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Article(id=1202979643944039166, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1202979639087030850, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.2257.2023.0427, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1667145600000, receivedDateStr=2022-10-31, revisedDate=null, revisedDateStr=null, acceptedDate=1672156800000, acceptedDateStr=2022-12-28, onlineDate=1764742297396, onlineDateStr=2025-12-03, pubDate=1690473600000, pubDateStr=2023-07-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1764742297396, onlineIssueDateStr=2025-12-03, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1764742297396, creator=13701087609, updateTime=1764742297396, updator=13701087609, issue=Issue{id=1202979639087030850, tenantId=1146029695717560320, journalId=1189873630562394117, year='2023', volume='48', issue='7', pageStart='749', pageEnd='870', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1764742296239, creator=13701087609, updateTime=1764742346610, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1202979850442203282, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1202979639087030850, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1202979850442203283, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1202979639087030850, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=761, endPage=767, ext={EN=ArticleExt(id=1202979644434772758, articleId=1202979643944039166, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Clinical value of Xpert MTB/RIF Ultra in rapid diagnosis of smeared negative pulmonary tuberculosis, columnId=1202979639976223301, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Special Issue Ⅱ on Prevention, Diagnosis and Treatment of Tuberculosis, runingTitle=null, highlight=null, articleAbstract=

Objective To evaluate the value of GeneXpert MTB/RIF Ultra (Xpert Ultra) in the early and rapid diagnosis of sputum and bronchoalveolar lavage fluid (BALF) samples in patients with smeared negative tuberculosis. Methods A total of 93 patients with sputum smear-negative suspected pulmonary tuberculosis who were admitted to Shandong Public Health Clinical Center from May 2020 to December 2021 were included in this study. Among them, 57 patients were clinically diagnosed as sputum smear-negative pulmonary tuberculosis and 36 patients were non-pulmonary tuberculosis. Sputum and BALF samples were collected from all patients, and Xpert Ultra, GeneXpert MTB/RIF (Xpert), BACTEC MGIT 960 culture (MGIT 960 culture) were performed. To evaluate the sensitivity, specificity and coincidence rate of various detection methods and their combined detection of sputum and bronchoalveolar lavage fluid samples in the diagnosis of smeared negative pulmonary tuberculosis. Results Taking clinical diagnosis as the reference standard, the sensitivity of sputum samples detected by Xpert Ultra for the diagnosis of smeared negative pulmonary tuberculosis was significantly higher than that of Xpert [56.14% (32/57) vs. 36.84% (21/57), P=0.039] and MGIT 960 culture [56.14% (32/57) vs. 33.33% (19/57), P=0.014]. The sensitivity of BALF samples detected by Xpert Ultra for the diagnosis of smeared negative pulmonary tuberculosis was significantly higher than that of Xpert [75.44% (43/57) vs. 56.14% (32/57),P=0.030] and MGIT 960 culture [75.44% (43/57) vs. 38.60% (22/57), P<0.01]. Three different methods of testing sputum samples, the area under the receiver operating characteristic curve (AUC) was the combination of the three elements (0.807)>Xpert Ultra+Xpert (0.798)>Xpert Ultra+MGIT 960 culture (0.789)>Xpert Ultra method (0.781)>Xpert (0.684)>MGIT 960 culture (0.667);Samples of BALF were examined, the AUC was the combination of the three elements (0.895)=Xpert Ultra+Xpert (0.895)>Xpert Ultra+MGIT 960 culture (0.877)=Xpert Ultra method (0.877)>Xpert (0.781)>culture method (0.693). Rifampicin resistance was not detected in the enrolled samples by the three detection methods. Conclusions Xpert Ultra has high clinical application value in the early and rapid diagnosis of smeared negative pulmonary tuberculosis, and the sensitivity of Xpert Ultra in the detection of BALF is higher than that of sputum sample, so the BALF sample is recommended as prior selection.

, correspAuthors=Yu Xiong, authorNote=null, correspAuthorsNote=
* E-mail:
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目的 评估超敏结核分枝杆菌和利福平耐药基因检测(Xpert Ultra)方案检测痰液及支气管肺泡灌洗液(BALF)标本在涂阴肺结核患者中早期、快速诊断的价值。方法 选择2020年5月－2021年12月在山东省公共卫生临床中心就诊的痰涂片阴性疑似肺结核患者93例，其中临床诊断为涂阴肺结核57例，非肺结核36例。收集所有患者的痰液及BALF标本，分别采用Xpert Ultra、GeneXpert MTB/RIF (Xpert)、BACTEC MGIT 960培养(MGIT 960培养)进行检测。以临床诊断为参考标准，评价3种检测方案及相互联合检测痰液及BALF标本时诊断涂阴肺结核的敏感度、特异度及符合率。结果 以临床诊断结果为参考标准，Xpert Ultra检测痰液标本对涂阴肺结核诊断的敏感度明显高于Xpert [56.14%(32/57) vs. 36.84%(21/57)，P=0.03]和MGIT 960培养[56.14%(32/57) vs. 33.33%(19/57)，P=0.014]；Xpert Ultra检测BALF标本对涂阴肺结核诊断的敏感度明显高于Xpert [75.44%(43/57) vs. 56.14%(32/57)，P=0.030]和MGIT 960培养[75.44%(43/57) vs. 38.60%(22/57)，P<0.01]。3种检测方案及相互联合检测痰液标本诊断涂阴肺结核，受试者工作特征(ROC)曲线下面积(AUC)依次为：三者联合(0.807)>Xpert Ultra+Xpert (0.798)>Xpert Ultra+MGIT 960培养(0.789)>Xpert Ultra (0.781)>Xpert (0.684)>MGIT 960培养(0.667)；检测BALF标本，AUC依次为：三者联合(0.895)=Xpert Ultra+Xpert(0.895)>Xpert Ultra+MGIT 960培养(0.877)=Xpert Ultra (0.877)>Xpert (0.781)>MGIT 960培养(0.693)。3种检测方案均未在入组患者中检测到利福平耐药。结论 Xpert Ultra对早期、快速诊断涂阴肺结核具有较高的临床应用价值；其检测BALF的敏感度高于痰液标本，建议优先选择BALF标本。

