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Diagnosis of pulmonary tuberculosis in HIV-uninfected adults

Author: John Bernardo, MD

Section Editor: C Fordham von Reyn, MD
Deputy Editor: Elinor L Baron, MD, DTMH

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2017. | This topic last updated: Dec 11, 2017.

INTRODUCTION — More than two billion people (about one-third of the world population) are estimated to be latently infected with
Mycobacterium tuberculosis [1]. In 2015, approximately 10.4 million individuals became ill with tuberculosis (TB), and 1.8 million
died [2]. Prompt diagnosis of active TB facilitates timely therapeutic intervention and minimizes community transmission [3,4].

The diagnosis of pulmonary TB in human immunodeficiency virus (HIV)-uninfected adults will be reviewed here. Issues related to
diagnosis of tuberculosis HIV-infected patients and children are discussed separately, as are issues related to the clinical
manifestations and treatment of TB. (See "Epidemiology, clinical manifestations, and diagnosis of tuberculosis in HIV-infected
patients" and "Tuberculosis disease in children", section on 'Diagnosis' and "Clinical manifestations and complications of pulmonary
tuberculosis" and "Treatment of drug-susceptible pulmonary tuberculosis in HIV-uninfected adults".)

OVERVIEW

General diagnostic approach — The diagnosis of pulmonary tuberculosis (TB) should be suspected in patients with relevant
clinical manifestations (cough >2 to 3 weeks' duration, lymphadenopathy, fevers, night sweats, weight loss) and relevant
epidemiologic factors (history of prior TB infection or disease, known or possible TB exposure, and/or past or present residence in
or travel to an area where TB is endemic) (table 1) [3]. Patients being evaluated for pulmonary tuberculosis who pose a public
health risk for transmission should be admitted and isolated with airborne precautions. (See "Tuberculosis transmission and
control", section on 'Clinical triaging'.)

The diagnosis of pulmonary tuberculosis is definitively established by isolation of M. tuberculosis from a bodily secretion (eg,
culture of sputum, bronchoalveolar lavage or pleural fluid) or tissue (pleural biopsy or lung biopsy) [5]. Additional diagnostic tools
include sputum acid-fast bacilli (AFB) smear and nucleic acid amplification (NAA) testing; positive NAA test (with or without AFB
smear positivity) is considered sufficient for diagnosis of tuberculosis (algorithm 1). Radiographic studies are important supportive
diagnostic tools [3].

The approach to diagnosis of tuberculosis begins with a history and physical examination to assess the patient's risk for TB (table
1). Patients meeting clinical criteria should undergo chest radiography; if imaging suggests TB of the lungs or airways, three
sputum specimens (obtained via cough or induction at least eight hours apart and including at least one early-morning specimen)
should be submitted for AFB smear, mycobacterial culture, and NAA testing (algorithm 1) [1,3,6].

In addition, a tuberculin skin test (TST) or interferon-gamma release assay (IGRA) should be performed. These are tools designed
for diagnosis of TB infection; a positive result supports (but cannot be used to establish) a diagnosis of active TB disease, and a
negative result does not rule out active TB disease [3,7,8].

Establishing a definitive laboratory diagnosis of TB may not be possible in some circumstances. No specific bacteriologic
confirmation is ever established in at least 15 to 20 percent of patients with a clinical diagnosis of TB [9,10]. In such cases, a
presumptive clinical diagnosis may be based on epidemiologic exposure together with physical findings, radiographic findings,
positive TST or IGRA, analysis of sputum or bronchoscopy specimens, and/or histopathology. In the setting of high clinical
suspicion for tuberculosis, initiation of empiric therapy based on these findings is appropriate. (See "Treatment of drug-susceptible
pulmonary tuberculosis in HIV-uninfected adults".)

