Respiratory Medicine 134 (2018) 12–15

Contents lists available at ScienceDirect

Respiratory Medicine
journal homepage: www.elsevier.com/locate/rmed

Diagnostic performances of the Xpert MTB/RIF in Brazil T

a,b,∗,1 c,1 d,e,1 b,f
Denise Rossato Silva , Giovanni Sotgiu , Lia D'Ambrosio , Giovana Rodrigues Pereira ,
Márcia Silva Barbosag, Natan José Dutra Diash, Laura Saderic, Rosella Centisd,
Giovanni Battista Migliorid,∗∗
a
Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
b
Programa de Pós-Graduação em Ciências Pneumológicas da UFRGS, Porto Alegre, Brazil
c
Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari, Sassari, Italy
d
World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Maugeri Care and Research Institute, IRCCS, Tradate, Italy
e
Public Health Consulting Group, Lugano, Switzerland
f
Setor de Tuberculose, Laboratório Municipal de Alvorada, Alvorada, Brazil
g
Microbiologia, Faculdade Factum, Porto Alegre, Brazil
h
Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil

A R T I C L E I N F O A B S T R A C T

Keywords: Background and objectives: As for all tests, the diagnostic performances of Xpert MTB/RIF might be different in
Tuberculosis settings with different tuberculosis prevalence. Aim of the study is to evaluate the performances of Xpert MTB/
Xpert MTB/RIF RIF to diagnose tuberculosis in Brazil, where 407 culture-confirmed tuberculosis patients were retrospectively
HIV enrolled in Rio Grande do Sul, between 2015 and 2016.
Diagnosis
Methods: Sensitivity, specificity, positive and negative predictive values of the test were calculated and a logistic
Brazil
regression analysis was performed to assess the role played by explanatory variables in the occurrence of true
positive and negative diagnostic results.
Results: Sensitivity of Xpert MTB/RIF was 100.0%, specificity 92.8%; positive and negative predictive values
were 71.4% and 100.0%, respectively. In the HIV- infected sub-group specificity was 59.3%.
In the multivariate logistic regression analysis, true positivity was associated with increasing age (1.0; p-
value: 0.02) while true positivity and negativity were negatively associated with alcohol abuse.
Conclusions: Xpert is sensitive and specific in the Brasilian settings.

1. Introduction affected by TB and if there is resistance to rifampicin (which is con-

Tuberculosis (TB) is a first-class health priority, with over 10.4
million cases notified in 2015, of whom 480,000 are affected by mul-
tidrug-resistant (MDR, defined as disease caused by strains of M. tu-
berculosis resistant to at least rifampicin and isoniazid) form of disease
and additional 100,000 have rifampicin-resistant TB (RR-TB) following
diagnosis with Xpert MTB/RIF [1–4].
In Brazil 84,000 TB incident cases were estimated to occur in 2015,
with 1900 MDR- and RR TB cases [1,5].
Xpert MTB/RIF has changed the programmatic approach to TB di-
agnosis, allowing the clinician to know in less than 2 h if his/her case is
sidered a proxy for MDR-TB) [6–8]. This is particularly true in high
incidence TB countries, where the sensitivity and specificity of the test
are high (88% and 98%, respectively) [6,7]. The test was endorsed by
World Health Organization (WHO) in 2011 [9–11].
However, the sensitivity of Xpert MTB/RIF is higher in sputum
smear positive than in negative cases (98% vs 67%) [6]. The positive
and negative predictive values of the test critically depend on the
prevalence of TB. The negative predictive value is high, but the positive
predictive value can be rather low in low TB incidence countries.
In countries where the incidence of TB is intermediate, like in Brazil,
information on Xpert MTB/RIF is lacking [12]. Given the potentialities

∗
Corresponding author. Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, 2350 Ramiro Barcelos Street, Porto Alegre, Brazil.
∗∗
Corresponding author. World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Maugeri Care and Research Institute, IRCCS, Via Roncaccio 16, 21049,
Tradate, Italy.
E-mail addresses: denise.rossato@terra.com.br (D.R. Silva), gsotgiu@uniss.it (G. Sotgiu), liadambrosio59@gmail.com (L. D'Ambrosio), gio.pereira.rs@gmail.com (G.R. Pereira),
marcia.barbosa@factum.edu.br (M.S. Barbosa), natandias39@hotmail.com (N.J.D. Dias), lsaderi89@gmail.com (L. Saderi), rosella.centis@icsmaugeri.it (R. Centis),
giovannibattista.migliori@icsmaugeri.it (G.B. Migliori).
1
Equally contributed.