, correspAuthors=熊瑜, authorNote=null, correspAuthorsNote=
熊瑜，E-mail：
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丁彩红，硕士研究生，主要从事结核病防治方面的研究

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丁彩红，硕士研究生，主要从事结核病防治方面的研究

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丁彩红，硕士研究生，主要从事结核病防治方面的研究

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Cochrane Database Syst Rev, 2021, 2: CD009593., articleTitle=Xpert Ultra versus Xpert MTB/RIF for pulmonary tuberculosis and rifampicin resistance in adults with presumptive pulmonary tuberculosis, refAbstract=null), Reference(id=1203005091361026476, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979643944039166, doi=null, pmid=null, pmcid=null, year=2019, volume=57, issue=2, pageStart=e01717, pageEnd=18, url=null, language=null, rfNumber=[23], rfOrder=25, authorNames=Opota O, Zakham F, Mazza-Stalder J, journalName=J Clin Microbiol, refType=null, unstructuredReference=Opota O, Zakham F, Mazza-Stalder J, et al. Added value of Xpert MTB/RIF Ultra for diagnosis of pulmonary tuberculosis in a low-prevalence setting[J]. J Clin Microbiol, 2019, 57(2): e01717-18., articleTitle=Added value of Xpert MTB/RIF Ultra for diagnosis of pulmonary tuberculosis in a low-prevalence setting, refAbstract=null), Reference(id=1203005091428135341, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979643944039166, doi=null, pmid=null, pmcid=null, year=2020, volume=162, issue=null, pageStart=105876, pageEnd=null, url=null, language=null, rfNumber=[24], rfOrder=26, authorNames=Pereira GR, Barbosa MS, Dias NJD, journalName=Respir Med, refType=null, unstructuredReference=Pereira GR, Barbosa MS, Dias NJD, et al. Evaluation of Xpert MTB/RIF Ultra performance for pulmonary tuberculosis (TB)diagnosis in a city with high TB incidence in Brazil[J]. 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Xpert Ultra. GeneXpert MTB/RIF Ultra；Xpert. GeneXpert MTB/RIF；培养. BACTEC MGIT 960培养；ROC. 受试者工作特征

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Xpert Ultra. GeneXpert MTB/RIF Ultra；Xpert. GeneXpert MTB/RIF；培养. BACTEC MGIT 960培养；BALF. 支气管肺泡灌洗液；ROC. 受试者工作特征

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Comparison of general data between the two groups of patients with smeared negative pulmonary tuberculosis

, figureFileSmall=null, figureFileBig=null, tableContent=
指标肺结核组非肺结核组U/χ2P
年龄[岁，M(Q1,Q3)]36.0(25.5,59.0)53.0(34.3,62.5)1.7080.088
性别[例(%)]
 男32(56.1)25(69.4)1.6460.199
 女25(43.9)11(30.6)
症状或体征[例(%)]
 发热10(17.5)7(19.4)0.0001.000
 咳嗽/咳痰30(52.6)22(61.1)0.6440.422
 痰中带血3(5.3)1(2.8)0.0030.960
 乏力3(5.3)3(8.3)0.0240.878
 盗汗2(3.5)2(5.6)0.0001.000
 体重下降2(3.5)4(11.1)1.0410.308
 胸闷/胸痛10(17.5)9(25)0.7550.385
并发症[例(%)]
 糖尿病7(12.3)6(16.7)0.3530.552
 高血压病3(5.3)4(11.1)0.4070.524
 冠状动脉粥样硬化性心脏病03(8.3)2.6020.107
 慢性阻塞性肺病1(1.8)4(11.1)2.1810.140
 支气管扩张1(1.8)3(8.3)0.9970.318
 哮喘1(1.8)2(5.6)0.1670.683
 肝炎1(1.8)00.0001.000
 慢性肾病1(1.8)1(1.8)0.0001.000
 心律失常1(1.8)3(8.3)0.9970.318
 肿瘤01(2.8)0.0540.816
), ArticleFig(id=1203005087393214729, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979643944039166, language=CN, label=表1, caption=

两组涂阴疑似肺结核患者临床资料比较

, figureFileSmall=null, figureFileBig=null, tableContent=
指标肺结核组非肺结核组U/χ2P
年龄[岁，M(Q1,Q3)]36.0(25.5,59.0)53.0(34.3,62.5)1.7080.088
性别[例(%)]
 男32(56.1)25(69.4)1.6460.199
 女25(43.9)11(30.6)
症状或体征[例(%)]
 发热10(17.5)7(19.4)0.0001.000
 咳嗽/咳痰30(52.6)22(61.1)0.6440.422
 痰中带血3(5.3)1(2.8)0.0030.960
 乏力3(5.3)3(8.3)0.0240.878
 盗汗2(3.5)2(5.6)0.0001.000
 体重下降2(3.5)4(11.1)1.0410.308
 胸闷/胸痛10(17.5)9(25)0.7550.385
并发症[例(%)]
 糖尿病7(12.3)6(16.7)0.3530.552
 高血压病3(5.3)4(11.1)0.4070.524
 冠状动脉粥样硬化性心脏病03(8.3)2.6020.107
 慢性阻塞性肺病1(1.8)4(11.1)2.1810.140
 支气管扩张1(1.8)3(8.3)0.9970.318
 哮喘1(1.8)2(5.6)0.1670.683
 肝炎1(1.8)00.0001.000
 慢性肾病1(1.8)1(1.8)0.0001.000
 心律失常1(1.8)3(8.3)0.9970.318
 肿瘤01(2.8)0.0540.816
), ArticleFig(id=1203005087502266636, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979643944039166, language=EN, label=Tab. 2, caption=