Suspected drug-resistant TB — The term "drug-resistant tuberculosis" refers to TB caused by an isolate of M. tuberculosis that is
resistant to one or more antituberculous drugs. (See "Treatment of drug-resistant pulmonary tuberculosis in adults", section on
'Definitions'.)
Drug-resistant TB should be suspected in the setting of relevant risk factors (table 2); these include prior episode of TB treatment,
progressive clinical and/or radiographic findings while on TB therapy, residence in or travel to a region with high prevalence of drug-
resistant TB (figure 1 and figure 2), and/or exposure to an individual with known or suspected infectious drug-resistant TB. (See
"Epidemiology and molecular mechanisms of drug-resistant tuberculosis".)

Definitive diagnosis of drug-resistant TB is established via laboratory identification of M. tuberculosis in sputum (or other clinical
specimen), with drug susceptibility testing (DST) demonstrating resistance to one or more antituberculous agents.

Patients for whom there is clinical suspicion for drug-resistant pulmonary TB should have sputum sent for the following laboratory
tests:

● Acid-fast bacilli smear and mycobacterial culture (three sputum specimens collected at least eight hours apart)

● Culture-based drug susceptibility testing

● Nucleic acid amplification test, with molecular detection for drug resistance (at least one sputum specimen, preferably a first-
morning specimen) (see 'Probe-based (NAA) tests' below)

Records of prior cultures, drug susceptibility testing, and treatment regimens should be obtained for the patient as well as any
known or suspected source case(s) that he or she has had contact with.

Obtaining clinical specimens

Sputum — Sputum may be obtained spontaneously (by coughing) or it may be induced; patients providing sputum samples
should understand that nasopharyngeal discharge and saliva are not sputum (table 3 and table 4) [11,12]. Sputum should represent
secretions from the lower respiratory tract, and at least 5 to 10 mL is optimal for adequate diagnostic yield [3,13]; protocols for
collecting high-quality sputum have been described [14]. A series of at least three single specimens should be collected in 8- to 24-
hour intervals (with at least one specimen obtained in the early morning), although the diagnosis often can be made with two
specimens [15-19]. Obtaining three specimens is useful for culture even if the first or second specimen is smear positive.

For patients who have difficulty producing sputum, sputum may be induced by inhalation of aerosolized hypertonic saline generated
by a nebulizer [20-22]. Such specimens may appear thin and watery and should be labeled "induced sputum" so they will not be
discarded by the laboratory as inadequate specimens. This procedure should be administered by trained personnel using
appropriate respiratory protection in an isolation booth or in an area with appropriate environmental controls. (See "Tuberculosis
transmission and control".)

In general, the yields of induced sputum and bronchoalveolar lavage specimens are comparable, and induced sputum is safer and
less costly [23-25].

Bronchoscopy specimens — Bronchoscopy with bronchoalveolar lavage and brushings should be reserved for the following
circumstances [3,23,24,26]:

● Unsuccessful attempts to obtain adequate expectorated or induced sputum samples

● Negative sputum studies in the setting of a high clinical suspicion for tuberculosis

● Potential alternative diagnosis for which diagnostic bronchoscopy is required

● Urgent diagnostic information is needed (in such circumstances, transbronchial biopsy may be warranted)

Sputum produced after bronchoscopy (during the immediate period following bronchoscopy and the day following the procedure)
should also be collected for AFB smear and mycobacterial culture to optimize diagnostic yield [3,27,28]. Bronchoscopy should be
performed by personnel using appropriate respiratory protection in an area with appropriate environmental controls. Careful
disinfection and sterilization of the bronchoscope and ancillary equipment is required. (See "Tuberculosis transmission and
control".)

Tissue biopsy — Tissue biopsy may establish a definitive diagnosis of tuberculosis when other testing is not diagnostic. Biopsy
specimens allow for both microbiologic studies and histopathologic examination. Biopsy specimens should be collected with and
without fixative; specimens without fixative are required for culture. Issues related to pleural biopsy are discussed separately. (See
"Tuberculous pleural effusion".)

