Diagnosis of tuberculosis and drug resistance: what can new tools bring us?
Diagnosis of tuberculosis and drug resistance: what can new tools bring us?
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DOI：
10.5588/ijtld.12.0180
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发表时间：
2012-07-01
影响因子：
4
通讯作者：
Papaventsis, D.
中科院分区：
文献类型：
--
作者：
Drobniewski, F.;Nikolayevskyy, V.;Papaventsis, D.
对于结核病诊断来说，这是一个激动人心的时刻。快速诊断肺痰涂片阳性结核和利福平耐药性的技术非常先进，检测方法具有高特异性和良好的敏感性。然而，目前结核病检测的敏感性意味着这些检测方法仍然不能取代结核病的标准诊断方法或传统的药敏试验（DST）。在肺外标本中，分子工具的性能各不相同，应分别考虑每种标本类型。在结核病和人类免疫缺陷病毒（HIV）合并感染的个体中使用这些检测方法检测结核病和耐药性的证据有限。由于只有在新发结核病患者中RMP耐药率为>15%时，RMP耐药阳性预测值才会达到>= 90%，这在全球范围内是罕见的，因此许多具有这种耐药的病例将是假耐药，强调需要进行二次确证检测。同样，结核病诊断的增加（或不正确）可能会增加需要抗结核治疗的个体数量，从而影响规划的有效性，除非经过仔细规划。未来，1)需要更高灵敏度的结核病检测方法；2)儿科结核病的快速诊断很重要，需要进行精心设计的研究，包括涉及艾滋病毒阳性儿童的研究；3)需要从纵向研究中获得更多的临床数据，特别是与快速诊断对疾病结局的影响有关的数据；4)使用未经处理的痰、血或尿进行即时检测，很少或根本没有设备，将带来不可估量的好处。虽然已经取得了很大的进展，但我们还没有达到目标。
This is an exciting time for tuberculosis (TB) diagnostics. The technology for rapid diagnosis of TB and rifampicin (RMP) resistance in pulmonary sputum smear-positive specimens is well advanced, and assays have high specificity with good sensitivity. Nevertheless, the current sensitivity of TB detection means that these assays still cannot replace the standard diagnostic methods for TB or conventional drug susceptibility testing (DST). In extra-pulmonary specimens, the performance of molecular tools varies and should be considered separately for each specimen type. Evidence for the use of these assays for TB and drug resistance detection in individuals co-infected with TB and the human immunodeficiency virus (HIV) is limited.As the positive predictive value for RMP resistance reaches >= 90% only when the prevalence of RMP resistance in new TB patients is >15%, which is rare globally, many cases with such resistance will be false-resistant, emphasising the need for a secondary confirmative test. Similarly, increased (or incorrect) diagnosis of TB may compromise programme effectiveness by increasing the numbers of individuals requiring anti-tuberculosis treatment, unless it is carefully planned.For the future, 1) assays with greater sensitivity for TB detection arc needed; 2) rapid diagnostics for paediatric TB are important, and there is a need for carefully designed studies, including those involving HIV-positive children; 3) more clinical data need to be obtained from longitudinal studies, especially related to the influence of rapid diagnostics on disease outcome; and 4) point-of-care tests using untreated sputum, blood or urine and little or no equipment would be of immeasurable benefit. Although great progress has been made, we are not there yet.