GeneXpert MTB/RIF技术在北京市区级机构提升肺结核病原学阳性检出及利福平耐药筛查中的应用价值

doi:10.19982/j.issn.1000-6621.20230206

摘要/Abstract

摘要：

目的分析GeneXpert MTB/RIF(简称“GeneXpert”)在北京市基层结核病防治机构临床实践中提升肺结核患者病原学阳性诊断水平,以及早期诊断利福平耐药性的价值。方法回顾性分析2018—2022年在北京市朝阳区结核病门诊部就诊的3060例可疑肺结核患者中,抗酸分枝杆菌(简称“抗酸杆菌”)涂片镜检、分枝杆菌改良罗氏固体分离培养(简称“固体培养”)和GeneXpert 3种检测技术的检测阳性率,以及病原学阳性患者中各检测方法所占的阳性比例。以固体培养方法为参考标准,分析GeneXpert对肺结核可疑症状者痰标本检测的敏感度和特异度。同时,分析GeneXpert检测利福平耐药性的情况。结果 2018—2022年活动性肺结核患者的病原学检测阳性率逐渐上升,从2018年的45.07%(215/477)提高至2022年的69.39%(102/147),差异有统计学意义( $χ 趋势 2$ =27.761,P<0.001)。抗酸杆菌涂片镜检(46.51%,347/746)、分枝杆菌固体培养(83.24%,621/746)、GeneXpert检测(82.71%,617/746)3种方法对病原学阳性患者的检测阳性率差异有统计学意义(χ²=320.000,P<0.001)。在所有病原学阳性患者中,涂片阴性而GeneXpert检测阳性患者的比例为36.86%(275/746),涂片和固体培养均为阴性但GeneXpert检测阳性患者的比例为12.60%(94/746)。以固体培养结果为参考标准,GeneXpert检测的敏感度和特异度分别为79.39%(493/621;95%CI:76.20%~82.56%)和93.39%(1751/1875;95%CI:92.27%~94.51%)。利用GeneXpert检测肺结核患者中的总利福平耐药率为7.46%(46/617),各突变探针的突变频率为探针E(63.27%,31/49)>AB、AD、DE和ABE联合突变(10.20%,5/49)>探针D(8.16%,4/49)>探针A(6.12%,3/49)=探针B(6.12%,3/49)>无突变(4.08%,2/49)>探针C(2.04%,1/49)。结论在基层结核病防治机构中应用GeneXpert,并将3份痰标本进行混合,有助于提高肺结核患者的病原学阳性率,同时能够及时发现利福平耐药患者。

关键词: 结核, 肺, 分子诊断技术, 抗药性, 敏感性与特异性, 对比研究

Abstract:

Objective: To analyze the value of GeneXpert MTB/RIF (GeneXpert) in improving the pathogenic positivity and early diagnosis of rifampicin resistance of pulmonary tuberculosis in primary tuberculosis prevention and treatment institution in Beijing. Methods: A retrospective analysis was performed on 3060 pulmonary tuberculosis suspects who visited the Tuberculosis Outpatient Department in Chaoyang District of Beijing from 2018 to 2022. The positive rates of acid-fast bacilli smear microscopy, Löwenstein-Jensen medium based solid culture for mycobacterium (solid culture), and GeneXpert among tuberculosis suspects, as well as the positive proportion of each testing method among overall laboratory confirmed patients were analyzed. The sensitivity and specificity of GeneXpert was analyzed in sputum samples using solid culture as a reference standard. The value of GeneXpert for detection of rifampicin resistance was also analyzed. Results: From 2018 to 2022, the laboratory confirmed cases in active pulmonary tuberculosis cases gradually increased from 45.07% (215/477) in 2018 to 69.39% (102/147) in 2022, with statistical significance ( $χ t r e n d 2$ =27.761, P<0.001). The positive rate of acid-fast bacilli smear microscopy (46.51%, 347/746), mycobacterial solid culture (83.24%, 621/746), and GeneXpert (82.71%, 617/746) among all laboratory confirmed pathogenic positive cases was statistically different (χ²=320.000, P<0.001). Among all pathogenic positive cases, the proportion of smear-negative and GeneXpert-positive cases was 36.86% (275/746), and smear-negative/solid culture-negative but GeneXpert-positive cases were 12.60% (94/746), respectively. The sensitivity and specificity of GeneXpert were 79.39% (493/621; 95%CI: 76.20%-82.56%) and 93.39% (1751/1875; 95%CI: 92.27%-94.51%), respectively. The total rifampicin resistance rate of pulmonary tuberculosis patients detected by GeneXpert was 7.46% (46/617). The frequency of each mutation probe was as follows: probe E (63.27%, 31/49) >combined mutation (AB, AD, DE and ABE, 10.20%, 5/49) >probe D (8.16%, 4/49) >probe A (6.12%, 3/49) =probe B (6.12%, 3/49) >no probe mutation (4.08%, 2/49) >probe C (2.04%, 1/49). Conclusion: In primary tuberculosis prevention and treatment institution, the application of GeneXpert combined with mixing three sputum samples can help improve the pathogenic positive rate of pulmonary tuberculosis patients, and early detect the rifampicin-resistant patients.

