Evaluation of Rifampicin-resistant Tuberculosis in Pediatric Patients by GeneXpert MTB/RIF

Abstract

Objectives: India has the largest burden of MDR-TB worldwide, with an annual incidence of 1,30 000 patients. Multidrug-resistant tuberculosis (MDR-TB) carries a poor prognosis, a high mortality rate, and treatment success rates as low as 65%. The mortality in India is estimated to be about 480,000 per year. The aim of the study was to evaluate Rifampicin-resistant Tuberculosis and its distribution by GeneXpert in a tertiary care hospital. Methods: A total of 2864 samples were processed from the patients attending outpatient departments and indoor wards as per the pediatrician's request. Acid-fast bacilli (AFB) smear microscopy was done on all samples by Acid-fast staining for early diagnosis followed by GeneXpert MTB/RIF (CBNAAT) testing. Specimens were transported and stored at 2–8 °C prior to processing for CBNAAT. Results were read and reported within 2 hours. Results: A total of 2864 samples were tested for TB using CBNAAT (including 645 [22.5%] extra-pulmonary and 2219 [77.5%] pulmonary samples). The test results were positive in a total of 346 (12%) samples by CBNAAT. The positivity is highest in the age group >10 years and in sputum samples (37.28%) followed by pus samples (23.26%) in pulmonary and extrapulmonary distribution. Out ZN staining was positive in 244 (8.5%) specimens. There were 102 (29.5%) CBNAAT positive specimens which showed negative results for Acid-fast bacilli (70.52% Sensitivity). Among 346 TB-positive patients, 10.46% samples were pulmonary and 17.67% were extrapulmonary. It was observed that in positive CBNAAT patients, the prevalence of Rifampicin resistance was 12.72% i.e. 44 samples which include 31(13.36%) and 13(11.40%) pulmonary and extra-pulmonary samples respectively. Among the Rifampicin resistant samples, there were 29.55% samples that were extrapulmonary. Conclusion: GeneXpert MTB/RIF is a very rapid diagnostic assay that provides information regarding the mutation pattern of RIF resistance in MTB isolates. J Microbiol Infect Dis 2021; 11(2):81-87.

Keywords

• CBNAAT
• Tuberculosis
• GeneXpert MTB/RIF

References

1. 1. Glaziou P, Floyd K, Raviglione MC. Global epidemiology of tuberculosis. Semin Respir Crit Care Med 2018; 39:271-85.
2. 2. World Health Organisation. Global Tuberculosis Report, 2019.
3. 3. Guidelines on programmatic management of drug resistant tuberculosis in India, RNTCP 2017.
4. 4. Weiss P, Chen W, Cook VJ, et al. Treatment outcomes from community-based drug resistant tuberculosis treatment programs: a systematic review and meta-analysis. BMC Infect Dis 2014; 14: 333.
5. 5. Central TB Division, Directorate General of Health Services, Ministry of Health with Family Welfare: Government of India. New Delhi: 2017. Revised National Tuberculosis Control Program. National Strategic Plan for Tuberculosis Elimination 2017–25.
6. 6. Marais BJ, Gie RP, Schaff HS, et al. The natural history of childhood intra-thoracic tuberculosis; a critical review of literature from the pre-chemotherapy era. Int J Tuberc Lung Dis 2004; 8:392-402.
7. 7. Jenkins HE, Tolman AW, Yuen CM, et al. Incidence of multidrug-resistant tuberculosis disease in children: systematic review and global estimates. Lancet 2014; 383:1572–9.
8. 8. Dodd PJ, Gardiner E, Coghlan R, Seddon JA. Burden of childhood tuberculosis in 22 high-burden countries: a mathematical modelling study. Lancet Glob Health 2014; 2:e453–459.