Microscopy of tissue biopsy specimens in the setting of tuberculosis typically demonstrates granulomatous inflammation.
Granulomas of tuberculosis characteristically contain epithelioid macrophages, Langhans giant cells, and lymphocytes. The centers
of tuberculous granulomas often have characteristic caseation ("cheese-like") necrosis; organisms may or may not be seen with
acid-fast staining. The demonstration of characteristic caseating granulomas on a tissue section in the appropriate clinical and
epidemiologic circumstances strongly supports a diagnosis of active tuberculosis, but it is not pathognomonic; culture is required to
establish a laboratory diagnosis [29].

Issues related to tissue biopsy in the setting of extrapulmonary TB are discussed separately. (See "Abdominal tuberculosis" and
"Tuberculous lymphadenitis" and "Skeletal tuberculosis" and "Central nervous system tuberculosis".)

Other specimens — Other specimens include gastric aspiration, pleural fluid, and serum:

● In general, gastric aspiration is not used for adults; it can be useful in children who cannot produce sputum. This is discussed
separately. (See "Tuberculosis disease in children", section on 'Gastric aspirate'.)

● Issues related to pleural fluid are discussed separately. (See "Tuberculous pleural effusion".)

● There is no role for use of serologic testing in diagnosis of TB; such tests are neither accurate nor cost-effective [30-34]. While
large numbers of individuals worldwide have TB antibodies, only about 10 percent of them go on to develop active disease. In
2011, the World Health Organization issued a strong negative recommendation against the use of serologic testing [33], which
was based on a meta-analysis of 92 studies concluding that use of commercial serological tests is supported only by data of
very low quality [32].

DIAGNOSTIC TOOLS — Tools for diagnosis of tuberculosis (TB) include radiographic imaging and laboratory studies.

Radiographic imaging — Chest radiography is part of the initial approach to a diagnostic evaluation of a patient with suspected
TB; it is a useful tool for evaluating symptomatic patients with appropriate epidemiologic risk factors for TB [35-39]. Active
pulmonary tuberculosis often cannot be distinguished from inactive disease on the basis of radiography alone, and readings of
"fibrosis" or "scarring" must be interpreted in the context of the clinical and epidemiologic presentation.

Reactivation pulmonary tuberculosis classically presents with focal infiltration of the upper lobe(s) (usually of the apical and/or
posterior segments) or the lower lobe(s) (usually of the apical, also called superior, segments) (image 1A-D). Disease may be
unilateral or bilateral. Cavitation may be present, and inflammation and tissue destruction may result in fibrosis with traction and/or
enlargement of hilar and mediastinal lymph nodes.

In some cases, pulmonary TB in adults may not present with the "classic" radiographic appearance described above. Lobar or
segmental infiltration may be visualized in other lung regions, with or without hilar adenopathy, lung mass (tuberculoma), small
fibronodular lesions (termed "miliary" because they resemble scattered millet seeds), or pleural effusions [37-39]. This is particularly
likely among patients with advanced HIV disease for whom "atypical" radiographic presentations are common [40-42]. (See
"Epidemiology, clinical manifestations, and diagnosis of tuberculosis in HIV-infected patients".)

Occasionally, specialized views of the chest may be required, such as an apical lordotic projection for careful evaluation of the lung
apices or a lateral decubitus series to evaluate for presence of pleural effusion.

Chest computed tomography (CT) is more sensitive than plain chest radiography for identifying early or subtle parenchymal and
nodal processes. The resolution provided by CT usually is not required for diagnosis or management of pulmonary TB; it may be
reserved for circumstances in which more precise resolution of features observed in a chest radiograph is required or where an
alternative diagnosis is suspected.

There is no role for routine use of positron emission tomography (PET) for evaluation of TB [43-45]. PET uptake of F-fluoro-2-
deoxyglucose (FDG) does not differentiate infection from tumor. The macrophages in active TB do not proliferate and do not need
11C-choline, resulting in low C-choline uptake, in contrast with the macrophages in malignancy. Therefore, the combination of a
high FDG and low 11C-choline uptake on PET may be useful for distinguishing active inflammatory (eg, infectious) and/or
neoplastic processes from inactive lesions (eg, fibrosis), although its sensitivity in the setting of clinical suspicion for tuberculosis
has not been established [45]. 68Ga-citrate PET accumulates in both pulmonary and extrapulmonary tuberculous lesions and may
provide a way of distinguishing active from inactive lesions for treatment response evaluation [46].

