measurements and Main Results: Induced sputum (IS) and nasopharyngeal aspirates (NPAs) were obtained. NPAs were frozen; IS underwent liquid culture, and an aliquot was frozen. Ultra was performed on thawed NPAs and IS specimens individually. Children were categorized as confirmed, unconfirmed, or unlikely tuberculosis according to NIH consensus case definitions. The diagnostic accuracy of Ultra was compared with liquid culture on IS. In total, 195 children (median age: 23.3 mo; 32 [16.4%] HIV-infected) had one IS and NPA, and 130 had two NPAs. There were 40 (20.5%) culture-confirmed cases. Ultra was positive on NPAs in 26 (13.3%) and on IS in 31 (15.9%). Sensitivity and specificity of Ultra on one NPA were 46% and 98%, respectively, and similar by HIV status. Sensitivity and specificity of Ultra on one IS were 74.3% and 96.9% respectively. Combining one NPA and one IS increased sensitivity to 80%. Sensitivity using Ultra on two NPAs was 54.2%, increasing to 87.5% with an IS Ultra.Conclusions: IS provides a better specimen than repeated NPA for rapid diagnosis using Ultra. However, Ultra testing of combinations of specimens provides a novel strategy that can be adapted to identify most children with confirmed pulmonary tuberculosis.
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Affiliation(s)
- Heather J. Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and South African Medical Research Council Unit on Child and Adolescent Health and
| | - Lesley J. Workman
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and South African Medical Research Council Unit on Child and Adolescent Health and
| | - Margaretha Prins
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and South African Medical Research Council Unit on Child and Adolescent Health and
| | - Linda J. Bateman
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and South African Medical Research Council Unit on Child and Adolescent Health and
| | - Slindile P. Mbhele
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Cynthia B. Whitman
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and South African Medical Research Council Unit on Child and Adolescent Health and
| | - Claudia M. Denkinger
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
- Center of Infectious Diseases, University of Heidelberg, Heidelberg, Germany and
| | - Mark P. Nicol
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
- School of Biomedical Sciences, University of Western Australia, Perth, Western Australia, Australia
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Schmidt CM, Lovero KL, Carvalho FR, Dos Santos DCM, Barros ACMW, Quintanilha AP, Barbosa AP, Pone MVS, Pone SM, Araujo JM, de Paula Martins C, Macedo SGD, Miceli AL, Vieira ML, Sias SMA, Queiroz A, Coca Velarde LG, Kritski AL, Silva AA, Sant'Anna CC, Riley LW, Araújo Cardoso CA. Serum anti-Mce1A immunoglobulin detection as a tool for differential diagnosis of tuberculosis and latent tuberculosis infection in children and adolescents. Tuberculosis (Edinb) 2020; 120:101893. [PMID: 32090854 DOI: 10.1016/j.tube.2019.101893] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 11/28/2019] [Accepted: 12/01/2019] [Indexed: 11/21/2022]
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Abstract
OBJECTIVES To review epidemiology, aetiology and management of childhood pneumonia in low-and-middle-income countries. DESIGN Review of published English literature between 2013 and 2019. RESULTS Pneumonia remains a major cause of morbidity and mortality. Risk factors include young age, malnutrition, immunosuppression, tobacco smoke or air pollution exposure. Better methods for specimen collection and molecular diagnostics have improved microbiological diagnosis, indicating that pneumonia results from several organisms interacting. Induced sputum increases microbiologic yield for Bordetella pertussis or Mycobacterium tuberculosis, which has been associated with pneumonia in high TB prevalence areas. The proportion of cases due to Streptococcus pneumoniae and Haemophilus influenzae b has declined with new conjugate vaccines; Staphylococcus aureus and H. influenzae non-type b are the commonest bacterial pathogens; viruses are the most common pathogens. Effective interventions comprise antibiotics, oxygen and non-invasive ventilation. New vaccines have reduced severity and incidence of disease, but disparities exist in uptake. CONCLUSION Morbidity and mortality from childhood pneumonia has decreased but a considerable preventable burden remains. Widespread implementation of available, effective interventions and development of novel strategies are needed.
