Smear-negative Patients Research Articles

REFRACTORY ANEMIA AND PANCYTOPENIA AS PRESENTATIONS OF FALCIPARUM MALARIA IN POPULATION OF KHYBER PAKHTUNKHWA, PAKISTAN

Background: Falciparum malaria is a common disease in our area. Apart from its classical presentation, at times it may present with refractory anemia or pancytopenia. The aim of this study was to determine the refractory anemia and pancytopenia as complications of falciparum malaria and apart from peripheral blood smears the significance of rapid antigen tests and bone marrow examination in the diagnosis of falciparum malaria. Material & Methods: The descriptive study included 200 consecutive cases of fever and refractory anemia or pancytopenia from 2011 to 2014. Stratification of patients according to the clinical scenario included Group-A having fever with refractory anemia and Group-B with fever and pancytopenia. A detailed history, thorough clinical examination, and pertinent laboratory tests were performed. All patients were treated with antimalarial drugs and followed-up for eight weeks. The pre and post treatment hematologic parameters were compared. Results: Among the 200 patients, 85 were males and 115 females. The age ranged from 15 to 55 years. Stratification of patients on clinical scenario revealed 175(87.5%) patients with fever and refractory anemia (Group-A). Among these, 125(62.5%) patients were reported smear positive for P. falciparum. In the remaining 50 smear negative patients rapid antigen tests were performed and all were reported positive. In 25 patients of Group B with fever and pancytopenia, the peripheral smear for malaria was positive only in 5 patients. In the remaining 20 cases both the peripheral blood smears and rapid antigen tests were reported negative. Bone marrow examination was planned to confirm the bone marrow suppression as the cause of peripheral pancytopenia, to exclude leukemia and to identify P. falciparum. The bone marrow examination revealed P. falciparum in all these cases. All the patients had a dramatic response to treatment with antimalarials in terms of disappearance of fever and correction of anemia and bone marrow rescue with reversal of pancytopenia to normal counts. Conclusion: Plasmodium falciparum should be considered in all cases of prolonged fever with refractory anemia or pancytopenia in malaria endemic areas, even with negative smear and rapid antigen tests. Bone examination is mandatory for the diagnosis in such cases. There is dramatic response of such patients to treatment with antimalarial drugs and hematinics.

Utility of Bronchoalveolar Lavage in the Diagnosis of Sputum Negative Pulmonary Tuberculosis

INTRODUCTION: Sputum smear examination for acid fast bacilli (AFB) by Ziehl-Neelsen stain (ZN stain) is the initial approach to the diagnosis of pulmonary tuberculosis (PTB). But 50% of the cases are reported to be sputum smear negative. This study was aimed to investigate the diagnostic yield of fibreoptic bronchoscopy (FOB) guided bronchoalveolar lavage (BAL) in patients suspected to have tuberculosis. The sample was tested for Mycobacterium tuberculosis using the XpertMTB/RIF assay, which is a new test that detects Mycobacterium tuberculosis complex and resistance to rifampin in less than two hours.
 MATERIAL AND METHODS: This is a prospective cross sectional study carried out on 58 sputum smear negative patients who were clinically suspected to have pulmonary tuberculosis from April 2017 to January 2019. All patients are subjected to FOB, BAL and BAL specimens were stained for AFB and also sent for Xpert (MTB)/RIF.
 RESULTS: Among 58 patients enrolled for the study 26 patients were positive for acid fast bacilli (AFB) through BAL stain and Xpert (MTB)/RIF combined.
 CONCLUSION: FOB guided BAL is a reliable, alternative and rapid method for diagnosing smear negative pulmonary tuberculosis with minimal complications.

Trends of tuberculosis case detection, mortality and co-infection with HIV in Ghana: A retrospective cohort study.