Key words: Tuberculosis, pulmonary, Molecular diagnostic techniques, Drug resistance, Sensitivity and specificity, Comparative study

中图分类号:

R521

赵爱兰, 余琴, 俞南, 张爱洁, 夏辉, 徐伟. GeneXpert MTB/RIF技术在北京市区级机构提升肺结核病原学阳性检出及利福平耐药筛查中的应用价值[J]. 中国防痨杂志, 2023, 45(11): 1064-1071. doi: 10.19982/j.issn.1000-6621.20230206

Zhao Ailan, Yu Qin, Yu Nan, Zhang Aijie, Xia Hui, Xu Wei. The value of GeneXpert MTB/RIF in improving the laboratory confirmed pulmonary tuberculosis and rifampicin resistance screening at district level institution in Beijing[J]. Chinese Journal of Antituberculosis, 2023, 45(11): 1064-1071. doi: 10.19982/j.issn.1000-6621.20230206

图/表 6

图1

表1

表2

表3

表4

病原学阳性患者中各检测方法阳性患者检出情况 [例(检出率,%)]

年份	例数	GeneXpert 阳性	涂片阳性	固体培养阳性	涂片阴性 GeneXpert阳性	涂片阴性培养阴性 GeneXpert阳性
2018	135	116(85.93)	82(60.74)	106(78.52)	34(25.19)	16(11.85)
2019	179	145(81.01)	90(50.28)	152(84.92)	57(31.84)	21(11.73)
2020	160	123(76.88)	69(43.13)	133(83.13)	57(35.63)	22(13.75)
2021	170	139(81.76)	64(37.65)	146(85.88)	75(44.12)	23(13.53)
2022	102	94(92.16)	42(41.18)	84(82.35)	52(50.98)	12(11.76)
合计	746	617(82.71)	347(46.51)	621(83.24)	275(36.86)	94(12.60)
χ²值		11.620	18.339	3.248	22.532	0.581
P值		0.020	0.002	0.489	<0.001	0.965
$χ 趋势 2$ 值		0.785	14.104	0.859	22.213	0.084
P值		0.376	<0.001	0.354	<0.001	0.772