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MESH Headings
- Age Factors
- Air Pollution/statistics & numerical data
- Anti-Bacterial Agents/therapeutic use
- Child Nutrition Disorders/epidemiology
- Child, Preschool
- Developing Countries
- Haemophilus Infections/epidemiology
- Haemophilus Infections/microbiology
- Haemophilus Infections/prevention & control
- Haemophilus Infections/therapy
- Humans
- Infant
- Infant, Newborn
- Noninvasive Ventilation/methods
- Oxygen Inhalation Therapy/methods
- Pneumonia/epidemiology
- Pneumonia/microbiology
- Pneumonia/prevention & control
- Pneumonia/therapy
- Pneumonia, Pneumococcal/epidemiology
- Pneumonia, Pneumococcal/microbiology
- Pneumonia, Pneumococcal/prevention & control
- Pneumonia, Pneumococcal/therapy
- Pneumonia, Staphylococcal/epidemiology
- Pneumonia, Staphylococcal/microbiology
- Pneumonia, Staphylococcal/therapy
- Risk Factors
- Tobacco Smoke Pollution/statistics & numerical data
- Tuberculosis, Pulmonary/epidemiology
- Tuberculosis, Pulmonary/microbiology
- Tuberculosis, Pulmonary/prevention & control
- Tuberculosis, Pulmonary/therapy
- Vaccines/therapeutic use
- Whooping Cough/epidemiology
- Whooping Cough/microbiology
- Whooping Cough/prevention & control
- Whooping Cough/therapy
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Affiliation(s)
- Diana Marangu
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya; Department of Paediatrics and Child Health and SA Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Heather J Zar
- Department of Paediatrics and Child Health and SA Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa.
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Affiliation(s)
- Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and South African Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa; and
| | - Mark P Nicol
- Division of Infection and Immunity, School of Biomedical Sciences, The University of Western Australia, Perth, Australia
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Zhang M, Xue M, He JQ. Diagnostic accuracy of the new Xpert MTB/RIF Ultra for tuberculosis disease: A preliminary systematic review and meta-analysis. Int J Infect Dis 2019; 90:35-45. [PMID: 31546008 DOI: 10.1016/j.ijid.2019.09.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/07/2019] [Accepted: 09/09/2019] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES The re-engineered Xpert MTB/RIF Ultra (Xpert Ultra) assay was developed due to the poor sensitivity of the Xpert MTB/RIF assay for the detection of tuberculosis (TB) in some conditions. This new assay has been recommended by the World Health Organization since 2017. A systematic review and meta-analysis was performed to assess the accuracy of Xpert Ultra for the detection of TB and rifampicin (RIF) resistance. METHODS The Medline (via PubMed), Embase (via OvidSP), ISI Web of Science, Cochrane Central Register of Controlled Trials, and Scopus databases were screened for original articles. Summary sensitivity and specificity were calculated with a bivariate mixed-effects model. A Fagan nomogram was used to assess the clinical utility. The sources of heterogeneity were investigated by meta-regression and subgroup analyses. RESULTS Sixteen studies were identified. The summary diagnostic accuracy of Xpert Ultra for the diagnosis of TB were as follows: sensitivity 87.2% (95% confidence interval (CI) 82.5-90.8%) and specificity 96.5% (95% CI 95.1-97.5%). For the detection of RIF resistance, sensitivity was 95.1% (95% CI 91.6-97.2%) and specificity was 98.9% (95% CI 97.6-99.5%). Meta-regression showed that the category of population, TB prevalence, reference standard, sample state, sample type, and study design attributed to the heterogeneity. Subgroup analyses found good performance of Xpert Ultra in settings with a low TB burden. CONCLUSIONS As a rapid and highly sensitive test for the detection of TB and simultaneous detection of RIF resistance, Xpert Ultra exhibits a viable alternative in sensitivities in both pulmonary TB (PTB) and extrapulmonary TB (EPTB), which was proved to be higher than Xpert in the comparative analysis, and also shows a good performance in the detection of RIF resistance. Additional studies with comparative consistency tests are needed to precisely describe this finding for more forms of EPTB.