In an era of renewed commitment to accelerate the declines in Tuberculosis (TB) incidence and mortality, there is the need for National Tuberculosis Programmes (NTPs) to monitor trends in key indicators across a geographical location and to provide reliable data for direct measurement of TB incidence and mortality. In this context, we explored the trends of TB case detection, mortality and HIV co-infection, and examined the predictors of TB deaths in Ten districts of the Volta region of Ghana. We conducted a retrospective cohort study of all TB cases registered from 2013 to 2017 in 10 districts of the Volta Region of Ghana. Case detection rate (CDR) was computed as the ratio of the number of new and relapse TB case notified to NTP to the number of estimated incident TB cases in a given year. Case fatality rates were estimated using data from 2012-2016 cohort of TB patients. Simple and multiple logistic regression were used to identify predictors of TB deaths with odds ratios and 95% confidence intervals estimated. Overall, there were 3,735 new and relapse TB patients who commenced anti-TB treatment during the period, representing the case detection rate of 40.1% with district variations. The CDR remained stable during the 5 years. Of the total cases, HIV status was documented for 3,144 (84.2%), among whom, 712 (22.6%) were HIV positive. The TB/HIV co-infection was more prevalent among children under 15 years of age (30.1%), males (30.6%), treatment after lost to follow-up patients (33.3%), and smear-negative pulmonary TB patients (29.1%). The prevalence of TB/HIV co-infection did not significantly change over the years. The overall case fatality rate was 13% (n = 486), with considerable variation among HIV-positives and HIV-negative TB patients (21.8% and 11% respectively) (p<0.001) and among districts. TB/HIV co-infection, sputum smear-negative pulmonary TB and district of anti-TB treatment predicted TB mortality. TB case detection rate was low and remained stable during the study period, whereas co-infection with HIV and mortality rates were quite high, indicating the need for feasible strategies such as active case finding to improve case detection, and improved case management to reduce mortality.

Role of cartridge based nucleic acid amplification test in bronchoscopy guided bronchial wash specimens in sputum smear negative PTB patients attending government general hospital, Kakinada

Tuberculosis is a global health burden still causing large mortality and morbidity. According to WHO’s 2018 Global TB Report two main routes for reducing TB incidence and death are- diagnosis and treatment. The main challenging issue with TB is to obtain a rapid and accurate diagnosis for initiating early treatment. Sometimes patient with active pulmonary tuberculosis fail to produce adequate sputum resulting in increase of false-negatives. Sputum-smear negative pulmonary tuberculosis is highly infectious and remains a diagnostic challenge. Fiber-optic bronchoscopy is an important tool for early detection and confirmation of sputum smear-negative and sputum-scarce PTB as it provides high-quality biological samples like bronchoalveolar lavage (BAL) fluid. The aim of the present study was to evaluate role of in Gene Xpert MTB/RIF on bronchoscopic specimens in sputum smear negative patients with suspicion of PTB. A prospective observational study was done on 100 patients with clinical suspicion of PTB who either have a negative sputum smear microscopy or unable to produce qualitative sputum attending outpatient and admitted in Pulmonology department, Government General Hospital, Kakinada.Out of 100 patients, 47 were diagnosed and confirmed as pulmonary tuberculosis of which bronchial specimens smear positive were 5(10.6%),bronchial specimens smear negative but CBNAAT positive were 42(89.3%). At last as CBNAAT has dual diagnostic advantage of detecting rifampicin resistance, about 5 cases were detected as rifampicin resistance. CBNAAT/RIF assay on BAL specimen provides an accurate diagnosis of PTB in patients with sputum smear negative results or those who cannot expectorate sputum and superior to sputum smears in detecting rifampicin resistance.

Diagnostic Accuracy of High-Resolution Computed Tomography of Chest in Diagnosing Sputum Smear Positive and Sputum Smear Negative Pulmonary Tuberculosis.