The diagnostic efficacy of Xpert Ultra, Xpert and MGIT960 culture to detect sputum samples with smeared negative pulmonary tuberculosis (clinical diagnosis as reference standard)

, figureFileSmall=null, figureFileBig=null, tableContent=
检测方案临床诊断(例)敏感度(%)特异度(%)阳性预测值(%)阴性预测值(%)符合率(%)Kappa值
肺结核组(n=57)非肺结核组(n=36)
Xpert Ultra  56.1410010059.0273.120.498*
 阳性320
 阴性2536
Xpert  36.8410010050.0061.290.311*
 阳性210
 阴性3636
MGIT960培养  33.3310010048.6559.140.279*
 阳性190
 阴性3836      
), ArticleFig(id=1203005087602929936, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979643944039166, language=CN, label=表2, caption=

Xpert Ultra、Xpert、MGIT960培养检测痰液标本对涂阴肺结核的诊断效能(以临床诊断结果为参考标准)

, figureFileSmall=null, figureFileBig=null, tableContent=
检测方案临床诊断(例)敏感度(%)特异度(%)阳性预测值(%)阴性预测值(%)符合率(%)Kappa值
肺结核组(n=57)非肺结核组(n=36)
Xpert Ultra  56.1410010059.0273.120.498*
 阳性320
 阴性2536
Xpert  36.8410010050.0061.290.311*
 阳性210
 阴性3636
MGIT960培养  33.3310010048.6559.140.279*
 阳性190
 阴性3836      
), ArticleFig(id=1203005087695204629, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979643944039166, language=EN, label=Tab. 3, caption=

ROC curve analysis of Xpert Ultra, Xpert and MGIT960 culture for diagnosis of smeared negative pulmonary tuberculosis by sputum samples detection

, figureFileSmall=null, figureFileBig=null, tableContent=
检测方案AUC(95%CI)P
Xpert Ultra0.781(0.689,0.873)<0.010
Xpert0.684(0.579,0.790)0.003
MGIT 960培养0.667(0.559,0.774)0.007
Xpert Ultra+Xpert0.798(0.710,0.887)<0.010
Xpert Ultra+MGIT 960培养0.789(0.699,0.880)<0.010
三者联合0.807(0.720,0.894)<0.010
), ArticleFig(id=1203005087804256537, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979643944039166, language=CN, label=表3, caption=

Xpert Ultra、Xpert 和 MGIT960 培养检测痰液标本诊断涂阴肺结核的ROC曲线分析

, figureFileSmall=null, figureFileBig=null, tableContent=
检测方案AUC(95%CI)P
Xpert Ultra0.781(0.689,0.873)<0.010
Xpert0.684(0.579,0.790)0.003
MGIT 960培养0.667(0.559,0.774)0.007
Xpert Ultra+Xpert0.798(0.710,0.887)<0.010
Xpert Ultra+MGIT 960培养0.789(0.699,0.880)<0.010
三者联合0.807(0.720,0.894)<0.010
), ArticleFig(id=1203005087896531227, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979643944039166, language=EN, label=Tab. 4, caption=

The diagnostic efficacy of Xpert Ultra, Xpert and MGIT960 culture to detect bronchoalveolar lavage fluid (BALF) samples with smeared negative pulmonary tuberculosis (the clinical diagnosis as reference standard)

, figureFileSmall=null, figureFileBig=null, tableContent=
检测方法临床诊断结果(例)敏感度(%)特异度(%)阳性预测值(%)阴性预测值(%)符合率(%)Kappa值
肺结核组(n=57)非肺结核组(n=36)
Xpert Ultra  75.441001007284.950.704*
 阳性430
 阴性1436
Xpert  56.1410010059.0273.120.498*
 阳性320
 阴性2536
MGIT 960培养  38.6010010050.7062.370.327*
 阳性220
 阴性3536      
), ArticleFig(id=1203005087980417313, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979643944039166, language=CN, label=表4, caption=

Xpert Ultra、Xpert、MGIT960培养检测BALF标本对痰涂阴肺结核的诊断效能(以临床诊断结果为参考标准)

, figureFileSmall=null, figureFileBig=null, tableContent=
检测方法临床诊断结果(例)敏感度(%)特异度(%)阳性预测值(%)阴性预测值(%)符合率(%)Kappa值
肺结核组(n=57)非肺结核组(n=36)
Xpert Ultra  75.441001007284.950.704*
 阳性430
 阴性1436
Xpert  56.1410010059.0273.120.498*
 阳性320
 阴性2536
MGIT 960培养  38.6010010050.7062.370.327*
 阳性220
 阴性3536      
), ArticleFig(id=1203005088060109094, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979643944039166, language=EN, label=Tab. 5, caption=