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Affiliation(s)
- Meng Zhang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu 610041, China
| | - Miao Xue
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu 610041, China
| | - Jian-Qing He
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu 610041, China.
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Sun Q, Wang S, Dong W, Jiang G, Huo F, Ma Y, Huang H, Wang G. Diagnostic value of Xpert MTB/RIF Ultra for osteoarticular tuberculosis. J Infect 2019; 79:153-158. [DOI: 10.1016/j.jinf.2019.06.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/09/2019] [Accepted: 06/10/2019] [Indexed: 10/26/2022]
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Atherton RR, Cresswell FV, Ellis J, Kitaka SB, Boulware DR. Xpert MTB/RIF Ultra for Tuberculosis Testing in Children: A Mini-Review and Commentary. Front Pediatr 2019; 7:34. [PMID: 30873392 PMCID: PMC6403143 DOI: 10.3389/fped.2019.00034] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 01/25/2019] [Indexed: 12/12/2022] Open
Abstract
Tuberculosis (TB) remains a significant, yet under-recognized cause of death in the pediatric population, with a WHO estimate of 1 million new cases of childhood TB in 2016 resulting in 250,000 deaths. Diagnosis is notoriously difficult; manifestations are protean due to the high proportion of cases of extra-pulmonary TB in children, and logistical problems exist in obtaining suitable specimens. These issues are compounded by the paucibacillary nature of disease with the result that an estimated 96% of pediatric TB-associated mortality occurs prior to commencing anti-tuberculous treatment. Further development of sensitive, rapid diagnostic tests and their incorporation into diagnostic algorithms is vital in this population, and central to the WHO End-TB strategy. Initial gains were made with the expansion of nucleic acid amplification technology, particularly the introduction of the GeneXpert fully-automated PCR Xpert MTB/Rif assay in 2010, and more recently, the Xpert MTB/Rif Ultra (Ultra) assay in 2017. Ultra provides increased analytical sensitivity when compared with the initial Xpert assay in vitro; a finding now also supported by six clinical studies to date, two of which included pediatric samples. Here, we review the published evidence for the performance of Ultra in TB diagnosis in children, as well as studies in adults with paucibacillary disease providing results relevant to the pediatric population. Following on from this, we speculate upon future directions for Ultra, with focus on its potential use with alternative diagnostic specimens, which may be of particular utility in children.
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Affiliation(s)
- Rachel R. Atherton
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fiona V. Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- LSHTM-MRC-UVRI Uganda Research Unit, Entebbe, Uganda
| | - Jayne Ellis
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Sabrina B. Kitaka
- Department of Paediatrics and Child Health, Mulago Hospital and Makerere University School of Medicine, Kampala, Uganda
| | - David R. Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
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Wang G, Wang S, Jiang G, Yang X, Huang M, Huo F, Ma Y, Dai G, Li W, Chen X, Huang H. Xpert MTB/RIF Ultra improved the diagnosis of paucibacillary tuberculosis: A prospective cohort study. J Infect 2019; 78:311-316. [PMID: 30796951 DOI: 10.1016/j.jinf.2019.02.010] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/26/2018] [Accepted: 02/18/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We assessed the diagnostic performance of Xpert MTB/RIF Ultra (Xpert Ultra) in comparison to Xpert MTB/RIF (Xpert) for the detection of paucibacillary tuberculosis (TB). METHODS Smear-negative sputum, pleural fluid and cerebrospinal fluid (CSF) were collected from TB suspects at Beijing Chest Hospital (Beijing, China) and were examined using smear, Xpert and culture. Xpert Ultra was tested using specimens stored at -80 °C. Drug susceptibility testing (DST) was conducted for all of the isolates recovered. The performances of Xpert Ultra and Xpert were evaluated using composite reference standard (CRS) as gold standard, which included clinical, laboratory, histopathological, radiological and follow-up features. RESULTS Totally 689 cases were included. The direct head-to-head diagnostic performance comparison showed higher sensitivity of Xpert Ultra in contrast with Xpert among 292 smear-negative pulmonary TB (PTB) (70.89% vs 57.88%, P = 0.001), 108 tuberculous pleurisy (61.11% vs 34.26%, P<0.001), and 43 tuberculous meningitis (44.19% vs 18.60%, P = 0.011). The percentage of definite PTB, tuberculous pleurisy and tuberculous meningitis increased from 67.12% to 78.77%, 61.11% to 69.44% and 23.26% to 51.16%, respectively after integrating Xpert Ultra outcomes. The specificity of Xpert Ultra and Xpert was 96.75% (238/246) and 98.37% (242/246), respectively. Xpert Ultra and Xpert performed similarly in detecting rifampicin resistance. CONCLUSION Xpert Ultra has higher sensitivity but relatively reduced specificity compared with Xpert in diagnosis of paucibacillary TB. Performing Xpert Ultra would improve the definite diagnosis of smear-negative pulmonary tuberculosis, tuberculous pleurisy and tuberculous meningitis.
