title: Diagnosing childhood pulmonary tuberculosis using a single sputum specimen on Xpert MTB/RIF at point of care.
abstract: BACKGROUND
  The GeneXpertMTB/RIF (Cepheid, USA) (Xpert) has proved successful for pulmonary tuberculosis (TB) diagnosis on decontaminated/concentrated induced sputum specimens from children. Capacity to perform induction in many settings is limited.
  
  
  OBJECTIVE
  To assess: (i) volumes of 'routinely obtained' sputum in a district-level academic hospital; (ii) whether sputum specimens not meeting Xpert-required testing volumes could still be tested; and (iii) performance of Xpert on a single paediatric sputum specimen at point of care (POC).
  
  
  METHODS
  Two sputa were collected from paediatric TB suspects (£14 years) at Rahima Moosa Mother and Child Hospital, Johannesburg, South Africa. One specimen was weighed at POC; if the volume was ≥0.1 mL but <0.5 mL, it was increased to 0.5 mL using saline. On-site Xpert testing (G3 cartridge) was performed by a dedicated laboratory technician. The second specimen was referred for TB smear microscopy and culture as per standard of care (SOC).
  
  
  RESULTS
  A total of 484 patients presumed to have TB (median age 24 months) were eligible for this study, performed between June 2011 and May 2012. Xpert could not be used on 4.1% of specimens because of volumes<0.1 mL, and 62.8% required addition of saline prior to Xpert testing. Xpert generated a 2.2% error and 3.7% invalid rate, compared with the SOC that rejected 2.3% because of insufficient volume and 2.3% that were contaminated. The diagnostic performance compared with culture was 62.5% (95% confidence interval (CI) 24.7-91) and 99.1% (95% CI 97.4-99.8) sensitivity and specificity, respectively, for Xpert (n=345) and 33.3% (7.9-69.9) and 99.5% (98.1-99.9) sensitivity and specificity, respectively, for smear microscopy (n=374).
  
  
  CONCLUSIONS
  Up to 67% of 'routinely obtained' sputum specimens from children (£14 years) are below the required volume for Xpert testing but can be 'topped up' with saline. XpertMTB/RIF performed better than microscopy and generated clinically relevant, timeous results, but sensitivity did not reach the same levels as culture in children.
authors.affiliation: Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. natasha.gous@gmail.com.
authors.forename: Natasha
authors.initials: N
authors.lastname: Gous
authors.forename: Lesley E
authors.initials: LE
authors.lastname: Scott
authors.forename: Sonjiha
authors.initials: S
authors.lastname: Khan
authors.forename: Gary
authors.initials: G
authors.lastname: Reubenson
authors.forename: Ashraf
authors.initials: A
authors.lastname: Coovadia
authors.forename: Wendy
authors.initials: W
authors.lastname: Stevens