ROC curve analysis of Xpert Ultra, Xpert and MGIT960 culture to detect bronchoalveolar lavage fluid(BALF) samples with smeared negative pulmonary tuberculosis

, figureFileSmall=null, figureFileBig=null, tableContent=
检测方法AUC(95%CI)P
Xpert Ultra0.877(0.806,0.949)<0.01
Xpert0.781(0.689,0.873)<0.01
MGIT 960培养0.693(0.588,0.798)<0.01
Xpert Ultra+Xpert0.895(0.828,0.961)<0.01
Xpert Ultra+MGIT 960培养0.877(0.806,0.949)<0.01
三者联合0.895(0.828,0.961)<0.01
), ArticleFig(id=1203005088156578090, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979643944039166, language=CN, label=表5, caption=

Xpert Ultra、Xpert和MGIT960培养检测BALF标本诊断涂阴肺结核的ROC曲线分析

, figureFileSmall=null, figureFileBig=null, tableContent=
检测方法AUC(95%CI)P
Xpert Ultra0.877(0.806,0.949)<0.01
Xpert0.781(0.689,0.873)<0.01
MGIT 960培养0.693(0.588,0.798)<0.01
Xpert Ultra+Xpert0.895(0.828,0.961)<0.01
Xpert Ultra+MGIT 960培养0.877(0.806,0.949)<0.01
三者联合0.895(0.828,0.961)<0.01
), ArticleFig(id=1203005088244658477, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979643944039166, language=EN, label=Tab. 6, caption=

Comparison of positive rate of sputum and bronchoalveolar lavage fluid (BALF) in patients with smeared negative pulmonary tuberculosis detected by Xpert Ultra, Xpert, and MGIT960 [n(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
检测方案痰液BALFχ2P
Xpert Ultra32(56.1)43(75.4)4.7160.030
Xpert21(36.8)32(56.1)4.2670.039
MGIT 960培养19(33.3)22(38.6)0.3430.558
), ArticleFig(id=1203005088345321777, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979643944039166, language=CN, label=表6, caption=

Xpert Ultra、Xpert和MGIT960培养对涂阴肺结核患者痰液和BALF的检测阳性率比较[例(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
检测方案痰液BALFχ2P
Xpert Ultra32(56.1)43(75.4)4.7160.030
Xpert21(36.8)32(56.1)4.2670.039
MGIT 960培养19(33.3)22(38.6)0.3430.558
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Xpert MTB/RIF Ultra快速诊断涂阴肺结核的临床价值
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丁彩红 , 王余余 , 王庆 , 高绪胜 , 解丹 , 熊瑜 *
解放军医学杂志 | 结核病的预防、诊断与治疗专题研究Ⅱ 2023,48(7): 761-767
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解放军医学杂志 | 结核病的预防、诊断与治疗专题研究Ⅱ 2023, 48(7): 761-767
Xpert MTB/RIF Ultra快速诊断涂阴肺结核的临床价值
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丁彩红, 王余余, 王庆, 高绪胜, 解丹, 熊瑜*
作者信息
  • 山东大学附属公共卫生临床中心结核内科，山东济南 250102

    • 丁彩红，硕士研究生，主要从事结核病防治方面的研究

通讯作者:

熊瑜，E-mail：
Clinical value of Xpert MTB/RIF Ultra in rapid diagnosis of smeared negative pulmonary tuberculosis
Cai-Hong Ding, Yu-Yu Wang, Qing Wang, Xu-Sheng Gao, Dan Xie, Yu Xiong*
Affiliations
  • Tuberculosis Medicine, Public Health Clinical Center Affiliated to Shandong University, Jinan, Shandong 250102, China
出版时间: 2023-07-28 doi: 10.11855/j.issn.0577-7402.2257.2023.0427
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摘要
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目的 评估超敏结核分枝杆菌和利福平耐药基因检测(Xpert Ultra)方案检测痰液及支气管肺泡灌洗液(BALF)标本在涂阴肺结核患者中早期、快速诊断的价值。方法 选择2020年5月－2021年12月在山东省公共卫生临床中心就诊的痰涂片阴性疑似肺结核患者93例，其中临床诊断为涂阴肺结核57例，非肺结核36例。收集所有患者的痰液及BALF标本，分别采用Xpert Ultra、GeneXpert MTB/RIF (Xpert)、BACTEC MGIT 960培养(MGIT 960培养)进行检测。以临床诊断为参考标准，评价3种检测方案及相互联合检测痰液及BALF标本时诊断涂阴肺结核的敏感度、特异度及符合率。结果 以临床诊断结果为参考标准，Xpert Ultra检测痰液标本对涂阴肺结核诊断的敏感度明显高于Xpert [56.14%(32/57) vs. 36.84%(21/57)，P=0.03]和MGIT 960培养[56.14%(32/57) vs. 33.33%(19/57)，P=0.014]；Xpert Ultra检测BALF标本对涂阴肺结核诊断的敏感度明显高于Xpert [75.44%(43/57) vs. 56.14%(32/57)，P=0.030]和MGIT 960培养[75.44%(43/57) vs. 38.60%(22/57)，P<0.01]。3种检测方案及相互联合检测痰液标本诊断涂阴肺结核，受试者工作特征(ROC)曲线下面积(AUC)依次为：三者联合(0.807)>Xpert Ultra+Xpert (0.798)>Xpert Ultra+MGIT 960培养(0.789)>Xpert Ultra (0.781)>Xpert (0.684)>MGIT 960培养(0.667)；检测BALF标本，AUC依次为：三者联合(0.895)=Xpert Ultra+Xpert(0.895)>Xpert Ultra+MGIT 960培养(0.877)=Xpert Ultra (0.877)>Xpert (0.781)>MGIT 960培养(0.693)。3种检测方案均未在入组患者中检测到利福平耐药。结论 Xpert Ultra对早期、快速诊断涂阴肺结核具有较高的临床应用价值；其检测BALF的敏感度高于痰液标本，建议优先选择BALF标本。