https://doi.org/10.1016/j.rmed.2017.11.012
Received 15 September 2017; Received in revised form 10 October 2017; Accepted 20 November 2017
Available online 21 November 2017
0954-6111/ © 2017 Elsevier Ltd. All rights reserved.
D.R. Silva et al. Respiratory Medicine 134 (2018) 12–15

of the test to improve TB diagnosis in Brazil, this study was designed to Table 1
evaluate the diagnostic performances of the test in the HIV- uninfected Demographic, epidemiological, and clinical characteristics of the enrolled cohort.
and – infected patients (sensitivity, specificity, positive and negative
Variables
predictive values) within the framework of the ERS (European Re-
spiratory Society)/SBPT (Brazilian Society of Respiratory Diseases) Median (IQR) age, years 54 (42–62)
collaborative TB project. Male, n (%) 238/407 (58.5)
White race, n (%) 313/407 (76.9)
Smoking, n (%) Non-smoker 44/159 (27.7)
2. Material and methods Former smoker 17/159 (10.7)
Active smoker 98/159 (61.6)
A Brazilian sample of culture-confirmed TB patients was retro- Median (IQR) number of cigarettes daily smoked 20 (20–20)
spectively enrolled in an outpatient TB clinic located in Alvorada – Rio Median (IQR) number of years of smoking habit 20 (10–30)
Median (IQR) number of years of smoking abstinence 2 (2–5)
Grande do Sul, from January 2015 to December 2016. Sampling was
Cough, n (%) 398/407 (97.8)
consecutive and no specific selection criteria were adopted. Paediatric Sputum production, n (%) 355/407 (87.2)
cases were excluded. Weight loss, n (%) 214/407 (52.6)
An ad-hoc electronic form was built on to collect demographic (e.g., Night sweats, n (%) 101/407 (24.8)
Dyspnoea, n (%) 56/407 (13.8)
age, gender, ethnicity), epidemiological (e.g., exposure to tobacco
Chest pain, n (%) 42/407 (10.3)
smoking, comorbidities, previous TB), clinical (e.g., symptoms, clinical Fever, n (%) 71/407 (17.4)
and radiological signs, treatment outcomes), and microbiological (e.g., Haemoptysis, n (%) 12/407 (3.0)
microscopic, culture, and molecular testing results) variables which Median (IQR) duration of symptoms, days 35 (30–60)
could explain the variability of the diagnostic accuracy. Previous TB, n (%) 38/159 (23.9)
Previous default, n (%) 18/159 (11.3)
Sputum smears were stained by Ziehl-Neelsen (ZN) staining tech-
Alcohol abuse, n (%) 57/159 (35.9)
nique for the detection of AFB (alcohol acid fast bacilli), and culture Drug abuse, n (%) 52/159 (32.7)
was performed using the Ogawa-Kudoh method. Institutionalization (past 3 years), n (%) 23/159 (14.5)
The Xpert MTB/RIF test was performed according to manufacturer's Comorbidities, n (%) 247/407 (60.7)
HIV infected, n (%) 47/407 (11.6)
instructions (Cepheid, Sunnyvale, Calif, USA, 2013).
Acid fast bacilli in the sputum, n (%) 90/407 (22.1)
In short, clinical sputum samples are treated with a sodium hydro- Mycobacterium tuberculosis culture positive, n (%) 75/407 (18.4)
xide and isopropanol-containing sample reagent (SR). The SR is added Normal chest X-ray, n (%) 254/407 (62.4)
to the sample and incubated at room temperature for 15 min. This step Lung cavitations, n (%) 57/406 (14.0)
is designed to reduce the viability of M. tuberculosis in sputum at least Reticular infiltrates, n (%) 62/406 (15.3)
Lung consolidation, n (%) 70/406 (17.2)
106-fold to reduce biohazard risk. The treated sample is then manually
Lung fibrotic changes, n (%) 89/404 (22.0)
transferred to the cartridge that is preloaded with liquid buffers and Miliary pattern, n (%) 9/406 (2.2)
lyophilized reagent beads necessary for sample processing, DNA ex- Resistant to rifampicin, n (%) 4/407 (1.0)
traction and heminested RT-PCR. Subsequent processing is fully auto- Xpert MTB/RIF, n (%) 108/407 (26.5)
Treatment outcome Cure 112/159 (70.4)
mated. The results are generated automatically on the screen and re-
Failure 12/159 (7.6)
ported as M. tuberculosis detected or not detected (with semi- Default 28/159 (17.6)
quantitative estimates of M. tuberculosis concentration reported as low, Death 7/159 (4.4)
medium or high) and susceptible or resistant to rifampicin.
Categorical and numerical variables were summarized with fre- IQR: interquartile range.
quencies (absolute and percentage) and medians (interquartile ranges,
IQR), respectively. A logistic regression analysis was performed to as- with that detected in the HIV- uninfected sub-group.
sess the role played by explanatory variables in the occurrence of true Out of 108 Xpert positive TB cases, 33 (30.6%) were culture nega-
positive and negative diagnostic results. A statistical significance was tive. All of these Xpert positive/culture negative patients had cough and
considered when two-tailed p-values were less than 0.05. Statistical a chest radiography typical or compatible with TB. Also, 11/33 (33.3%)
computations were carried out with the version 13 of the statistical were HIV infected. In summary, based on clinical/radiological criteria,
software STATA (StataCorp, College Station, TX, USA). they were likely to have TB.
The multivariate logistic regression analysis found that a true po-
3. Results sitivity is associated with increasing age (1.0; p-value: 0.02), whereas
true positivity and negativity in a multivariate model was negatively
A cohort of 407 individuals was recruited; the majority was male associated with alcohol abuse (data not shown).
(238, 58.5%), white (313/407, 76.9%) with a median (IQR) age of 54
(42–62) years (Table 1). 4. Discussion
More than 70% of the cases were current or former smokers and less
than one quarter (23.9%) had a previous TB episode. The proportion of Aim the study was to evaluate the diagnostic performance of the test
HIV- infected patients was higher than 10%. More than 60% did not in the HIV- uninfected and HIV- infected patients in Brazil.
show radiological abnormalities at the chest radiography. Only 1.0% of In HIV-negative individuals sensitivity and specificity were both
the patients were resistant to rifampicin. Treatment outcome was de- very high (100% and 92.8% respectively), consistent with the results by
scribed for 159 patients: 70.4% were cured, 17.6% defaulted, 7.6% Rachow A et al. [13,14] who described a sensitivity of 98.0% and a
failed, and 4.4% died. specificity of 90.9%.
The Xpert MTB/RIF and the culture were performed in all 407 pa- One-third of the cases had positive Xpert and negative culture.
tients. The results in HIV- infected and uninfected patients were de- Using culture as the gold standard, in HIV- infected patients the spe-
scribed in Table 2. cificity was as low as 59.3%, which is difficult to explain. Among the
Using culture as the gold standard, the diagnostic performance of possible reasons, we mention the relatively small sample size and the
the Xpert MTB/RIF in the HIV-negative patients was as follows: sensi- immunosuppression-related lower sputum smear positivity rate.
tivity 100.0%, specificity 92.8%; positive and negative predictive va- The results of the multivariate model suggest that the true positivity
lues were 71.4% and 100.0%, respectively. In the HIV- infected sub- increases with age. These results are consistent with the findings of 2
group the specificity was significantly lower (59.3%) in comparison existing paediatric studies. In a first study, Sekkade et al. found that age

