Treatment decisions and mortality in HIV-positive presumptive smear-negative TB in the Xpert\xae MTB/RIF era: a cohort study

Sabine M Hermans,Yukari C Manabe,Robert Colebunders,Barbara Castelnuovo,Rosalind Parkes-Ratanshi,Juliet A Babirye,Francis Kakooza,Olive Mbabazi,Christine Sekaggya-Wiltshire

doi:10.1186/s12879-017-2534-2

Abstract

BackgroundThe Xpert® MTB/RIF (XP) has a higher sensitivity than sputum smear microscopy (70% versus 35%) for TB diagnosis and has been endorsed by the WHO for TB high burden countries to increase case finding among HIV co-infected presumptive TB patients. Its impact on the diagnosis of smear-negative TB in a routine care setting is unclear. We determined the change in diagnosis, treatment and mortality of smear-negative presumptive TB with routine use of Xpert MTB/RIF (XP).MethodsProspective cohort study of HIV-positive smear-negative presumptive TB patients during a 12-month period after XP implementation in a well-staffed and trained integrated TB/HIV clinic in Kampala, Uganda. Prior to testing clinicians were asked to decide whether they would treat empirically prior to Xpert result; actual treatment was decided upon receipt of the XP result. We compared empirical and XP-informed treatment decisions and all-cause mortality in the first year.ResultsOf 411 smear-negative presumptive TB patients, 175 (43%) received an XP; their baseline characteristics did not differ. XP positivity was similar in patients with a pre-XP empirical diagnosis and those without (9/29 [17%] versus 14/142 [10%], P = 0.23). Despite XP testing high levels of empirical treatment prevailed (18%), although XP results did change who ultimately was treated for TB. When adjusted for CD4 count, empirical treatment was not associated with higher mortality compared to no or microbiologically confirmed treatment.ConclusionsXP usage was lower than expected. The lower sensitivity of XP in smear-negative HIV-positive patients led experienced clinicians to use XP as a “rule-in” rather than “rule-out” test, with the majority of patients still treated empirically.

Highlights

The Xpert® MTB/RIF (XP) has a higher sensitivity than sputum smear microscopy (70% versus 35%) for TB diagnosis and has been endorsed by the World Health Organization (WHO) for TB high burden countries to increase case finding among Human Immunodeficiency Virus (HIV) co-infected presumptive TB patients
Sputum smear microscopy has a low sensitivity for detecting TB among people living with HIV
The median age of the study participants was 38 years, 56% were female, 15% had been previously treated for TB, 50% were on ART at the time of investigation, and the median CD4+ T cell (CD4) count at presentation was 275/mm3 (Table 1)

Summary

Introduction

The Xpert® MTB/RIF (XP) has a higher sensitivity than sputum smear microscopy (70% versus 35%) for TB diagnosis and has been endorsed by the WHO for TB high burden countries to increase case finding among HIV co-infected presumptive TB patients. We determined the change in diagnosis, treatment and mortality of smear-negative presumptive TB with routine use of Xpert MTB/RIF (XP). Sputum smear microscopy has a low sensitivity for detecting TB among people living with HIV. World Health Organization (WHO) endorsed Xpert® MTB/RIF (Cepheid, Sunnyvale, California, USA) (XP) [1], the first fully automated, real-time nucleic acid amplification technology for the rapid detection of TB [1, 2] which can be performed with only 1 day of training by most health care workers. WHO policy updates in October 2013 recommending broad use of Xpert for TB diagnosis [3] and concessionary

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