IntroductionPulmonary tuberculosis (PTB) is caused by species of organisms in the Mycobacterium tuberculosis complex. It is a major public health problem worldwide and is endemic in Pakistan. Various clinical and biochemical markers exist for its diagnosis. Radiology has an important role in the diagnosis of PTB. Initially, a chest radiograph is warranted for PTB evaluation. High-resolution computed tomography (HRCT) also has high sensitivity and specificity for PTB diagnosis. Features of primary TB include consolidation, lymphadenopathy, pleural effusion and miliary nodules whereas post-primary TB include apical consolidation, nodules and cavitation. The aim of this study was to determine the diagnostic accuracy of HRCT chest in diagnosing sputum smear positive and smear negative PTB.MethodsA cross-sectional study was conducted at a large tertiary care teaching hospital. A retrospective review of medical records of patients who underwent HRCT chest and sputum acid-fast bacillus (AFB) direct smear and AFB culture for suspicion of PTB was undertaken. All HRCT chest examinations were performed on multislice computed tomography (CT) scanner. On HRCT, PTB was defined as the presence of consolidation, centrilobular nodules, branching nodules with tree in bud appearance with or without lymphadenopathy and pleural effusion. Diagnostic accuracy of HRCT including sensitivity, specificity, positive and negative predictive values was calculated using 2 x 2 table, taking findings of AFB culture as a gold standard.ResultsA total of 108 patients were included in this study with a mean age of 51.85 ± 16.86 years. Diagnostic accuracy of HRCT in diagnosing PTB was found to be 84.26% with sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 89.09%, 79.25%, 81.67%, and 87.50%, respectively. In sputum smear positive patients, HRCT has diagnostic accuracy, sensitivity, specificity, PPV and NPV of 87.50%, 88.57%, 84.62%, 93.94%, and 73.33%, respectively. In sputum smear negative patients, HRCT has diagnostic accuracy, sensitivity, specificity, PPV and NPV of 81.67%, 90.00%, 77.50%, 66.67%, and 93.94%, respectively.ConclusionHRCT has high sensitivity in diagnosing sputum smear positive and sputum smear negative PTB. The specificity of HRCT in diagnosing sputum smear positive PTB was high, whereas it was slightly low in diagnosing sputum smear negative PTB. Overall diagnostic accuracy of HRCT was high in diagnosing PTB.

Prompt recognition of infectious pulmonary tuberculosis is critical to achieving elimination goals: a retrospective cohort study

IntroductionAll pulmonary tuberculosis (PTB) cases are presumed to be infectious to some degree. This spectrum of infectiousness is independently described by both the acid-fast bacilli smear and radiographic findings. Smear-positive...

Diagnostic performance of non-invasive, stool-based molecular assays in patients with paucibacillary tuberculosis

Timely diagnosis of paucibacillary tuberculosis (TB) which includes smear-negative pulmonary TB (PTB) and extra-pulmonary TB (EPTB) remains a challenge. This study was performed to assess the diagnostic utility of stool as a specimen of choice for detection of mycobacterial DNA in paucibacillary TB patients in a TB-endemic setting. Stool samples were collected from 246 subjects including 129 TB patients (62 PTB and 67 EPTB) recruited at TB hospital in Delhi, India. Diagnostic efficacy of stool IS6110 PCR (n = 228) was measured, using microbiologically/clinically confirmed TB as the reference standard. The clinical sensitivity of stool PCR was 97.22% (95% confidence interval (CI), 85.47-99.93) for detection of Mycobacterium tuberculosis in stool samples of smear-positive PTB patients and 76.92% (CI, 56.35–91.03) in samples from smear-negative PTB patients. Overall sensitivity of PCR for EPTB was 68.66% (CI, 56.16–79.44), with the highest sensitivity for stool samples from patients with lymph node TB (73.5%), followed by abdominal TB (66.7%) and pleural effusion (56.3%). Stool PCR presented a specificity of 95.12%. The receiver operating characteristic curve also indicated the diagnostic utility of stool PCR in TB detection (AUC: 0.882). The performance characteristic of the molecular assay suggests that stool DNA testing has clinical value in detection of TB.

Comparison of diagnostic accuracy of papanicoloau (PAP) Smear and visual inspection using acetic acid (VIA) in screening of cervical carcinoma, taking biopsy as gold standard.

Study Design: Cross-sectional descriptive study. Setting: Department of Obstetrics &amp; Gynecology, Bahawal Victoria Hospital, Bahawalpur. Period: 05 August 2016 to 05 Feb 2017. Material &amp; Methods: A total of 228 suspected patients of cervical carcinoma and age of 20-50 years were included. Patients with acute cervicitis, pregnant females, h/o abnormal cytology and obvious lesion on cervix were excluded. All the patients were underwent papanicoloau (PAP) smear and visual inspection using acetic acid. The results of papanicoloau (PAP) smear and visual inspection using acetic acid (VIA) were compared with cervical biopsy report. Results: In 110 papanicoloau (PAP) smear positive patients, 97 were True Positive and 13 were False Positive. Among, 118 papanicoloau (PAP) smear negative patients, 18 were False Negative whereas 100 were True Negative. Overall sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of papanicoloau ( PAP )smear in screening of cervical carcinoma was 84.35%, 88.50%, 88.18%, 84.75% and 86.40% respectively. In 114 visual inspection using acetic acid (VIA) positive patients, 95 were True Positive and 19 were False Positive. Among, 114 visual inspection using acetic acid (VIA) negative patients, 20 were False Negative whereas 94 were True Negative. Overall sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of visual inspection using acetic acid ( VIA) in screening of cervical carcinoma was 82.61%, 83.19%, 83.33% 82.46% and 82.89% respectively. Conclusion: This study concluded that papanicoloau ( PAP) smear and visual inspection using acetic acid (VIA) in screening of cervical carcinoma are highly sensitive, accurate and having almost equal diagnostic accuracy.

