title: Mixed infection and clonal representativeness of a single sputum sample in tuberculosis patients from a penitentiary hospital in Georgia.
abstract: BACKGROUND
  Studies on recurrent tuberculosis (TB), TB molecular epidemiology and drug susceptibility testing rely on the analysis of one Mycobacterium tuberculosis isolate from a single sputum sample collected at different disease episodes. This scheme rests on the postulate that a culture of one sputum sample is homogeneous and representative of the total bacillary population in a patient.
  
  
  METHODS
  We systematically analysed several pre-treatment isolates from each of 199 smear-positive male adult inmates admitted to a prison TB hospital by standard IS6110 DNA fingerprinting, followed by PCR typing based on multiple loci containing variable number of tandem repeats (VNTRs) on a subset of isolates. Drug susceptibility testing (DST) was performed on all isolates for isoniazid, rifampicin, streptomycin and ethambutol.
  
  
  RESULTS
  We found mixed infection in 26 (13.1%) cases. In contrast, analysis of a single pre-treatment isolate per patient would have led to missed mixed infections in all or 14 of these 26 cases by using only standard DNA fingerprinting or the PCR multilocus-based method, respectively. Differences in DST among isolates from the same patient were observed in 10 cases, of which 6 were from patients with mixed infection.
  
  
  CONCLUSIONS
  These results suggest that the actual heterogeneity of the bacillary population in patients, especially in high TB incidence settings, may be frequently underestimated using current analytical schemes. These findings have therefore important implications for correct interpretation and evaluation of molecular epidemiology data and in treatment evaluations.
authors.affiliation: Prince Leopold Institute of Tropical Medicine, Mycobacteriology Unit, Nationalestraat 155, B-2000 Antwerp, Belgium. icshamputa@itg.be
authors.forename: Isdore C
authors.initials: IC
authors.lastname: Shamputa
authors.forename: Levan
authors.initials: L
authors.lastname: Jugheli
authors.forename: Nikoloz
authors.initials: N
authors.lastname: Sadradze
authors.forename: Eve
authors.initials: E
authors.lastname: Willery
authors.forename: Françoise
authors.initials: F
authors.lastname: Portaels
authors.forename: Philip
authors.initials: P
authors.lastname: Supply
authors.forename: Leen
authors.initials: L
authors.lastname: Rigouts
mesh_terms: D000328:Adult; D000995:Antitubercular Agents / Q000494:pharmacology / Q000627:therapeutic use; D016172:DNA Fingerprinting; D024881:Drug Resistance, Bacterial; D005846:Georgia (Republic); D006761:Hospitals; D006801:Humans; D007538:Isoniazid / Q000494:pharmacology / Q000627:therapeutic use; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D018598:Minisatellite Repeats; D009169:Mycobacterium tuberculosis / Q000187:drug effects / Q000235:genetics / Q000302:isolation & purification*; D012150:Polymorphism, Restriction Fragment Length; D011329:Prisoners; D011446:Prospective Studies; D011786:Quality Control; D012293:Rifampin / Q000494:pharmacology / Q000627:therapeutic use; D013183:Sputum / Q000382:microbiology*; D013307:Streptomycin / Q000494:pharmacology / Q000627:therapeutic use; D014376:Tuberculosis / Q000188:drug therapy / Q000235:genetics / Q000382:microbiology*
chemical_list: D000995:Antitubercular Agents; D007538:Isoniazid; D012293:Rifampin; D013307:Streptomycin