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Intensified tuberculosis case-finding in HIV-positive adults managed at Ethiopian health centers: diagnostic yield of Xpert MTB/RIF compared with smear microscopy and liquid culture.
PLoS One. 2014; 9(1):e85478.Plos

Abstract

BACKGROUND

Detection of active tuberculosis (TB) before antiretroviral therapy (ART) initiation is important, but optimal diagnostic methods for use in resource-limited settings are lacking. We assessed the prevalence of TB, evaluated the diagnostic yield of Xpert MTB/RIF in comparison with smear microscopy and culture, and the impact of Xpert results on clinical management in HIV-positive adults eligible for ART at health centers in a region of Ethiopia.

METHODS

Participants were prospectively recruited and followed up at 5 health centers. Trained nurses collected data on socio-demographic characteristics, medical history and symptoms, and performed physical examination. Two paired morning sputum samples were obtained, and lymph node aspirates in case of lymphadenopathy. Diagnostic yield of Xpert MTB/RIF in sputum was compared with smear microscopy and liquid culture.

RESULTS

TB was diagnosed in 145/812 participants (17.9%), with bacteriological confirmation in 137 (16.9%). Among bacteriologically confirmed cases, 31 were smear-positive (22.6%), 96 were Xpert-positive (70.1%), and 123 were culture-positive (89.8%). Xpert MTB/RIF increased the TB detection rate by 64 cases (47.4%) compared with smear microscopy. The overall sensitivity of Xpert MTB/RIF was 66.4%, and was not significantly lower when testing one compared with two samples. While Xpert MTB/RIF was 46.7% sensitive among patients with CD4 cell counts >200 cells/mm(3), this increased to 82.9% in those with CD4 cell counts ≤100 cells/mm(3). Compared with Xpert-positive TB patients, Xpert-negative cases had less advanced HIV and TB disease characteristics.

CONCLUSIONS

Previously undiagnosed TB is common among HIV-positive individuals managed in Ethiopian health centers. Xpert MTB/RIF increased TB case detection, especially in patients with advanced immunosuppression. An algorithm based on the use of a single morning sputum sample for individuals with negative sputum smear microscopy could be considered for intensified case finding in patients eligible for ART. However, technical and cost-effectiveness issues relevant for low-income countries warrant further study.

Authors+Show Affiliations

Infectious Disease Research Unit, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden ; Ministry of Health, Addis Ababa, Ethiopia.Clinical Microbiology, Regional and University Laboratories, Region Skåne, Sweden.Infectious Disease Research Unit, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden ; Regional Department of Infectious Disease Control and Prevention, Malmö, Sweden.Infectious Disease Research Unit, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.Infectious Disease Research Unit, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.Oromia Health Bureau, Addis Ababa, Ethiopia.Columbia University Mailman School of Public Health, International Center for AIDS Care and Treatment Programs- Ethiopia, Addis Ababa, Ethiopia.Department of Medical Microbiology, Faculty of Health Sciences, Linköping University, Sweden ; Department of Clinical Microbiology and Infectious diseases, Kalmar County Hospital, Sweden.Infectious Disease Research Unit, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.

Pub Type(s)

Comparative Study
Journal Article
Multicenter Study
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

