title: Role of clinical judgment in the application of a nucleic acid amplification test for the rapid diagnosis of pulmonary tuberculosis.
abstract: BACKGROUND
  Several nucleic acid amplification (NAA) tests for Mycobacterium tuberculosis (MTB) have been licensed for the rapid diagnosis of active pulmonary tuberculosis (PTB) in respiratory secretions. There is uncertainty however regarding the practical application of these tests in clinical decision making.
  
  
  OBJECTIVE
  To evaluate the utility of the COBAS AMPLICOR assay (Roche Diagnostics; Singapore) for MTB as applied by specialists for the rapid diagnosis of PTB in the routine clinical setting.
  
  
  METHODS
  A prospective study of consecutive patients suspected of PTB and tested with the AMPLICOR assay under the care of respiratory physicians. The final diagnosis was based on all relevant clinical information after at least 3 months of follow-up. Accuracy of the NAA test was compared with that of the initial expectant treatment. Expectant treatment was based on an integrated approach that incorporated clinical evaluation with results of direct smear and NAA tests.
  
  
  RESULTS
  The incidence of PTB in 168 patients was 32%. The basis for expectant treatment of PTB was positive smear result in 47%, clinical suspicion in 26%, and positive AMPLICOR result in 23%. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the AMPLICOR test were 77%, 100%, 99%, 90%, and 93%, respectively. In comparison, they were 96%, 97%, 94%, 98%, and 97%, respectively, for the integrated clinical approach.
  
  
  CONCLUSIONS
  In the rapid diagnosis of PTB, the clinical judgment of specialists augmented the utility of the NAA test: (1) specialists selected patients with high-to-moderate pretest probabilities, (2) they commenced treatment promptly on a positive NAA test result, and (3) they were willing to start treatment in some patients on the basis of high clinical suspicion despite negative smear and negative NAA test results.
authors.affiliation: Department of Medicine, National University Hospital, Lower Kent Ridge Road, Singapore 119074. mdclimtk@nus.edu.sg
authors.forename: T K
authors.initials: TK
authors.lastname: Lim
authors.forename: Amartya
authors.initials: A
authors.lastname: Mukhopadhyay
authors.forename: Annie
authors.initials: A
authors.lastname: Gough
authors.forename: Kay-Leong
authors.initials: KL
authors.lastname: Khoo
authors.forename: See-Meng
authors.initials: SM
authors.lastname: Khoo
authors.forename: Kang-Hoe
authors.initials: KH
authors.lastname: Lee
authors.forename: Gamini
authors.initials: G
authors.lastname: Kumarasinghe
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000995:Antitubercular Agents / Q000627:therapeutic use; D019091:Critical Pathways; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009169:Mycobacterium tuberculosis / Q000302:isolation & purification*; D021141:Nucleic Acid Amplification Techniques; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D012846:Singapore; D013183:Sputum / Q000382:microbiology; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000188:drug therapy
chemical_list: D000995:Antitubercular Agents