Effects of Introducing Xpert MTB/RIF on Diagnosis and Treatment of Drug-Resistant Tuberculosis Patients in Indonesia: A Pre-Post Intervention Study

Abstract

Background: In March 2012, the Xpert MTB/RIF assay (Xpert) was introduced in three provincial public hospitals in Indonesia as a novel diagnostic to detect tuberculosis and rifampicin resistance among high risk individuals.

Objective: This study assessed the effects of using Xpert in place of conventional solid and liquid culture and drug-susceptibility testing on case detection rates, treatment initiation rates, and health system delays among drug-resistant tuberculosis (TB) patients.

Methods: Cohort data on registration, test results and treatment initiation were collected from routine presumptive patient registers one year before and one year after Xpert was introduced. Proportions of case detection and treatment initiation were compared using the Pearson Chi square test and median time delays using the Mood's Median test.

Results: A total of 975 individuals at risk of drug-resistant TB were registered in the pre-intervention year and 1,442 in the post-intervention year. After Xpert introduction, TB positivity rate increased by 15%, while rifampicin resistance rate reduced by 23% among TB positive cases and by 9% among all tested. Second-line TB treatment initiation rate among rifampicin resistant patients increased by 19%. Time from client registration to diagnosis was reduced by 74 days to a median of a single day (IQR 0-4) and time from diagnosis to treatment start was reduced by 27 days to a median of 15 days (IQR 7-51). All findings were significant with p<0.001.

Conclusion: Compared to solid and liquid culture and drug-susceptibility testing, Xpert detected more TB and less rifampicin resistance, increased second-line treatment initiation rates and shortened time to diagnosis and treatment. This test holds promise to improve rapid case finding and management of drug-resistant TB patients in Indonesia.

Fig 1. Diagnosis and treatment of individuals at risk of multidrug-resistant pulmonary TB at three provincial hospitals in Java, Indonesia.

The flowchart shows the number of tested, detected and treated individuals in two cohort years. From March 2011 to Feb 2012 (Year 1), individuals were tested with conventional culture and drug-susceptibility testing. From March 2012 to February 2013 (Year 2), individuals were tested with culture and drug-susceptibility testing or Xpert MTB/RIF. Abbreviations: TB, tuberculosis; DST, drug-susceptibility testing; RIF, rifampicin; MDR-TB, multidrug-resistant TB; N, number.

Fig 2. Time to diagnosis and treatment of rifampicin-resistant TB patients in three provincial hospitals in Java, Indonesia.

These figures show Kaplan Meier time-to-event graphs of health system delays (a), diagnostic delays (b) and treatment delays (c) for rifampicin resistance TB patients detected with culture drug-susceptibility testing from March 2011 to February 2012 and Xpert MTB/RIF from March 2012 to February 2013. Abbreviations: TB, tuberculosis; DST, drug-susceptibility testing; RIF, rifampicin.