Magnetic resonance imaging (MRI) may demonstrate intrathoracic lymphadenopathy, pericardial thickening, and pericardial and
pleural effusions [47].

Radiographic findings in the setting of pulmonary tuberculosis are discussed further separately. (See "Clinical manifestations and
complications of pulmonary tuberculosis".)

Microbiologic testing — Tools for microbiologic testing include sputum acid-fast bacilli (AFB) smear, mycobacterial culture, and
molecular tests.

Laboratory tools for drug susceptibility testing (DST) include culture-based testing (which provides phenotypic information) and
molecular testing (which provides genotypic information) [48,49]:

● Conventional (phenotypic) culture-based drug susceptibility testing is the gold standard for diagnosis of drug-resistant TB; it
allows comparison of growth on drug-containing medium with growth on control medium to establish presence or absence of
drug resistance. Culture may take at least a month to perform. (See 'Mycobacterial culture' below.)

● Molecular tests for drug-resistant TB have faster turnaround time than culture-based DST (results available within hours to
days) and are useful for guiding initial decisions regarding therapy until definitive culture-based DST is available. (See
'Molecular tests' below.)

Not all laboratories perform all tests; some local and hospital laboratories may perform initial tests, such as sputum smears, and
then refer samples to reference laboratories for culture, identification, and drug susceptibility testing. Some laboratories require
specific orders for testing beyond culture and identification, such as drug susceptibility testing, so close communication with the
laboratory is critical. All United States jurisdictions require submission of culture isolates identified as M. tuberculosis complex by
any laboratory to their jurisdictional public health laboratory for confirmation of identification and drug susceptibility testing. Positive
cultures are also reported to public health authorities for oversight and case management.

Sputum AFB smear — The detection of acid-fast bacilli (AFB) on microscopic examination of stained sputum smears is the
most rapid and inexpensive TB diagnostic tool. Smears may be prepared directly from clinical specimens or from concentrated
preparations; concentrated material is preferred [3]. Sputum should be of good quality and at least 3 mL in volume [3].

Sputum AFB smears are less sensitive than nucleic acid amplification (NAA) or culture; approximately 10,000 bacilli per mL are
needed for detection of bacteria in AFB smear using light microscopy [50].

The sensitivity and positive predictive value of AFB smear microscopy are approximately 45 to 80 percent and 50 to 80 percent,
respectively [12]. Sensitivity increases with specimen concentration and increased specimen number and can be as high as 90
percent. The sensitivity of stained smears is diminished in patients with a small organism burden [51-54].

Acid-fast bacteria visualized on a slide may represent M. tuberculosis or nontuberculous mycobacteria (NTM), so species
identification requires culture and/or nucleic acid amplification (algorithm 1). Acid-fast pulmonary disease in United States–born
patients is more likely to represent NTM infection than TB [55,56].

Among individuals at risk for drug-resistant tuberculosis with positive sputum AFB smear, rapid molecular testing for rifampin
resistance should be performed. (See 'Molecular tests' below and "Epidemiology and molecular mechanisms of drug-resistant
tuberculosis", section on 'Risk factors for development of drug resistance'.)

Mycobacterial culture

Conventional culture techniques — All clinical specimens suspected of containing mycobacteria should be cultured.
Conventional culture is the most sensitive tool for detection of TB and can detect as few as 10 bacteria/mL; the sensitivity and
specificity of sputum culture are about 80 and 98 percent, respectively [57-59]. Culture is required for drug susceptibility testing and
for species identification.