24465572

Citation

Balcha, Taye T., et al. "Intensified Tuberculosis Case-finding in HIV-positive Adults Managed at Ethiopian Health Centers: Diagnostic Yield of Xpert MTB/RIF Compared With Smear Microscopy and Liquid Culture." PloS One, vol. 9, no. 1, 2014, pp. e85478.
Balcha TT, Sturegård E, Winqvist N, et al. Intensified tuberculosis case-finding in HIV-positive adults managed at Ethiopian health centers: diagnostic yield of Xpert MTB/RIF compared with smear microscopy and liquid culture. PLoS One. 2014;9(1):e85478.
Balcha, T. T., Sturegård, E., Winqvist, N., Skogmar, S., Reepalu, A., Jemal, Z. H., Tibesso, G., Schön, T., & Björkman, P. (2014). Intensified tuberculosis case-finding in HIV-positive adults managed at Ethiopian health centers: diagnostic yield of Xpert MTB/RIF compared with smear microscopy and liquid culture. PloS One, 9(1), e85478. https://doi.org/10.1371/journal.pone.0085478
Balcha TT, et al. Intensified Tuberculosis Case-finding in HIV-positive Adults Managed at Ethiopian Health Centers: Diagnostic Yield of Xpert MTB/RIF Compared With Smear Microscopy and Liquid Culture. PLoS One. 2014;9(1):e85478. PubMed PMID: 24465572.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Intensified tuberculosis case-finding in HIV-positive adults managed at Ethiopian health centers: diagnostic yield of Xpert MTB/RIF compared with smear microscopy and liquid culture. AU - Balcha,Taye T, AU - Sturegård,Erik, AU - Winqvist,Niclas, AU - Skogmar,Sten, AU - Reepalu,Anton, AU - Jemal,Zelalem Habtamu, AU - Tibesso,Gudeta, AU - Schön,Thomas, AU - Björkman,Per, Y1 - 2014/01/22/ PY - 2013/07/18/received PY - 2013/11/28/accepted PY - 2014/1/28/entrez PY - 2014/1/28/pubmed PY - 2014/12/15/medline SP - e85478 EP - e85478 JF - PloS one JO - PLoS One VL - 9 IS - 1 N2 - BACKGROUND: Detection of active tuberculosis (TB) before antiretroviral therapy (ART) initiation is important, but optimal diagnostic methods for use in resource-limited settings are lacking. We assessed the prevalence of TB, evaluated the diagnostic yield of Xpert MTB/RIF in comparison with smear microscopy and culture, and the impact of Xpert results on clinical management in HIV-positive adults eligible for ART at health centers in a region of Ethiopia. METHODS: Participants were prospectively recruited and followed up at 5 health centers. Trained nurses collected data on socio-demographic characteristics, medical history and symptoms, and performed physical examination. Two paired morning sputum samples were obtained, and lymph node aspirates in case of lymphadenopathy. Diagnostic yield of Xpert MTB/RIF in sputum was compared with smear microscopy and liquid culture. RESULTS: TB was diagnosed in 145/812 participants (17.9%), with bacteriological confirmation in 137 (16.9%). Among bacteriologically confirmed cases, 31 were smear-positive (22.6%), 96 were Xpert-positive (70.1%), and 123 were culture-positive (89.8%). Xpert MTB/RIF increased the TB detection rate by 64 cases (47.4%) compared with smear microscopy. The overall sensitivity of Xpert MTB/RIF was 66.4%, and was not significantly lower when testing one compared with two samples. While Xpert MTB/RIF was 46.7% sensitive among patients with CD4 cell counts >200 cells/mm(3), this increased to 82.9% in those with CD4 cell counts ≤100 cells/mm(3). Compared with Xpert-positive TB patients, Xpert-negative cases had less advanced HIV and TB disease characteristics. CONCLUSIONS: Previously undiagnosed TB is common among HIV-positive individuals managed in Ethiopian health centers. Xpert MTB/RIF increased TB case detection, especially in patients with advanced immunosuppression. An algorithm based on the use of a single morning sputum sample for individuals with negative sputum smear microscopy could be considered for intensified case finding in patients eligible for ART. However, technical and cost-effectiveness issues relevant for low-income countries warrant further study. SN - 1932-6203 UR - https://www.unboundmedicine.com/medline/citation/24465572/Intensified_tuberculosis_case_finding_in_HIV_positive_adults_managed_at_Ethiopian_health_centers:_diagnostic_yield_of_Xpert_MTB/RIF_compared_with_smear_microscopy_and_liquid_culture_ DB - PRIME DP - Unbound Medicine ER -