Hubungan Antara Kadar Laju Endap Darah (LED) Dengan Kadar C-Reaktiv Protein (CRP) Pada Penderita Tuberkulosis (TBC) Di Wilayah Kerja Puskesmas Alas Barat

Tuberculosis is a disease caused by rod-shaped bacteria (basil) with another name Mycrobacterium tuberculosis. Mycrobacterium tuberculosis enters the body then causes inflammation, inflammation and bacterial invasion which then induces liver cells to synthesize acute phase C-reactive protein protein (CRP). CRP will increase sharply after inflammation, as well as the formation of aggregates derived from the acute phase protein hormone which causes an increase in the Erythrocyte sedimentation rate (ESR)). The purpose of this study was to determine the relationship Erytrocyte sedimentation rate (ESR) and levels of C-Reactiv protein (CRP) in tuberculosis (TBC) patients. This research is an analytical descriptive study using cross sectional. Data collectors are done using the Non Random Accidental Sampling technique. The number of respondents in this study were 11 people with tuberculosis. Based on the results of this study it is known that TBC patients with smear negative as much as 7 people (63.6%) and TB patients with positive smear as much as 4 people (36.4%), both in TB patients with negative smear and positive smear both have levels of ESR not normal with an average ESR level in positive smear of 101.3 mm / hour and the average ESR level in smear negative is 20.8 mm / hour. All TBC patients with smear positive CRP levels (not normal) with an average mean value of CRP of 36 mg / L or an average CRP level in TBC smear negative patients of 0.9 mg / L. Based on the Pearson test results between levels of erythrocyte sedimentation rate (ESR) with C-Reactive protein (CRP) in tuberculosis (TBC) patients obtained a value of p &lt;0.01 (0.000 &lt;0.01). This shows a strong relationship between LED and CRP levels in TB patients

Diagnosing sputum smear negative pulmonary tuberculosis patients by transbronchial biopsy and bronchoalveolar lavage smear.

Pulmonary tuberculosis is one of the leading causes of infectious disease related mortality. Transbonchial biopsy and bronchoalveolar lavage smear obtained by bronchoscopy provides greater quantity of material for analysis, thus increases the chances of diagnosing the disease. Objectives: To diagnose sputum smear negative pulmonary tuberculosis patients by Transbronchial Biopsy and Bronchoalveolar smear keeping bronchoalvelar lavage culture as gold standard. To calculate and compare the diagnostic accuracy of transbronchial biopsy and bronchoalveolar lavage smear in sputum negative patients. Study Design: Cross-sectional validation study. Setting: Department of histopathology, Foundation University Medical College, Islamabad and Department of Pulmonology and Microbiology, Fauji Foundation Hospital, Rawalpindi. Period: From May 2016 to May 2017. Materials &amp; Methods: It comprised 96 patients who underwent bronchoscopy. Transbronchial biopsy, bronchoalveolar lavage smear preparation and bronchoalveolar lavage culture was performed on specimens of all patients. Results: Out of 96 patients 22 (22.91%) patients were actually having tuberculosis whereas 74 (77%) had only clinical and radiological suspicion of tuberculosis. The mean age of patients was 43 years with a standard deviation of ±19.1 .The age range was 12-80 years. The sensitivity, specificity, positive predictive value, negative predictive value and true positives of transbronchial biopsy were 68.1%, 77%, 46.8%, 89% and15.62% while the values for bronchoalveolar lavage were 50%, 97.29%, 84.6%, 86.7% and 11.45% respectively. Thus, the diagnostic accuracy calculated for transbronchial biopsy and bronchoalveolar lavage was 75% and 13.54% respectively. Conclusions: Bronchoscopy should be done in all sputum negative tuberculosis patients having strong clinical and radiological suspicion to obtain transbronchial biopsy and bronchoalveolar lavage for timely diagnosis, treatment and prevention of disease transmission as well as to avoid empirical treatment and its side effects in patients having no tuberculosis. The diagnostic accuracy of transbronchial biopsy is almost 5 times more compared to bronchoalveolar lavage smear.