超敏结核分枝杆菌和利福平耐药基因检测  /  涂阴肺结核  /  分子诊断技术  /  耐药  /  早期诊断

Objective To evaluate the value of GeneXpert MTB/RIF Ultra (Xpert Ultra) in the early and rapid diagnosis of sputum and bronchoalveolar lavage fluid (BALF) samples in patients with smeared negative tuberculosis. Methods A total of 93 patients with sputum smear-negative suspected pulmonary tuberculosis who were admitted to Shandong Public Health Clinical Center from May 2020 to December 2021 were included in this study. Among them, 57 patients were clinically diagnosed as sputum smear-negative pulmonary tuberculosis and 36 patients were non-pulmonary tuberculosis. Sputum and BALF samples were collected from all patients, and Xpert Ultra, GeneXpert MTB/RIF (Xpert), BACTEC MGIT 960 culture (MGIT 960 culture) were performed. To evaluate the sensitivity, specificity and coincidence rate of various detection methods and their combined detection of sputum and bronchoalveolar lavage fluid samples in the diagnosis of smeared negative pulmonary tuberculosis. Results Taking clinical diagnosis as the reference standard, the sensitivity of sputum samples detected by Xpert Ultra for the diagnosis of smeared negative pulmonary tuberculosis was significantly higher than that of Xpert [56.14% (32/57) vs. 36.84% (21/57), P=0.039] and MGIT 960 culture [56.14% (32/57) vs. 33.33% (19/57), P=0.014]. The sensitivity of BALF samples detected by Xpert Ultra for the diagnosis of smeared negative pulmonary tuberculosis was significantly higher than that of Xpert [75.44% (43/57) vs. 56.14% (32/57),P=0.030] and MGIT 960 culture [75.44% (43/57) vs. 38.60% (22/57), P<0.01]. Three different methods of testing sputum samples, the area under the receiver operating characteristic curve (AUC) was the combination of the three elements (0.807)>Xpert Ultra+Xpert (0.798)>Xpert Ultra+MGIT 960 culture (0.789)>Xpert Ultra method (0.781)>Xpert (0.684)>MGIT 960 culture (0.667);Samples of BALF were examined, the AUC was the combination of the three elements (0.895)=Xpert Ultra+Xpert (0.895)>Xpert Ultra+MGIT 960 culture (0.877)=Xpert Ultra method (0.877)>Xpert (0.781)>culture method (0.693). Rifampicin resistance was not detected in the enrolled samples by the three detection methods. Conclusions Xpert Ultra has high clinical application value in the early and rapid diagnosis of smeared negative pulmonary tuberculosis, and the sensitivity of Xpert Ultra in the detection of BALF is higher than that of sputum sample, so the BALF sample is recommended as prior selection.