13
D.R. Silva et al. Respiratory Medicine 134 (2018) 12–15

Table 2 Author contributions'

Relationship between Xpert MTB/RIF and culture results in HIV- infected and - uninfected
subjects.
All authors contributed to the conception and design of the study,
HIV- Infected cases Culture drafted the article, revised it critically and finally approved this sub-
mitted version.
n (%)
Conflicts of interest
Xpert MTB/RIF Negative Positive Total

Positive 11(35.5) 20 (64.5) 31 None.

Negative 16 (100) 0 (0) 16
Total 27 (57.4) 20 (42.6) 47 Acknowledgements
HIV-Negative cases Culture
This article has been developed within the ERS (European
Xpert MTB/RIF Negative Positive Total Respiratory Society)/SBPT (Brazilian Society of Respiratory Diseases)
collaborative TB project.
Positive 22 (28.6) 55 (71.4) 77
Negative 283 (100) 0 (0) 283
Total 305 (84.7) 55 (15.3) 360 References

[1] World Health Organization. Global tuberculosis report, WHO/HTM/TB/2016.13

Diagnostic indicator HIV- infected cases HIV- uninfected cases
Geneva, World Health Organization, 2016 2016.
[2] S.E. Borisov, K. Dheda, M. Enwerem, R. Romero Leyet, L. D'Ambrosio, R. Centis,
% (95% CI) % (95% CI)
et al., Effectiveness and safety of bedaquiline containing regimens in the treatment
of MDR- and XDR-TB: a multicentre study, Eur. Respir. J. 49 (2017) 1700387
Sensitivity 100.0 (83.2–100.0) 100.0 (93.5–100.0) https://doi.org/10.1183/13993003.00387-2017.
Specificity 59.3 (38.8–77.6) 92.8 (89.3–95.4) [3] M. Dalcolmo, R. Gayoso, G. Sotgiu, L. D'Ambrosio, J.L. Rocha, L. Borga, et al.,
Positive predictive value 64.5 (45.4–80.8) 71.4 (60.0–81.2) Resistance profile to the drugs composing the ‘shorter’ regimen for multidrug-re-
Negative predictive value 100.0 (79.4–100.0) 100.0 (98.7–100.0) sistant TB in Brazil, Eur. Respir. J. 2017 (2000-2015) 49 1602309 https://doi.org/
Positive likelihood ratio 2.5 (1.6–3.9) 13.9 (9.3–20.7) 10.1183/13993003.02309-2016].
Negative likelihood ratio 0.0 (−) 0.0 (−) [4] M. Dalcolmo, R. Gayoso, G. Sotgiu, L. D'Ambrosio, J.L. Rocha, L. Borga, et al.,
Effectiveness and safety of clofazimine within a standard multidrug-resistant tu-
CI: Confidence Interval. berculosis regimen in Brazil: first nation-wide report on over 2,500 cases, Eur.
Respir. J. 49 (3) (2017; Mar 22), http://dx.doi.org/10.1183/13993003.02445-2016
pii: 1602445.
>5 years was associated with a positive Xpert test [15]. In a second [5] V.C. Micheletti, S. Moreira Jda, M.O. Ribeiro, A.L. Kritski, J.U. Braga, Drug-resistant
study done on children with less than 3 years of age absence of BCG tuberculosis in subjects included in the second national survey on antituberculosis
drug resistance in Porto Alegre, Brazil, J. Bras. Pneumol. 40 (2) (2014 Mar-Apr)
(Bacillus Calmette Guerin) scar and contact with a TB case were asso-
155–163.
ciated with a positive test [16]. [6] S.D. Lawn, P. Mwaba, M. Bates, A. Piatek, H. Alexander, B.J. Marais, L.E. Cuevas,
To our knowledge this is the first study in the literature describing T.D. McHugh, L. Zijenah, N. Kapata, I. Abubakar, R. McNerney, M. Hoelscher,
the association between age and positive Xpert test in an adult popu- Z.A. Memish, G.B. Migliori, P. Kim, M. Maeurer, M. Schito, A. Zumla, Advances in
tuberculosis diagnostics: the Xpert MTB/RIF assay and future prospects for a point-
lation, and the first study investigating the performances of the test of-care test, Lancet Infect. Dis. 13 (4) (2013) 349–361, http://dx.doi.org/10.1016/
under programmatic conditions in Brazil. S1473-3099(13)70008-2.
Interestingly, while different studies were able to describe associa- [7] K.R. Steingart, I. Schiller, D.J. Horne, M. Pai, C.C. Boehme, N. Dendukuri, Xpert(R)