9. 9. Automated real-time nucleic acid amplification technology for rapid and simultaneous detection of tuberculosis and rifampicin resistance: Xpert MTB/RIF system for the diagnosis of pulmonary and extrapulmonary TB in adults and children: policy update. Geneva, World Health Organization, 2013.
10. 10. Rachow A, Clowes P, Saathoff E, et al. Increased and expedited case detection by Xpert MTB/RIF assay in childhood tuberculosis: a prospective cohort study. Clin Infect Dis 54. 2012: 1388-96.
11. 11. Haldar S, Bose M, Chakrabarti P, et al. Improved laboratory diagnosis of tuberculosis-The Indian experience. Tuberculosis (Edinb) 2011; 91(5): 414-426.
12. 12. Ichhpujani RL, Agarwal SP, Chauhan LS. Diagnostic needs and status of new diagnostic tools for tuberculosis. In: Agarwal SP, Chauhan LS.Tuberculosis control in India. Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India, New Delhi, India, 2005, pp. 165-78.
13. 13. Bianchi L, Galli L, Moriondo M, et al. Interferon-gamma release assay improves the diagnosis of tuberculosis in children. Pediatr Infect Dis J 2014; 28(6): 510-4.
14. 14. Pai M, Nathavitharana R. Extrapulmonary Tuberculosis: New Diagnostics and New Policies. Indian J Chest Dis Allied Sci 2014; 56(2): 71-73.
15. 15. World Health Organization (2017) Automated real-time nucleic acid amplification technology for rapid and simultaneous detection of tuberculosis and rifampicin resistance: Xpert MTB/RIF assay for the diagnosis of pulmonary and extrapulmonary TB in adults and children: policy update. World Health Organization, Geneva, Switzerland.
16. 16. Lawn SD, Nicol MP. Xpert® MTB/RIF assay: Development, evaluation and implementation of a new rapid molecular diagnostic for tuberculosis and rifampicin resistance. Future Microbiol 2011; 6:1067 82.
17. 17. Helb D, Jones M, Story E, et al. Rapid detection of mycobacterium tuberculosis and rifampicin resistance by use of on demand, near-patient technology. J Clin Microbiol 2010; 48:229-37.
18. 18. Ajaykumar T, San S, Shiju S, Balasangameshwara VH, Kumar P. External Quality Assessment System for Sputum Smear Microscopy in India: Operational and Technical Implementation Aspects. NTI Bulletin 2005; 41(1 & 2):18-32.
19. 19. Xpert MTB/RIF Implementation Manual: Technical and Operational ‘How-To’; Practical Considerations. Geneva: World Health Organization; 2014. Annex 2, Standard Operating Procedure (SOP) for processing extrapulmonary specimens (CSF, lymph nodes and other tissues) for Xpert MTB/RIF Assay.
20. 20. Arega B, Menbere F, Getachew Y. Prevalence of rifampicin resistant Mycobacterium tuberculosis among presumptive tuberculosis patients in selected governmental hospitals in Addis Ababa, Ethiopia. BMC Infect Dis 2019; 19, 307.
21. 21. Nicol MP, Workman L, Isaacs W, et al. Accuracy of the Xpert MTB/RIF test for the diagnosis of pulmonary tuberculosis in children admitted to hospital in Cape Town, South Africa: a descriptive study. Lancet Infect Dis 2011;11(11): 819-824.
22. 22. Sekadde MP, Wobudeya E, Joloba ML, et al. Evaluation of the Xpert MTB/RIF test for the diagnosis of childhood pulmonary tuberculosis in Uganda: a cross-sectional diagnostic study. BMC Infect Dis 2013; 13:133.
23. 23. Phuljhele S, Beck P, Sinha A, Saroj AK. Diagnostic accuracy of CBNAAT (Gene-Xpert) Vs liquid culture in clinically diagnosed presumptive childhood tuberculosis admitted in Pt. J.N.M. Medical College & Dr. Bhim Rao Ambedkar Memorial Hospital, Raipur (C.G.). Int J Pediatr Res.2019; 6(09):467-473.
24. 24. Jain SK, Ordonez A, Kinikar A, et al. Pediatric Tuberculosis in Young Children in India: A Prospective Study. Biomed Res Int. 2013; 2013:783698.
25. 25. Verma D, Malhotra B, Goyal S, Shah T, Gupta KN. Prevalence of MDR-TB and mutational pattern in rpoB gene of Mycobacterium tuberculosis at Eastern Rajasthan. Microcon 2014. (38th National Conference of Indian Association of Medical Microbiologist) 2014; MP39:253.
26. 26. Kaur R, Jindal N, Arora S, Kataria S. Epidemiology of Rifampicin Resistant Tuberculosis and Common Mutations in rpoB Gene of Mycobacterium tuberculosis: A Retrospective Study from Six Districts of Punjab (India) Using Xpert MTB/RIF Assay. J Lab Physicians 2016; 8(2):96‐100.
27. 27. Kasat S, Biradar M, Deshmukh A, Jadhav S, Deshmukh H. Effectiveness of CBNAAT in the diagnosis of extrapulmonary tuberculosis. Int J Res Med Sci2018; 6:3925-3928.
28. 28. Sharma SK, Mohan A. Extrapulmonary tuberculosis. Indian J Med Res 2004; 120:316–53.
29. 29. WHO (2012) Tuberculosis countries profiles. World Health Organization.
30. 30. Gurung R, Bhattacharya SK, Pradhan B, Gurung S, Singh Y. Phenotypic characterisation and drug sensitivity testing of mycobacteria isolated from extrapulmonary tuberculosis. Kathmandu Univ Med J 2010; 8(29):57–61.
31. 31. Chakraborty S, Chakraborty A, Talukder T, Mukherjee M, Chatterjee T. Prevalence of Mycobacterium tuberculosis Strains Isolated from Both Pulmonary and Extra Pulmonary Samples and Their Resistance to Rifampicin: A Study from Kolkata and Surrounding Suburbs. J Tuberculosis Res 2016; 4:61-71.