表4

表5

参考文献 16

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年份 GeneXpert MTB/ RIF检测	固体培养		敏感度 (%,95%CI)	特异度 (%,95%CI)	阳性预测值 (%,95%CI)	阴性预测值 (%,95%CI)	Kappa值	一致率 (%,95%CI)
年份 GeneXpert MTB/ RIF检测	阳性(例)	阴性(例)	敏感度 (%,95%CI)	特异度 (%,95%CI)	阳性预测值 (%,95%CI)	阴性预测值 (%,95%CI)	Kappa值	一致率 (%,95%CI)
2018			82.08 (74.78~89.38)	90.91 (87.76~94.06)	75.00 (67.12~82.88)	93.85 (91.17~96.53)	0.71	88.71 (85.70~91.72)
阳性	87	29
阴性	19	290
合计	106	319
2019			78.29 (71.74~84.84)	94.82 (92.98~96.76)	82.07 (75.83~88.31)	93.52 (91.38~95.66)	0.74	90.98 (88.78~93.18)
阳性	119	26
阴性	33	476
合计	152	502
2020			72.18 (64.55~79.81)	93.43 (91.03~95.83)	78.05 (70.74~85.36)	91.21 (88.51~93.91)	0.67	88.24 (85.53~90.95)
阳性	96	27
阴性	37	384
合计	133	411
2021			78.77 (72.14~85.40)	94.23 (91.99~96.47)	82.73 (76.45~89.01)	92.67 (90.19~95.15)	0.74	90.21 (87.75~92.67)
阳性	115	24
阴性	31	392
合计	146	416
2022			90.48 (84.20~96.76)	92.07 (88.55~95.59)	80.85 (72.90~88.80)	96.31 (93.80~98.82)	0.81	91.64 (88.56~94.72)
阳性	76	18
阴性	8	209
合计	84	227
总计			79.39 (76.20~82.56)	93.39 (92.27~94.51)	79.90 (76.74~83.06)	93.19 (92.05~94.33)	0.73	89.90 (88.72~91.08)
阳性	493	124
阴性	128	1751
合计	621	1875

涂片结果 GeneXpert MTB/ RIF检测结果	固体培养		敏感度 (%,95%CI)	特异度 (%,95%CI)	阳性预测值 (%,95%CI)	阴性预测值 (%,95%CI)	Kappa值	一致率 (%,95%CI)
涂片结果 GeneXpert MTB/ RIF检测结果	阳性(例)	阴性(例)	敏感度 (%,95%CI)	特异度 (%,95%CI)	阳性预测值 (%,95%CI)	阴性预测值 (%,95%CI)	Kappa值	一致率 (%,95%CI)
涂片阳性			98.73 (97.50~99.96)	96.77 (90.55~100.00)	99.68 (99.05~100.00)	88.24 (77.41~99.07)	0.92	98.56 (97.31~99.81)
阳性	312	1
阴性	4	30
合计	316	31
涂片阴性			59.34 (53.83~64.85)	94.90 (93.90~95.90)	65.82 (60.21~71.43)	93.38 (92.25~94.51)	0.57	89.86 (88.58~90.14)
阳性	181	94
阴性	124	1750
合计	305	1844
总计			79.39 (76.20~82.56)	93.39 (92.27~94.51)	79.90 (76.74~83.06)	93.19 (92.05~94.33)	0.73	89.90 (88.72~91.08)
阳性	493	124
阴性	128	1751
合计	621	1875

年份	肺结核可疑症状者中GeneXpert检测情况		活动性肺结核比例(%)^c	活动性肺结核患者病原学阳性率(%)^d
年份	检测比例(%)^a	阳性率(%)^b	活动性肺结核比例(%)^c	活动性肺结核患者病原学阳性率(%)^d
2018	47.54(425/894)	31.76(135/425)	53.36(477/894)	45.07(215/477)
2019	92.67(654/696)	27.37(179/654)	56.32(392/696)	47.96(188/392)
2020	97.84(544/556)	29.41(160/544)	54.14(301/556)	53.16(160/301)
2021	97.06(562/579)	30.25(170/562)	52.68(305/579)	55.74(170/305)
2022	98.11(311/317)	32.80(102/311)	46.37(147/317)	69.39(102/147)
合计	82.05(2496/3042)	29.89(746/2496)	53.32(1622/3042)	51.48(835/1622)

年份	病原学阳性例数	利福平耐药例数	利福平耐药率(%)	耐药基因类型总数	患者突变探针型
2018	116	6	5.17	2	A:1;E:5
2019	145	12	8.28	3	D:1;E:10;AB:1
2020	123	11	8.94	7	A:2;B:1;C:1;E:6;AB:1;ABE:1;无突变:1
2021	139	10	7.19	5	B:1;D:1;E:7;AD:1;无突变:1
2022	94	7	7.45	4	B:1;D:2;E:3;DE:1