MTB/RIF assay for pulmonary tuberculosis and rifampicin resistance in adults,
tion between alcohol abuse and TB [17–19], we are the first to describe Cochrane Database Syst. Rev. 1 (2014), http://dx.doi.org/10.1002/14651858.
the relationship between alcohol abuse and Xpert performances. CD009593.pub3 CD009593.
In fact, it is known that alcohol consumption (>40 g/day) is re- [8] M.A. Telles, A. Menezes, A. Trajman, Bottlenecks and recommendations for the
incorporation of new technologies in the tuberculosis laboratory network in Brazil,
sponsible of a 13% adult population attributable fraction, being a J. Bras. Pneumol. 38 (6) (2012 Nov-Dec) 766–770.
common habit in the 22 high TB burden countries (although the re- [9] C.C. Boehme, M.P. Nicol, P. Nabeta, J.S. Michael, E. Gotuzzo, R. Tahirli, et al.,
lative risk for TB is rather low - 2.9) [20]. Feasibility, diagnostic accuracy, and effectiveness of decentralised use of the Xpert
MTB/RIF test for diagnosis of tuberculosis and multidrug resistance: a multicentre
According to a recent systematic review [19] alcohol consumption
implementation study, Lancet 377 (9776) (2011 Apr 30) 1495–1505, http://dx.doi.
is responsible, globally, of 22.02 incidence cases and 2.35 deaths per org/10.1016/S0140-6736(11)60438-8.
100,000 population, which corresponds to about 17% of all incidence [10] World Health Organization, Xpert MTB/RIF Implementation Manual: Technical and
Operational ‘how-to’; Practical Considerations. Document WHO/HTM/TB/2014.1,
cases and death.
World Health Organization, Geneva, 2014.
However, the relationship between alcohol consumption and Xpert [11] K. Weyer, F. Mirzayev, G.B. Migliori, W. Van Gemert, L. D'Ambrosio, M. Zignol,
positivity has never been previously analysed. et al., Rapid molecular TB diagnosis: evidence, policy making and global im-
plementation of Xpert MTB/RIF, Eur. Respir. J. 42 (1) (2013) 252–271.
[12] M. Pinto, A.P. Entringer, R. Steffen, A. Trajman, Cost analysis of nucleic acid am-
plification for diagnosing pulmonary tuberculosis, within the context of the
5. Conclusions Brazilian Unified Health Care System, J. Bras. Pneumol. 41 (6) (2015 Nov-Dec)
536–538.
[13] A. Rachow, A. Zumla, N. Heinrich, G. Rojas-Ponce, B. Mtafya, K. Reither, et al.,
The study results demonstrate that Xpert is sensitive and specific in Rapid and accurate detection of Mycobacterium tuberculosis in sputum samples by
countries with an intermediate TB incidence, such as Brazil, and, Cepheid Xpert MTB/RIF assay–a clinical validation study, PLoS One 6 (6) (2011)
therefore, its scale-up is important to ensure quality-assured diagnosis e20458, http://dx.doi.org/10.1371/journal.pone.0020458.
[14] N. Heinrich, A. Rachow, M. Hoelscher, Rapid molecular detection of tuberculosis,
and effective treatment, which are core activities to control TB. N. Engl. J. Med. 364 (2) (2011 Jan 13) 182, http://dx.doi.org/10.1056/
NEJMc1011919#SA1 author reply 184-5.
[15] M.P. Sekadde, E. Wobudeya, M.L. Joloba, W. Ssengooba, H. Kisembo, S. Bakeera-
Kitaka, et al., Evaluation of the Xpert MTB/RIF test for the diagnosis of childhood
Funding source
pulmonary tuberculosis in Uganda: a cross-sectional diagnostic study, BMC Infect.
Dis. 13 (2013 Mar 12) 133, http://dx.doi.org/10.1186/1471-2334-13-133.
This research did not receive any specific grant from funding [16] Q.Q. Yin, W.W. Jiao, R. Han, A.X. Jiao, L. Sun, J.L. Tian, et al., Rapid diagnosis of
childhood pulmonary tuberculosis by Xpert MTB/RIF assay using bronchoalveolar
agencies in the public, commercial, or not-for-profit sectors.
lavage fluid, Biomed. Res. Int. 2014 (2014) 310194, http://dx.doi.org/10.1155/
2014/310194.