Quantitative analysis of serum-based IgG agalactosylation for tuberculosis auxiliary diagnosis.

Tuberculosis (TB) is the leading infectious cause of mortality worldwide, especially in developing countries. However, effective means for TB diagnosis, especially for bacillus-negative (Bn) TB laboratory diagnosis, are urgently needed. In the present study, serum IgG from each tuberculosis patients and healthy controls was purified using affinity chromatography. The samples were then analyzed using mass spectrometry (MS) and ultraperformance liquid chromatography (UPLC) methods. We quantitatively assessed the changes of serum IgG galactosylation in 567 human serum samples including 377 pulmonary TB patients and 190 healthy donors (HDs). We found significantly more agalactosylated (G0) vs monogalactosylated (G1) and digalactosylated (G2) N-glycans of IgG in TB patients, including smear-negative TB patients, than in HDs. The detection rate of TB diagnostic performance by MS for IgG-Gal ratio G0/(G1+G2×2) is 90.48% for bacillus-positive (Bp) and 73.16% for Bn TB patients. Further, combination of MS method with other routine laboratory TB diagnostic methods significantly increased the detection rate to 91.01%-98.39%. Similar results were observed in Mycobacterium tuberculosis (M. tb) infection mouse models. The decrease in galactosylation of IgG in TB patients was also qualitatively confirmed using specific lectin blot assay. Using the above techniques, we can discriminate the content of IgG G0 with terminal N-acetylglucosamine and IgG-Gal ratio G0/(G1+G2×2) between TB patients and HDs. Our data suggest that quantitative analysis of serum-based IgG-Gal ratio G0/(G1+G2×2) could be used for TB auxiliary diagnosis with high effectiveness and feasibility and its combination with other routine laboratory TB diagnostic methods could remarkably improve the detection rate.

Application of CBNAAT (Xpert MTB/RIF assay) in new smear negative pulmonary tuberculosis patients.

Presumptive pulmonary tuberculosis (PTB) patients whose sputum are detected to be smear negative for acid fast bacilli (AFB) present a significant challenge for a treating physician. Initiating these patients on anti tuberculous treatment (ATT) on empirical basis is not a good strategy as many were found to be sputum culture for tuberculosis negative on further evaluation according to many previous studies. In India due to resource limited settings and lack of knowledge about newest diagnostic modalities patients are often initiated only on the basis of characteristic clinical symptoms and chest radiographic abnormalities. This study was conducted to identify the advantage of application of sputum cartridge based nucleic acid amplification test (CBNAAT) in sputum AFB smear negative presumptive pulmonary TB patients. Our study concluded that clinical symptoms and radiological characteristics cannot differentiate TB patients from non-TB patients. Treating patients only on empirical basis would have resulted in unnecessary treatment of 41 patients.

Xpert MTB/RIF Ultra and Xpert MTB/RIF for diagnosis of tuberculosis in an HIV-endemic setting with a high burden of previous tuberculosis: a two-cohort diagnostic accuracy study

