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Diagnostic Performance of the Xpert MTB/ RIF Assay in BAL Fluid

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Diagnostic Performance of the Xpert MTB/ RIF Assay in BAL Fluid J Bras Pneumol. 2021;47(2):e20200581 https://dx.doi.org/10.36416/1806-3756/e20200581 ORIGINAL ARTICLE Diagnostic performance of the Xpert MTB/ RIF assay in BAL fluid samples from patients under clinical suspicion of pulmonary tuberculosis: a tertiary care experience in a high-tuberculosis-burden area Guilherme Machado Xavier de Brito1a, Thiago Thomaz Mafort2a, Marcelo Ribeiro-Alves3a, Larissa Vieira Tavares dos Reis2a, Janaína Leung2a, Robson Souza Leão4a, Rogério Rufino2a, Luciana Silva Rodrigues1a 1. Laboratório de Imunopatologia, ABSTRACT Faculdade de Ciências Médicas, Universidade do Estado do Rio de Objective: To assess the diagnostic performance of the Xpert MTB/RIF assay, a rapid Janeiro – UERJ – Rio de Janeiro (RJ) molecular test for tuberculosis, comparing it with that of AFB staining and culture, in Brasil. BAL fluid (BALF) samples from patients with clinically suspected pulmonary tuberculosis 2. Disciplina de Pneumologia e Tisiologia, (PTB) who are sputum smear-negative or produce sputum samples of insufficient Hospital Universitário Pedro Ernesto, quantity. Methods: This was a retrospective study of 140 cases of suspected PTB in Universidade do Estado do Rio de Janeiro – UERJ – Rio de Janeiro (RJ) patients who were smear-negative or produced insufficient sputum samples and were Brasil. evaluated at a tertiary teaching hospital in the city of Rio de Janeiro, Brazil. All of the 3. Laboratório de Pesquisas Clínicas patients underwent fiberoptic bronchoscopy with BAL. The BALF specimens were em DST/AIDS, Instituto Nacional de evaluated by AFB staining, mycobacterial culture, and the Xpert MTB/RIF assay. Results: Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Among the 140 patients, results for all three microbiological examinations were available Rio de Janeiro (RJ) Brasil. for 73 (52.1%), of whom 22 tested positive on culture, 17 tested positive on AFB staining, 4. Departamento de Microbiologia, and 20 tested positive on the Xpert MTB/RIF assay. The sensitivity, specificity, positive Imunologia e Parasitologia, Faculdade predictive value, negative predictive value, and overall accuracy for AFB staining were de Ciências Médicas, Universidade do 68.1%, 96.1%, 88.2%, 87.5%, and 87.6%, respectively, compared with 81.8%, 96.1%, Estado do Rio de Janeiro – UERJ – Rio de Janeiro (RJ) Brasil. 90.0%, 92.4%, and 91.8%, respectively, for the Xpert MTB/RIF assay. The agreement between AFB staining and culture was 82.3% (kappa = 0.46; p < 0.0001), whereas that Submitted: 21 November 2020. between the Xpert MTB/RIF assay and culture was 91.8% (kappa = 0.8; p < 0.0001). Accepted: 8 March 2021. Conclusions: In BALF samples, the Xpert MTB/RIF assay performs better than do Study carried out in the Disciplina de traditional methods, providing a reliable alternative to sputum analysis in suspected Pneumologia e Tisiologia, Hospital cases of PTB. However, the rate of discordant results merits careful consideration. Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro – UERJ – Keywords: Tuberculosis; Molecular diagnostic techniques; Bronchoscopy; Rio de Janeiro (RJ) Brasil. Bronchoalveolar lavage fluid; Mycobacterium tuberculosis. INTRODUCTION One major concern regarding the management of cases of tuberculosis is that microbiological confirmation Tuberculosis, a disease caused by infection with is achieved in only 40-60% of patients with pulmonary Mycobacterium tuberculosis, continues to be an alarming tuberculosis (PTB), the main clinical manifestation and public health problem, with high rates of morbidity the type of tuberculosis that is the most relevant in the and mortality worldwide. It has been estimated that chain of transmission. In addition, approximately half of there were approximately 10.0 million new cases of all patients with PTB are sputum smear-negative for AFB tuberculosis in 2019, a year in which 1.2 million and or are unable to produce sputum samples of sufficient 208,000 tuberculosis-related deaths occurred among quantity,(1,3) making the diagnosis quite challenging. In non-HIV-infected and HIV-infected individuals, respectively. such patients, fiberoptic bronchoscopy with BAL is a Although the efforts made have saved millions of lives reliable, rapid method of collecting useful specimens for worldwide, reducing tuberculosis mortality by 42% since the diagnosis of PTB.(3-6) However, conventional methods, 2000, an annual decrease of approximately 4-5%, rather such as Ziehl-Neelsen staining, which detects AFB, and than the current 2%, would be needed in order to reach mycobacterial cultures, have poor diagnostic yields. the End TB Strategy target of a 95% reduction by 2035. Sputum smear microscopy for AFB is limited by its low In Brazil, which is one of the 30 countries with the highest sensitivity (approximately 40%), whereas mycobacterial tuberculosis burden,(1) the estimated number of new culture, which is considered the gold standard, performs cases of tuberculosis in 2019 was more than 90,000.