Xpert MTB/RIF Ultra  /  smeared negative pulmonary tuberculosis  /  molecular diagnostic techniques  /  drug resistance  /  early diagnosis
丁彩红, 王余余, 王庆, 高绪胜, 解丹, 熊瑜. Xpert MTB/RIF Ultra快速诊断涂阴肺结核的临床价值. 解放军医学杂志, 2023 , 48 (7) : 761 -767 . DOI: 10.11855/j.issn.0577-7402.2257.2023.0427
Cai-Hong Ding, Yu-Yu Wang, Qing Wang, Xu-Sheng Gao, Dan Xie, Yu Xiong. Clinical value of Xpert MTB/RIF Ultra in rapid diagnosis of smeared negative pulmonary tuberculosis[J]. Medical Journal of Chinese People’s Liberation Army, 2023 , 48 (7) : 761 -767 . DOI: 10.11855/j.issn.0577-7402.2257.2023.0427
正文
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结核病(tuberculosis，TB)是严重危及公共卫生的重大传染性疾病之一。2021年全球新发结核病1060万例，死亡约160万例，是仅次于新型冠状病毒感染的全球第二大单一传染源致死原因[1]。在2021年全球新诊断的640万例结核病中，仅38%是采用快速分子诊断技术诊断的，其中检出耐药结核病166 991例，较2020年增多6.4%。我国2021年估算的新发结核病78万例，为全球第三大结核病高负担国家[1]，结核病的诊断和治疗仍存在较大缺口。
抗酸杆菌涂片染色镜检法和结核分枝杆菌培养法是诊断结核病的传统实验室检查方法。萋尼抗酸染色涂片镜检方法敏感度(20%～30%)较低，诊断涂阴肺结核时存在一定局限性[2]。结核分枝杆菌培养及药物敏感性试验是结核病和耐药结核病诊断的“金标准”，但因培养等待时间较长，不利于结核病和耐药结核病的早期快速诊断[3-4]。研究发现，有30%～60%的肺结核患者往往因痰涂片阴性无细菌学依据、痰结核分枝杆菌培养周期长等原因，导致涂阴肺结核患者延误诊治[4-5]，其病死率近20%；10%～20%的肺结核传播可归因于涂阴肺结核患者[6]。因此，快速、准确诊断涂阴肺结核是加强结核病控制的重要措施。结核分枝杆菌和利福平耐药基因检测(GeneXpert MTB/RIF，Xpert)在肺结核临床诊断的应用已较为广泛，超敏Xpert(GeneXpert MTB/RIF Ultra，Xpert Ultra)采用新一代分子生物学快速诊断技术，具有快速、敏感、准确等优点，可提高结核分枝杆菌检测和利福平耐药性诊断的敏感度。本研究通过对痰抗酸杆菌涂片阴性疑似肺结核患者的痰液及支气管肺泡灌洗液(bronchoalveolar lavage fluid，BALF)进行检测，评估Xpert Ultra快速诊断涂阴肺结核的诊断性能，旨在为临床提高涂阴肺结核的诊断率和缩短诊断与开始治疗时间提供依据。
1 资料与方法
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1.1 一般资料
1.1.1 标本来源
选取2020年5月－2021年12月就诊于山东省公共卫生临床中心，痰抗酸杆菌涂片阴性且符合纳入标准的疑似肺结核患者93例。患者标本均行Xpert Ultra、Xpert、MGIT 960培养，对结核分枝杆菌培养阳性的标本行药物敏感性试验，检测利福平耐药情况。
1.1.2 诊断标准
根据2013年中华医学会结核病学分会制定的诊断标准，以下几种情况应考虑为涂阴肺结核：(1)3次不同时间(早晨、夜间、即时)痰涂片抗酸染色为阴性，胸部影像学检查显示病变符合活动性肺结核且伴有咳嗽、咳痰、咯血等肺结核可疑症状；(2)3次痰涂片阴性，胸部影像学检查显示病变符合活动性肺结核且抗结核抗体检查阳性；(3)3次痰涂片阴性，胸部影像学检查显示病变符合活动性肺结核且结核菌素试验强阳性；(4)3次痰涂片阴性，胸部影像学检查显示病变符合活动性肺结核且肺外组织病理检查显示结核病变者；(5)3次痰涂片阴性的疑似肺结核病例，经诊断性治疗或随访观察可排除其他肺部疾病者。
1.1.3 纳入与排除标准
纳入标准：(1)符合涂阴肺结核患者及其他肺部疾病患者；(2)年龄≥15岁，且≤80岁；(3)自愿签署知情同意书参加研究并配合完成研究内容。排除标准：(1)孕妇；(2)有严重心、肝或肾病变，患有精神或神经疾病、变态反应性疾病。
1.2 方法
1.2.1 分组与观察指标
将纳入的患者分为肺结核组与非肺结核组。记录两组患者年龄、性别、症状、既往病史(糖尿病、高血压病、冠状动脉粥样硬化性心脏病等)；并对收集的标本分别采用Xpert Ultra、Xpert、BACTE MGIT 960培养(MGIT 960)培养方案进行检测。
1.2.2 检测方法
MGIT 960培养参照《结核病诊断实验室检验规程》[7]进行标准化操作；Xpert和Xpert Ultra按照各自检测试剂盒的说明书进行操作，报无效结果者使用相同样本重复进行Xpert Ultra或Xpert检测。
1.3 统计学处理
采用SPSS 22.0软件进行统计分析。计量资料均呈非正态分布，以M(Q1，Q3)表示，采用非参数检验中独立样本Mann-Whitney U检验进行比较分析。计数资料以例(%)表示，组间比较采用χ2检验。以临床诊断结果为参考标准，分析3种检测方案诊断痰涂阴肺结核的敏感度、特异度、阳性预测值、阴性预测值、符合率、Kappa值。一般认为Kappa≥0.75提示两者一致性较好，0.4≤Kappa<0.75提示两者一致性一般，Kappa<0.4提示两者一致性较差。应用Kappa检验探讨3种检测方案结果的一致性，绘制3种检测方案诊断结果的受试者工作特征(receiver operating characteristic，ROC)曲线，并计算曲线下面积(area under curve，AUC)，评价各检测方案的诊断效能。P<0.05为差异有统计学意义。
2 结果
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2.1 两组基本情况和临床资料比较
共纳入涂阴疑似肺结核患者93例，男57例，女36例；年龄(43.9±18.2)岁。临床诊断结果为57例涂阴肺结核，36例非肺结核。所有患者均为HIV阴性。在36例非肺结核患者中，肺炎19例，肺癌5例，肺非结核分枝杆菌病10例，硅沉着病1例，肺隔离症1例。两组年龄、性别、症状及并发疾病等基础资料比较差异无统计学意义(P>0.05，表1)。
