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. 2017 Jul 7;12(7):e0180572.
doi: 10.1371/journal.pone.0180572. eCollection 2017.

Sputum quality and diagnostic performance of GeneXpert MTB/RIF among smear-negative adults with presumed tuberculosis in Uganda

Amanda J Meyer  1 , Collins Atuheire  2 , William Worodria  3 , Samuel Kizito  4 , Achilles Katamba  4 , Ingvar Sanyu  5 , Alfred Andama  3   5 , Irene Ayakaka  5 , Adithya Cattamanchi  6 , Freddie Bwanga  7 , Laurence Huang  6   8 , J Lucian Davis  1   9
Affiliations

Sputum quality and diagnostic performance of GeneXpert MTB/RIF among smear-negative adults with presumed tuberculosis in Uganda

Amanda J Meyer et al. PLoS One. .

Abstract

Background: Introduction of GeneXpert MTB/RIF (Xpert) assay has constituted a major breakthrough for tuberculosis (TB) diagnostics. Several patient factors may influence diagnostic performance of Xpert including sputum quality.

Objective: We carried out a prospective, observational, cross-sectional study to determine the effect of sputum quality on diagnostic performance of Xpert among presumed TB patients in Uganda.

Methods: We collected clinical and demographic information and two sputum samples from participants. Staff recorded sputum quality and performed LED fluorescence microscopy and mycobacterial culture on each sample. If both smear examinations were negative, Xpert testing was performed. We calculated diagnostic yield, sensitivity, specificity, and other indicators for Xpert for each stratum of sputum quality in reference to a standard of mycobacterial culture.

Results: Patients with salivary sputum showed a trend towards a substantially higher proportion of samples that were Xpert-positive (54/286, 19%, 95% CI 15-24) compared with those with all other sputum sample types (221/1496, 15%, 95% CI 13-17). Blood-stained sputum produced the lowest sensitivity (28%; 95% CI 12-49) and salivary sputum the highest (66%; 95% CI 53-77). Specificity didn't vary meaningfully by sample types. Salivary sputum was significantly more sensitive than mucoid sputum (+13%, 95% CI +1 to +26), while blood-stained sputum was significantly less sensitive (-24%, 95% CI -42 to -5).

Conclusions: Our findings demonstrate the need to exercise caution in collecting sputum for Xpert and in interpreting results because sputum quality may impact test yield and sensitivity. In particular, it may be wise to pursue additional testing should blood-stained sputum test negative while salivary sputum should be readily accepted for Xpert testing given its higher sensitivity and potentially higher yield than other sample types. These findings challenge conventional recommendations against collecting salivary sputum for TB diagnosis and could inform new standards for sputum quality.

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Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Study population.
Abbreviations: AFB, acid-fast bacilli; MTB, Mycobacterium tuberculosis; Xpert, Xpert MTB/RIF assay.
Fig 2
Fig 2. Xpert proportion positive differences and unadjusted differences in sputum Xpert sensitivity and specificity, stratified by sputum quality*.
Legend: * Mucoid sputum utilized as the reference group.
See this image and copyright information in PMC

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