(2) better (with a sensitivity of approximately 86%), Correspondence to: Luciana Silva Rodrigues. Avenida Professor Manuel de Abreu, 444, 4º andar, Vila Isabel, CEP 20550-170, Rio de Janeiro, RJ, Brasil. Tel.: 55 21 2868-8690. E-mail: [email protected] Financial support: None: © 2021 Sociedade Brasileira de Pneumologia e Tisiologia ISSN 1806-3713 1/8 Diagnostic performance of the Xpert MTB/RIF assay in BAL fluid samples from patients under clinical suspicion of pulmonary tuberculosis: a tertiary care experience in a high-tuberculosis-burden area although the latter is time consuming, requiring 6-8 insufficient sputum samples, or testing negative weeks to produce a diagnosis.(7,8) Therefore, new for M. tuberculosis on sputum culture; and having methods have been proposed and in some cases been referred for fiberoptic bronchoscopy. Patients implemented to improve diagnostic accuracy, which who tested positive for M. tuberculosis in sputum would allow the appropriate treatment to be instituted samples (by smear microscopy or culture) were early, thus avoiding the spread of tuberculosis and excluded, as were those with malignancy, those with minimizing the associated deaths. The Xpert MTB/ fungal infection, those who were on antituberculosis RIF assay (GeneXpert; Cepheid, Sunnyvale, CA, regimens for more than 2 weeks, and those with a USA), an automated cartridge-based assay that uses confirmed diagnosis of infection with nontuberculous quantitative heminested real-time PCR, is a rapid (≤ mycobacteria (NTM). A confirmed diagnosis of PTB was 2 h) molecular test for the detection of M. tuberculosis defined as M. tuberculosis growth on mycobacterial and of resistance to rifampin.(9,10) The Xpert MTB/RIF culture of a BALF sample, which was considered the assay has proven to have high sensitivity and specificity, reference method. A probable diagnosis of PTB was as well as being a test of low complexity that is safe defined as not meeting the criteria for a confirmed and cost-effective for the diagnosis and management diagnosis of PTB but having clinical and radiological of suspected cases of tuberculosis.(11-13) Currently, a findings suggestive of tuberculosis, as well as showing range of clinical specimens other than spontaneous a clinical response to antituberculosis treatment. or induced sputum, such as pleural fluid, urine, Sociodemographic and clinical characteristics, such as cerebrospinal fluid, tracheal aspirate, and BAL fluid gender, age, smoking status, history of tuberculosis, (BALF), have been shown to be suitable for analysis HIV status, and the presence of cavitary disease, with the Xpert MTB/RIF assay.(14,15) However, there were collected from hospital records. Smokers were are few data in the literature regarding the analysis defined as individuals who had smoked at least 100 of BALF samples by the Xpert MTB/RIF assay for the cigarettes (or the equivalent) in their lifetime, and diagnosis of PTB, especially at tertiary care facilities, former smokers were defined as those who had quit as well as regarding its comparison with conventional smoking more than 12 months prior. microbiological methods. Therefore, the present study aimed to assess the performance of Xpert MTB/RIF Patient evaluation and sample collection assays of BALF samples from patients with suspected In patients under intravenous sedation, clinical PTB who are sputum smear-negative or produce investigators used a flexible fiberoptic bronchoscope insufficient sputum samples. To that end, we evaluated to perform transnasal bronchoscopy, during which such patients at a university hospital in the city of Rio there was continuous monitoring of heart rate, blood de Janeiro, which ranks second among Brazilian cities pressure, and SpO2. In brief, after the bronchial tree in terms of tuberculosis burden.(2) We also evaluated had been inspected, BAL was performed by instilling the Xpert MTB/RIF assay in comparison with AFB sterile saline (0.9%) in serial 20-mL aliquots (up to staining, processing the BALF samples in parallel and a maximum of 200 mL). At least 50% of the total using mycobacterial culture as the reference. volume of the aspirate was returned, then being divided into three parts and sent to the laboratory for Ziehl-Neelsen (AFB) staining, mycobacterial culture, METHODS and Xpert MTB/RIF assay. Ethical aspects Smear microscopy The study was approved by the Research Ethics The BALF specimens collected from all patients were Committee of Pedro Ernesto University Hospital of centrifuged at 3,000 × g for
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