14
D.R. Silva et al.
[17] S. Hermosilla, P. You, A. Aifah, T. Abildayev, A. Akilzhanova, U. Kozhamkulov,
et al., Identifying risk factors associated with smear positivity of pulmonary tu-
berculosis in Kazakhstan, PLoS One 12 (3) (2017 Mar 1) e0172942, http://dx.doi.
org/10.1371/journal.pone.0172942. eCollection 2017.
[18] J. Francisco, O. Oliveira, Gaio AR. Felgueiras Ó, R. Duarte, How much is too much
alcohol in tuberculosis? Eur. Respir. J. 49 (1) (2017 Jan 18), http://dx.doi.org/10.
1183/13993003.01468-2016 pii: 1601468.
15
Respiratory Medicine 134 (2018) 12–15
[19] S. Imtiaz, K.D. Shield, M. Roerecke, A.V. Samokhvalov, K. Lönnroth, J. Rehm,
Alcohol consumption as a risk factor for tuberculosis: meta-analyses and burden of
disease, Eur. Respir. J. 50 (1) (2017), http://dx.doi.org/10.1183/13993003.00216-
2017 pii:1700216.
[20] J. Creswell, M.C. Raviglione, S. Ottmani, G.B. Migliori, M. Uplekar, L. Blanc, et al.,
Tuberculosis and noncommunicable diseases: neglected links and missed opportu-
nities, Eur. Respir. J. 37 (5) (2011) 1269–1282.