Empiric treatment of pulmonary TB in the Xpert era: Correspondence of sputum culture, Xpert MTB/RIF, and clinical diagnoses

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dc.contributor.authorKendall, Emily A.
dc.contributor.authorKamoga, Caleb
dc.contributor.authorKitonsa, Peter J.
dc.contributor.authorNalutaaya, Annet
dc.contributor.authorSalvatore, Phillip P.
dc.contributor.authorRobsky, Katherine
dc.contributor.authorNakasolya, Olga
dc.contributor.authorMukiibi, James
dc.contributor.authorIsooba, David
dc.contributor.authorCattamanchi, Adithya
dc.contributor.authorKato-Maeda, Midori
dc.contributor.authorKatamba, Achilles
dc.contributor.authorDowdy, David W.
dc.date.accessioned2023-01-14T18:45:37Z
dc.date.available2023-01-14T18:45:37Z
dc.date.issued2019
dc.description.abstractClinical tuberculosis diagnosis and empiric treatment have traditionally been common among patients with negative bacteriologic test results. Increasing availability of rapid molecular diagnostic tests, including Xpert MTB/RIF and the new Xpert Ultra cartridge, may alter the role of empiric treatment. Methods We prospectively enrolled outpatients age > = 15 who were evaluated for pulmonary tuberculosis at three health facilities in Kampala, Uganda. Using sputum mycobacterial culture, interviews, and clinical record abstraction, we estimated the accuracy of clinical diagnosis relative to Xpert and sputum culture and assessed the contribution of clinical diagnosis to case detection. Results Over a period of 9 months, 99 patients were diagnosed with pulmonary tuberculosis and subsequently completed sputum culture; they were matched to 196 patients receiving negative tuberculosis evaluations in the same facilities. Xpert was included in the evaluation of 291 (99%) patients. Compared to culture, Xpert had a sensitivity of 92% (95% confidence interval 83–97%) and specificity of 95% (92–98%). Twenty patients with negative Xpert were clinically diagnosed with tuberculosis and subsequently had their culture status determined; two (10%) were culture-positive. Considering all treated patients regardless of Xpert and culture data completeness, and considering treatment initiations before a positive Xpert (N = 4) to be empiric, 26/101 (26%) tuberculosis treatment courses were started empirically. Compared to sputum smear- or Xpert-positive patients with positive cultures, empiricallytreated, Xpert-negative patients with negative cultures had higher prevalence of HIV (67% versus 37%), shorter duration of cough (median 4 versus 8 weeks), and lower inflammatory markers (median CRP 7 versus 101 mg/L). Conclusion Judged against sputum culture in a routine care setting of high HIV prevalence, the accuracy of Xpert was high. Clinical judgment identified a small number of additional culture-positive cases, but with poor specificity. Although clinicians should continue to prescribe tuberculosis treatment for Xpert-negative patients whose clinical presentations strongly suggest pulmonary tuberculosis, they should also carefully consider alternative diagnoses.en_US
dc.identifier.citationKendall EA, Kamoga C, Kitonsa PJ, Nalutaaya A, Salvatore PP, Robsky K, et al. (2019) Empiric treatment of pulmonary TB in the Xpert era: Correspondence of sputum culture, Xpert MTB/RIF, and clinical diagnoses. PLoS ONE 14(7): e0220251. https://doi.org/10.1371/journal. pone.0220251en_US
dc.identifier.urihttps://doi.org/10.1371/journal. pone.0220251
dc.identifier.urihttps://nru.uncst.go.ug/handle/123456789/6924
dc.language.isoenen_US
dc.publisherPLoS ONEen_US
dc.subjectEmpiric treatmenten_US
dc.subjectPulmonary TBen_US
dc.subjectXpert eraen_US
dc.subjectSputum cultureen_US
dc.subjectXpert MTB/RIFen_US
dc.titleEmpiric treatment of pulmonary TB in the Xpert era: Correspondence of sputum culture, Xpert MTB/RIF, and clinical diagnosesen_US
dc.typeArticleen_US
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