Xpert MTB/RIF Ultra (Ultra) is a new test for tuberculosis undergoing global roll-out. We assessed the performance of Ultra compared with Xpert MTB/RIF (Xpert) in an HIV-endemic setting where previous tuberculosis is frequent and current test performance is suboptimal. In this two-cohort diagnostic accuracy study, we used sputum samples from patients in South Africa to evaluate the accuracy of Ultra and Xpert against a single culture reference standard. For the first cohort (cohort A), we recruited adults (aged ≥18 years) with symptoms of presumptive tuberculosis at Scottsdene clinic in Cape Town, South Africa. We collected three sputum samples from each patient in cohort A, two at the first visit of which one was tested using Xpert and the other was tested using culture, and one sample the next morning which was tested using Ultra. In a separate cohort of patients with presumptive tuberculosis and recent previous tuberculosis (≤2 years) who had submitted sputum samples to the National Health Laboratory Services (cohort B), decontaminated sediments were, after processing, randomly allocated (1:1) for testing with Ultra or Xpert. For both cohorts we calculated the sensitivity and specificity of Ultra and Xpert and evaluated the effects of different methods of interpreting Ultra trace results. Between Feb 6, 2016, and Feb 2, 2018, we recruited 302 people into cohort A, all of whom provided sputum samples and 239 were included in the head-to-head analyses of Ultra and Xpert. For cohort B, we collected sputum samples from eligible patients who had submitted samples between Dec 6, 2016, and Dec 21, 2017, to give a cohort of 831 samples, of which 352 were eligible for inclusion in analyses and randomly assigned to Ultra (n=173) or Xpert (n=179). In cohort A, Ultra gave more non-actionable results (not positive or negative) than did Xpert (28 [10%] 275 vs 14 [5%] 301; p=0·011). In the head-to-head analysis, in smear-negative patients, sensitivity of Ultra was 80% (95% CI 64-90) and of Xpert was 73% (57-85; p=0·45). Overall, specificity of Ultra was lower than that of Xpert (90% [84-94] vs 99% [95-100]; p=0·001). In cohort B, overall sensitivity was 92% (81-98) for Xpert versus 86% (73-95; p=0·36) for Ultra and overall specificity was 69% (60-77) for Ultra versus 84% (78-91; p=0·005) for Xpert. Ultra specificity estimates improved after reclassification of results with the lowest Ultra-positive semiquantitation category (trace) to negative (15% [8-22]). In cohort A, the positive predictive value (PPV) for Ultra was 78% (67-87) and for Xpert was 96% (87-99; p=0·004); in cohort B, the PPV for Ultra was 50% (43-57) and for Xpert was 70% (61-78; p=0·014). Ultra PPV estimates in previously treated patients were low: at 15% tuberculosis prevalence, half of Ultra-positive patients with presumptive tuberculosis would be culture negative, increasing to approximately 70% in patients with recent previous tuberculosis. In cohort B, 21 (28%) of 76 samples that were Ultra positive were rifampicin indeterminate (all trace) and, like cohort A, most were culture negative (19 [90%] of 21). In a setting with a high burden of previous tuberculosis, Ultra generated more non-actionable results and had diminished specificity compared with Xpert. In patients with recent previous tuberculosis, a quarter of Ultra-positive samples were indeterminate for rifampicin resistance and culture negative, suggesting that additional drug-resistance testing will probably be unsuccessful. Our data have implications for the handling of Ultra-positive results in patients with previous tuberculosis in high burden settings. South African Medical Research Council, the EDCTP2 program, and the Faculty of Medicine and Health Sciences, Stellenbosch University.

Bronchoscopic Analysis in Sputum Smear Negative Pulmonary Tuberculosis Patients A Hospital based Study

Bronchoscopic Analysis in Sputum Smear Negative Pulmonary Tuberculosis Patients A Hospital based Study

Treatment outcomes and associated factors of tuberculosis patients on directly observed treatment (short course) in a tertiary hospital in Port Harcourt, Nigeria

Introduction: Although concerted efforts have been implemented to achieve tuberculosis (TB) prevention and control, varying outcomes have been reported in several quarters, despite the implementation of the directly observed treatment short-course (DOTS) strategy in virtually all parts of the world. It was considered necessary to assess the treatment outcomes of TB patients on DOTS strategy and the associated factors against the World Health Organization (WHO) target at the University of Port Harcourt Teaching Hospital (UPTH) Port Harcourt, to stimulate improvements in efforts toward patients care in the hospital and elsewhere. Methods: A health facility-based review of patients' records (January 1, 2014–December 31, 2018) at the TB Clinic of UPTH was carried out using a validated data record sheet. Patients undergoing treatment were excluded. Data were analyzed with the SPSS software version 20. Outcome frequencies were summarized, and the Pearson's Chi-square test was used to determine the association between the outcome and independent variables at P ≤ 0.05 statistical significance level. Results: Overall, 174 (25.7%) had completed treatment, 181 (26.7%) were cured, 95 (14.0%) died, 70 (10.3%) transferred out, 45 (6.6%) defaulted, 49 (7.2%) were not evaluated, 44 (6.5%) were lost to follow-up, and 8 (1.2%) failed treatment. There was a 17.6% decline in the proportion of patients that completed treatment from 35.9% in 2014 to 18.3% in 2018. On the contrary, there was an increase in the proportion of patients that were cured, from 14.1% in 2014% to 26.1% in 2018. Conclusions: The treatment success rate for TB in the hospital was below the WHO benchmark of 85% cure rate throughout the period under review. Basic reforms in the service delivery processes that specifically targets groups at risk (male patients, sputum smear-negative TB patients, and patients with human immunodeficiency virus/TB co-infection) with drug adherence counselling, defaulter tracing arrangements, and emphasis on drug-susceptibility testing are recommended to improve treatment outcomes.

