Xpert® MTB/RIF for national tuberculosis programmes in low-income countries: when, where and how?
Xpert® MTB/RIF for national tuberculosis programmes in low-income countries: when, where and how?
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DOI：
10.5588/ijtld.11.0392
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发表时间：
2011-12-01
影响因子：
4
通讯作者：
Rieder, H. L.
中科院分区：
文献类型：
--
作者：
Trebucq, A.;Enarson, D. A.;Rieder, H. L.
Xpert（R）MTB/RIF为痰涂片阴性结核病（TB）和/或利福平（RMP）耐药性的诊断提供了新的重要可能性，许多试剂盒正在鼓励快速和广泛的实施。这个简单的测试几乎可以在任何地方实施，并在几个小时内提供结果。然而，在低收入国家，其成本、环境限制（稳定和正常的电力、适当的室温）以及供应和维护方面的困难是主要障碍。虽然它可能适用于主要的参考医院，但在其用于外围水平之前，需要进行操作研究以评估该测试及其在高质量涂片显微镜和临床算法之上的额外产量。与此同时，直接显微镜检查仍应是结核病疑似者的初步诊断试验。在大多数低收入国家，新发结核病患者中RMP耐药的流行率非常低;因此，Xpert MTB/RIF结果表明RMP耐药始终需要通过另一项检测进行确认。然而，在RMP耐药风险较高（>15%）的人群中，Xpert MTB/RIF对RMP耐药的阳性预测值较高，RMP耐药的鉴定是耐多药结核病（MDR-TB）的一个很好的替代指标。如果且仅如果能够进行出色的耐多药结核病管理，该检测方法应广泛用于此目的，这既是出于伦理原因，也是为了降低广泛耐药结核病的风险。
Xpert (R) MTB/RIF offers new and important possibilities for the diagnosis of sputum smear-negative tuberculosis (TB) and/or rifampicin (RMP) resistance, and many are encouraging rapid and widespread implementation. This simple test can be implemented almost everywhere, and it provides results within a few hours. In low-income countries (LICs), however, its cost, environmental limitations (stable and regular electricity, adequate room temperature) and difficulties involved in supply and maintenance are major obstacles. While it may be suitable for major reference hospitals, operational research is needed to evaluate the test and its additional yield above high-quality smear microscopy and clinical algorithms before its use at the peripheral level. In the meantime, direct microscopy should remain the initial diagnostic test for TB suspects. In most LICs, the prevalence of RMP resistance among new TB patients is very low; an Xpert MTB/RIF result indicating RMP resistance will thus always need confirmation by another test. In a population at high risk of RMP resistance (>15%), however, the positive predictive value for RMP resistance by Xpert MTB/RIF is high, and identification of RMP resistance is an excellent proxy for multidrug-resistant TB (MDR-TB). The assay should be widely used for this purpose if, and only if, excellent MDR-TB management is available, both for ethical reasons and to reduce the risk of extensively drug-resistant TB.