2.2 Xpert Ultra、Xpert、MGIT960培养检测痰液标本对痰涂阴肺结核的诊断效能比较
以临床诊断结果为参考标准，Xpert Ultra检测57例涂阴肺结核的敏感度明显高于Xpert[56.14%(32/57) vs.36.84%(21/57)，P=0.039]，也明显高于MGIT 960培养[56.14%(32/57) vs. 33.33%(19/57)，P=0.014]；Xpert与MGIT 960培养的诊断涂阴肺结核的敏感度差异无统计学意义(P=0.70)。一致性分析显示，Xpert Ultra与临床诊断比较一致性一般，Xpert、MGIT 960培养与临床诊断比较一致性较差；三者联合的AUC最大，诊断效能最高，其后依次为Xpert Ultra+Xpert、Xpert Ultra+MGIT 960培养、Xpert Ultra、Xpert、MGIT 960培养(表2、表3、图1)。
2.3 Xpert Ultra、Xpert、MGIT 960培养检测BALF标本对涂阴肺结核的诊断效能
以临床诊断结果为参考标准，Xpert Ultra检测BALF标本诊断涂阴肺结核患者的敏感度高于Xpert[75.44%(43/57) vs.56.14%(32/57)，P=0.03]，且高于MGIT 960培养[75.44%(43/57) vs. 38.60%(22/57)，P<0.01]；Xpert与MGIT 960培养诊断涂阴肺结核的敏感度差异无统计学意义(P=0.06)。一致性分析显示，Xpert Ultra、Xpert与临床诊断比较一致性一般，MGIT 960培养与临床诊断比较一致性较差。三者联合与Xpert Ultra+Xpert的ROC曲线下面积最大，诊断效能最高，其次为Xpert Ultra及Xpert Ultra+MGIT 960培养，再依次为Xpert、MGIT 960培养(表4、表5、图2)。
2.4 涂阴肺结核患者痰液和BALF标本的3种方案检测结果比较
对57例痰涂阴肺结核患者的痰液及BALF标本的3种方案检测结果进行比较，BALF标本的Xpert Ultra及Xpert检测阳性率均明显高于痰液(P=0.030，P=0.039)，而MGIT 960培养检测两种标本的阳性率差异无统计学意义(P>0.05，表6)。
3 讨论
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近年来，快速分子检测技术的应用显著提高了结核病的诊断效能。Xpert检测方案的应用，使全球耐多药结核病的检出例数增加了3～8倍[8]。Xpert在诊断痰涂片阳性肺结核时具有较高的敏感度，但对少杆菌结核(如痰涂片阴性、肺外结核、HIV感染者和儿科结核)诊断的敏感度较低[9-10]。2017年3月，WHO推荐使用新一代检测方案Xpert Ultra替代Xpert。一项Meta分析纳入了16项研究，结果显示Xpert Ultra诊断结核病的准确度为87.2%，特异度为96.5%；用于利福平耐药检测的敏感度为95.1%，特异度为98.9%[11]。Bahr等[12]发现，采用Xpert Ultra检测脑脊液中结核分枝杆菌的敏感度优于培养法。Khonga等[13]发现，Xpert Ultra用于诊断结核性脑膜炎的准确度和敏感度较高。多项研究发现，Xpert Ultra较Xpert和结核菌培养法敏感度更高，其应用可提高涂片阴性肺结核、结核性胸膜炎和结核性脑膜炎的诊断率；Xpert Ultra和Xpert在检测利福平耐药方面表现相近。
本研究发现，在57例临床诊断为痰涂阴肺结核患者中，Xpert Ultra检测痰液标本诊断痰涂阴肺结核的敏感度高于Xpert和MGIT 960培养，与Dorman等[14]的研究结果一致。Dorman等[14]在痰涂片阴性和培养阳性的137例肺结核病患者中，Xpert Ultra的敏感度(63%)高于Xpert(46%)。Wang等[15]在中国结核病高负担和艾滋病低负担环境的研究发现，Xpert Ultra诊断痰涂阴肺结核的敏感度(70.89%)，高于Xpert(57.88%)；在涂片阴性培养阳性样本中Xpert Ultra敏感度(87.18%)，也高于Xpert(76.92%)；涂片阴性培养阴性标本中Xpert Ultra敏感度(60.00%)仍高于Xpert(45.14%)。Wang等[16]另一项纳入1079例患者的研究发现，以结核分枝杆菌培养为参考标准，在349例确诊肺结核患者中，Xpert Ultra检测结核分枝杆菌的敏感度(92.26%)略高于Xpert(89.40%)，在涂片阴性肺结核患者中Xpert Ultra的敏感度(83.70%)也高于Xpert(78.52%)，结果与前一研究一致，提示Xpert Ultra在检测涂片阴性肺结核时比Xpert更敏感。但在本研究中，Xpert Ultra、Xpert检测痰液标本诊断涂阴肺结核的敏感度均低于上述文献的结果，可能的原因有：(1)上述部分研究以结核分枝杆菌培养诊断结果为参考标准，而本研究以肺结核临床诊断结果为参考标准；(2)痰涂阴肺结核患者的痰液标本荷菌量相对较低。
本研究发现，Xpert Ultra检测BALF标本的敏感度(75.44%)也明显高于Xpert(56.14%)及MGIT 960培养法(38.60%)。Chien等[17]研究发现，以肺结核临床诊断为参考标准，Xpert Ultra检测BALF的敏感度(63.0%)高于培养法(33.3%)。在一项招募了99例疑似肺结核的HIV感染者的研究中，以BALF结核分枝杆菌培养结果为参考标准，Xpert Ultra和Xpert的敏感度分别为96.0%、80.0%，特异度分别为91.9%、95.9%[18]，与本研究结果基本一致。本研究对同一患者的痰液及BALF两种不同呼吸道标本进行了3种检测方案的对比分析，结果发现Xpert Ultra和Xpert检测BALF标本阳性率优于痰液标本。薛建昌等[19]发现，结核分枝杆菌培养在痰液中阳性率明显高于BALF中阳性率。Pan等[20]提出，在评价Xpert时应选择BALF而不是痰液，提示Xpert Ultra使用BALF样品的诊断性能可能较使用痰液更好。本研究显示两种呼吸道标本，Xpert Ultra对涂阴肺结核的诊断效能均优于Xpert、MGIT960培养法。与Xpert比较，Xpert Ultra在痰液及BALF标本中均额外检测到11例结核分枝杆菌感染者，显著提高了检出率，提示Xpert Ultra可提高少菌量标本诊断肺结核的敏感度。