Protection of healthcare workers against transmission of Mycobacterium tuberculosis in hospitals: a review of the evidence.

BackgroundEmployees in contact with infectious tuberculosis (TB) patients in healthcare facilities of low-incidence countries are still at considerable risk of acquiring TB infections. However, formal precautions recommended on the protection of healthcare workers may not only vary from country to country but also within a single country. The objective of this study was to compare current guidelines with respect to hospital infection control of TB, focusing on common shared priorities and discrepancies between sets of recommendations.MethodsFive types of procedures captured in guidelines of the World Health Organization, the United States of America, the United Kingdom and Germany are compared and the underlying evidence is discussed.ResultsUncontroversially, personal protection by respirators in the TB ward and during aerosol-generating procedures is key to reducing Mycobacterium tuberculosis exposure. However, there is no consensus on the types of masks that should be worn in different situations. Closely connected to this, there is considerable uncertainty with respect to the optimal date of removing sputum smear-negative and multidrug-resistant TB patients from isolation. Indeed, the use of notable new tools for this purpose, such as the highly sensitive PCR tests recommended by the World Health Organization for detecting TB/multidrug-resistant TB, have yet to be sufficiently incorporated into TB guidelines. Perceptions differ, too, as to whether long-term control measures for M. tuberculosis infections in healthcare workers by serial testing for latent TB infection should be established and, if so, how testing results should be interpreted.ConclusionsAlthough the current recommendations on protection of healthcare workers are otherwise homogeneous, there are considerable discrepancies that have important implications for daily practice.

Role of bronchoalveolar lavage cartridge-based nuclear acid amplification test in the diagnosis of sputum smear-negative pulmonary tuberculosis

Background Approximately 40–60% of clinical and radiological suspected cases of pulmonary tuberculosis (PTB) will have sputum smear result negative for acid-fast bacilli (AFB). Establishing early diagnosis and starting treatment early can have significant effect on morbidity and mortality in these patients. Bronchoalveolar lavage (BAL) samples obtained by bronchoscopy can be tested with cartridge-based nuclear acid amplification test (CBNAAT) for rapid diagnosis of sputum smear-negative PTB cases. Objectives To assess the role of BAL CBNAAT in the early diagnosis of sputum smear-negative PTB cases. Patients and methods A total of 112 patients with clinicoradiological findings suggestive of PTB with two consecutive sputum smear-negative results for AFB were enrolled in the study. BAL samples were subjected to Ziehl–Neelsen staining, CBNAAT (Xpert MTB/Rif; Cepheid), and liquid culture by mycobacteria growth indicator tube method as standard reference. Sputum samples from the same patients were also cultured. Results BAL samples were positive for AFB on Ziehl–Neelsen staining in 64.2% of smear-negative patients. CBNAAT was positive in 75.8%, whereas mycobacteria growth indicator tube was positive in 76.7% as compared with sputum culture positivity, which was positive in 19.6% of patients. Sensitivity and specificity of CBNAAT were 96.51 and 86.3%, respectively, when compared with culture results. Overall, 76.7% of patients were diagnosed as having culture-positive PTB. Conclusion BAL CBNAAT is useful in the early diagnosis of sputum smear-negative PTB, thus reducing the morbidity and mortality among these patients.

Diagnostic Yield of Bronchoalveolar lavage Xpert MTB/RIF Assay (Gene Xpert ® in Sputum Smear Negative Pulmonary Tuberculosis Patients – A One Year Cross Sectional Study