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Affiliation(s)
- Guirong Wang
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beiguan St #9, Beijing, China.
| | - Shuqi Wang
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beiguan St #9, Beijing, China
| | - Guanglu Jiang
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beiguan St #9, Beijing, China
| | - Xinting Yang
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, China
| | - Mailing Huang
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, China
| | - Fengmin Huo
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beiguan St #9, Beijing, China
| | - Yifeng Ma
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beiguan St #9, Beijing, China
| | - Guangming Dai
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beiguan St #9, Beijing, China
| | - Weimin Li
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beiguan St #9, Beijing, China
| | - Xiaoyou Chen
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, China.
| | - Hairong Huang
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beiguan St #9, Beijing, China.
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Opota O, Zakham F, Mazza-Stalder J, Nicod L, Greub G, Jaton K. Added Value of Xpert MTB/RIF Ultra for Diagnosis of Pulmonary Tuberculosis in a Low-Prevalence Setting. J Clin Microbiol 2019; 57:e01717-18. [PMID: 30541937 DOI: 10.1128/JCM.01717-18] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 12/04/2018] [Indexed: 12/14/2022] Open
Abstract
Xpert MTB/RIF (Xpert) for direct molecular detection of Mycobacterium tuberculosis and rifampin resistance from clinical specimens has dramatically improved the diagnosis of tuberculosis (TB). Xpert MTB/RIF Ultra (Ultra) is proposed as a substitute of Xpert with increased sensitivity and improved rifampin resistance detection. Xpert MTB/RIF (Xpert) for direct molecular detection of Mycobacterium tuberculosis and rifampin resistance from clinical specimens has dramatically improved the diagnosis of tuberculosis (TB). Xpert MTB/RIF Ultra (Ultra) is proposed as a substitute of Xpert with increased sensitivity and improved rifampin resistance detection. We evaluated the diagnostic performance of Ultra and Xpert for pulmonary TB diagnosis in a low-TB-burden setting. Performance of Ultra and Xpert were compared to culture on respiratory specimens from patients with suspected pulmonary TB (November 2016 to August 2018; n = 196) in Lausanne (Switzerland). Clinical data were used to investigate discrepant results. Correlation between semiquantitative result of Ultra and smear microscopy status for the detection of acid-fast bacilli (AFB) was established. The sensitivities of Xpert and Ultra were 82.9% (39/47) and 95.8% (45/47), respectively, when considering all culture-positive specimens, 100% (23/23) for both assays on smear-positive specimens, and 66.7% (16/24) and 91.7% (22/24) on smear-negative specimens. Using culture as gold standard, the specificities of Xpert and Ultra were 97.3% (145/149) and 96.64% (144/149), respectively. All the patients with Ultra-positive results with the new category “trace” were diagnosed with active TB based on clinical findings and microbiological culture. The semiquantitative results of both Xpert and of Ultra positively correlated with the semiquantitative result of AFB detection. Our data support an increased sensitivity of Ultra compared to Xpert in a low-prevalence setting. Correlation between the Ultra semiquantitative result and AFB burden can help in evaluating a patient’s transmission potential.
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