本研究中3种检测方案的ROC曲线及AUC结果显示，Xpert Ultra检测BALF及痰液的AUC最高(痰液为0.781，BALF为0.877)，均高于Xpert和MGIT 960培养(痰液的AUC分别为0.684、0.667，BALF的AUC分别为0.781和0.693)；Kappa分析显示，在痰液和BALF标本中，Xpert Ultra检测结果与肺结核临床诊断的一致性均最高，且敏感度明显高于Xpert及MGIT 960培养。提示Xpert Ultra对痰涂阴肺结核的诊断性能明显优于Xpert和MGIT 960培养。
分析Xpert Ultra敏感度及准确度提高的原因，主要是由于其包含两种不同的扩增靶标(IS6110和IS1081)和一个更大的DNA扩增反应室[21]。Xpert检测的是rpoB基因，其拷贝数在每个基因组中只有1个，而Ultra检测的序列是IS6110和IS1081，其拷贝数在不同结核分枝杆菌株中有10～12个[3]。同时，Xpert在用于检测利福平耐药时偶尔出现假阳性结果，但Xpert Ultra规避了Xpert检测Q513Q和F514F沉默突变菌株时的假阳性结果，且检测的异质耐药性、兼容性和排他性更好，对耐药结核病的快速诊断具有重要价值，且其操作简便，可减少基因检测污染的问题。另外，Xpert Ultra将报阳与报阴检测时间由Xpert的110 min分别缩短至77 min和66 min，并将检测结核分枝杆菌的低限从Xpert的112.6 CFU/ml[21]下降至15.6 CFU/ml。因此，Xpert Ultra检测少菌标本的敏感度明显优于Xpert和MGIT 960培养。
然而，有关Xpert和Xpert Ultra对比的研究发现，Xpert Ultra敏感度的提高是以特异度降低为代价的[14，21]。特异度降低可能导致结核病假阳性结果(与培养法相比)增多，而假阳性结果通常来自有结核病史的患者，与Xpert Ultra可从既往有结核病史的患者中检测出死杆菌的DNA有关[22]。因此，由于患者的结核病史，特异度下降更有可能发生在结核病中、高发国家，Xpert Ultra在高结核病负担国家中诊断肺结核的特异度降低是值得慎重考虑及关注的问题[23]。Wang等[16]发现，Xpert Ultra检测痰涂片阴性肺结核患者的特异度(96.30%)略低于Xpert(98.25%)。也有研究发现，Xpert Ultra的敏感度比Xpert高5.0%，特异度低3.2%[24]。但本研究发现，Xpert Ultra、Xpert、MGIT960培养法检测痰液及BALF标本诊断痰涂阴肺结核的特异度均为100%，未观察到Xpert Ultra与Xpert检测的特异度差异，与既往国内外相关报道的Xpert Ultra特异度低于Xpert结果不一致，可能的原因为本研究样本量较少，既往存在肺结核病史的患者数量较少。因此，鉴于本研究样本量较少，对于上述3种方案检测痰涂阴肺结核的敏感度及特异度在判定时可能存在一定偏差，未来需要进一步增加样本量，以达到更精确的判断。
耐多药结核病仍是全球关注的问题，Xpert Ultra可用于提高利福平耐药检测的特异度。然而，在本研究中，Xpert Ultra及Xpert均未检测到利福平耐药情况，且所有结核菌培养阳性标本的药敏试验均显示利福平敏感。笔者认为，本研究中Xpert Ultra未检测到利福平耐药的原因可能与研究样本量相对较少有关；其次，本研究纳入的患者89%为初治涂阴肺结核患者，仅11%为复治涂阴肺结核患者，无涂阳肺结核患者，在初治涂阴肺结核患者中利福平耐药率较低，若样本量加大或增加复治涂阳患者，可能增大Xpert Ultra检测到利福平耐药的概率。
总之，Xpert Ultra检测的高敏感度有利于痰涂片阴性肺结核病及耐药肺结核患者的快速诊断，可为提高涂阴肺结核及耐药结核的临床诊断率、缩短诊断时间及开始治疗时间提供新方案和新思路，为耐药结核病的诊断与治疗提供依据。临床推广Xpert Ultra检测，可更好地辅助临床医师对涂阴肺结核及耐药结核患者进行早期诊断和治疗，为结核病的控制与预防提供更有力的支持。
基金
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  • 山东省重点研发计划（重大科技创新工程）项目(2021SFGC0504)
  • 山东省医药卫生科技发展计划项目(2019WS523)
  • 山东省中医药科技项目(2020M059)
文献
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2023年第48卷第7期
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文章信息
doi: 10.11855/j.issn.0577-7402.2257.2023.0427
  • 接收时间：2022-10-31
  • 首发时间：2025-12-03
  • 出版时间：2023-07-28
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  • 收稿日期：2022-10-31
  • 录用日期：2022-12-28
基金
Project of Key research and development Program (Major Scientific and Technological Innovation Project) of Shandong Province(2021SFGC0504)
山东省重点研发计划（重大科技创新工程）项目(2021SFGC0504)
Project of Medical and Health Science and Technology Development Plan of Shandong Province(2019WS523)
山东省医药卫生科技发展计划项目(2019WS523)
Traditional Chinese Medicine Science and Technology Project of Shandong Province(2020M059)
山东省中医药科技项目(2020M059)
作者信息
    山东大学附属公共卫生临床中心结核内科，山东济南 250102

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2种不同金属材料的力学参数
科
Family		 属数
Number of
genus		 种数
Number of
species		 占总种数比例
Percentage of
total species (%)		 属
Genus		 种数
Number of
species		 占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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