Introduction: Tuberculosis remains a major public health issue and is one of the top ten causes of death worldwide. Seven countries worldwide account for 64% of the total incidence and India leading the count. Only about 50-60% of the cases are sputum smear positive, while rest are sputum scare or smear negative cases. Since December 2010, WHO has recommended the use of Xpert MTB/RIF assay due to its high-quality performance, as compared to microscopy in the diagnosis of tuberculosis. The present study was done to evaluate the early diagnosis of sputum smear negative pulmonary tuberculosis patients using Xpert MTB/RIF assay test in broncho-alveolar fluid and to evaluate prevalence of rifampicin resistance in these patients.&#x0D; Methods: This was a one year cross section study conducted in a tertiary care hospital. A total of 143 suspected cases of pulmonary tuberculosis patients who were sputum smear negative were included in the study. All patients underwent bronchoscopy and the BAL specimen was subjected for Xpert MTB/RIF assay, smear by ZN staining and AFB Culture using MGIT 960 medium. The sensitivity and specificity of the Xpert MTB/RIF assay was compared to AFB culture which is considered as the gold standard method for diagnosing TB was calculated.&#x0D; Results: Majority of the patients were males (74.83%) and under the age group of 30 years (26.57%). Out of 143 suspected, the final diagnosis of PTB was done in 93 patients. Out of 93 cases of PTB, 87(93.5%) patients were Xpert MTB/RIF assay positive, 80(86.0%) were AFB culture positive and 39(41.9%) patients were AFB smear positive. The sensitivity and specificity of BAL Xpert MTB/RIF assay was 92.5% and 79.37% respectively (p &lt;0.0001).&#x0D; Conclusion: The Xpert MTB/RIF assay is more sensitive and specific than smear microscopy for the diagnosis of PTB in sputum smear negative on specimens obtained from broncho-alveolar lavage (BAL).

Comparison of induced sputum and bronchial washings for CBNAAT in diagnosing sputum smear negative pulmonary tuberculosis

Introduction: Tuberculosis is one of the most infectious public health problems for decades and has also become difficult to diagnose in recent times due to association with immunocompromised status. With the advent of the newer diagnostic technique like CBNAAT, can providing positive results even in less number of tuberculos bacilli in specimen samples. The present study was aimed to compare induced sputum and bronchial washings for CBNAAT in diagnosing sputum smear negative tuberculosis. Materials and Methods: A prospective, observational study was conducted in the Department of Pulmonary Medicine, Maharaja Institute of Medical Sciences (MIMS), Vizianagaram, Andhra Pradesh, India. A total of 43 patients with sputum negative tuberculosis were enrolled and induced sputum and BAL fluid for CBNAAT sent for analysis under RNTCP in district hospital. Results: Male patients (67.45%) were more compared to the females (32.55%). Majority belongs to 51-60 years with mean age group of 49.18 years. Most common X- ray presentation was infiltration followed by consolidation. Induced sputum CBNAAT was positive in only 07 patients compare d to bronchial washings CBNAAT in 27 patients. Conclusions: As CBNAAT can diagnose rapidly and prevent transmission and mortality in smearnegative in pulmonary tuberculosis patients, all smear-negative and immunocompromised patients should be subjected to CBNAAT. CBNAAT detects pulmonary TB in PLHIV with greater efficacy than sputum microscopy, also helping in early diagnosis in less than 2 hours, so that early therapy can be started, thus decreasing the incidence of MDR-TB and associated its mortality. Keywords: Bronchial washings, CBNAAT, Induced sputum, Pulmonary tuberculosis, Smear negative.

Value of the Xpert MTB/RIF assay in diagnosis of presumptive pulmonary tuberculosis in general hospitals in China

ObjectivesTo evaluate the value of Xpert MTB/RIF in the diagnosis of pulmonary tuberculosis (PTB) in general hospitals, which are usually where patients first visit. Materials and methodsPresumptive PTB patients, based on imaging results, in a general hospital in China, were enrolled from August 2015 to April 2017. The sensitivity and specificity of four tuberculosis (TB) detection methods, including sputum smear, Xpert MTB/RIF, T-SPOT.TB and TB-DNA were studied. To predict the effectiveness of the methods, different combinations were assessed using the receiver operating characteristic (ROC) curve. Results283 PTB suspect patients were enrolled, 81 of which were diagnosed as TB infections based on the golden standard. The TB detection rate for sputum smear was 11.7% (33/283). The respective sensitivity and specificity of Xpert MTB/RIF were 87.8% (71/81) and 99.5% (201/202). For the smear negative TB patients, the sensitivity of Xpert MTB/RIF was 79.2% (38/48). Combined with several methods, the Xpert MTB/RIF assay had the highest area under curve (AUC) value (0.913). ConclusionsXpert MTB/RIF showed tremendous promise for early, rapid and accurate diagnosis of TB. Multicentre evaluation and adoption of Xpert MTB/RIF in general hospitals in China should be embraced and promoted in order to establish an effective TB identification system.