There are three types of traditional culture media: egg based (Lowenstein-Jensen), agar based (Middlebrook 7H10 or 7H11), and
liquid (Middlebrook 7H12 and other commercially available broths). Growth in liquid media is faster (generally one to three weeks)
than growth on solid media (three to eight weeks) [57]. Growth tends to be slightly better on egg-based medium, but growth is more
rapid on agar medium. Agar medium permits examination of colony morphology and detection of mixed cultures.

Commercially available automated liquid broth culture systems that use colorimetric systems for detection of mycobacteria are
important technical advances in the detection of M. tuberculosis.

Specimens should be inoculated onto at least one container of solid medium and used in conjunction with a liquid/broth culture
system [3]. Lowenstein-Jensen slants are a useful backup for detection of strains that may not grow on other media. Automated
liquid systems should be examined for growth at least every two to three days; some platforms (such as MGIT 960) provide real-
time monitoring with immediate notification of growth detection. Solid media should be examined for growth once or twice weekly.

Once growth is detected, a sample should be processed or forwarded to a reference laboratory for species identification and drug
susceptibility testing. Species identification can be performed using nucleic acid hybridization with a DNA/RNA probe, high-
pressure liquid chromatography (HPLC), biochemical methods, or mass spectrophotometry (matrix-assisted laser
desorption/ionization–time of flight [MALDI-TOF]) [60-63]. DNA/RNA probe-based identification is the most common method used
in the United States.

Drug susceptibility testing for at least isoniazid, rifampin, pyrazinamide, and ethambutol should be performed. In addition, isolates
from patients at risk for drug-resistant disease should undergo routine testing for susceptibility to second-line agents. (See 'Drug
susceptibility testing' below and "Epidemiology and molecular mechanisms of drug-resistant tuberculosis", section on 'Risk factors
for development of drug resistance'.)

In regions where available, routine genotyping for patients with culture-positive tuberculosis is beneficial for clinical and
epidemiologic purposes [3].

Drug susceptibility testing — Conventional (phenotypic) culture-based drug susceptibility testing is the gold standard for
diagnosis of drug-susceptible and drug-resistant TB. This technique allows comparison of growth on drug-containing medium with
growth on control medium to establish presence or absence of drug resistance [59]. Solid media (agar proportion method is the
reference standard) or liquid (also termed broth) media may be used. Culture-based DST usually requires at least seven days for
liquid media and at least a month for solid media [12,59].

The breakpoint between a resistant and susceptible strain is established via the "critical concentration"; this is the level of drug in
the culture medium that inhibits 95 percent of wild-type TB strains that have not been exposed to the drug but does not appreciably
suppress the growth of strains that are resistant to the drug (established via clinical treatment failure). Methods and interpretation of
TB drug susceptibility testing are provided by the Association of Public Health Laboratories [64].

Some drugs, such as isoniazid, are routinely tested at more than one concentration. A drug that demonstrates resistance at a lower
concentration but susceptibility at a higher concentration may be used in a treatment regimen if it is possible to achieve sufficiently
high serum drug concentrations to overcome resistance at the lower concentration while avoiding toxicity.

A critical concentration differs from a minimum inhibitory concentration (MIC) that is used for reporting drug susceptibility of most
other bacteria. MIC testing consists of growing the organism at a series of drug concentrations to identify the lowest drug
concentration that inhibits growth of the bacteria. It may be appropriate to pursue MIC testing in the setting of resistance to
fluoroquinolones or injectable agents (determined by critical concentration), to determine whether a higher drug dose may be
beneficial.

Identification of resistance to rifampin or more than one first-line drug (isoniazid, rifampin, pyrazinamide, or ethambutol) should
prompt susceptibility testing for second-line drugs including at least amikacin, capreomycin, a fluoroquinolone, and ethionamide.
Other drugs that may be important include cycloserine, para-aminosalicylic acid, rifabutin, linezolid, clofazimine, and other agents.
(See "Antituberculous drugs: An overview", section on 'Second-line agents'.)

Rapid culture techniques — Rapid culture techniques employ use of liquid rather than solid media; tools include the
Mycobacteria Growth Indicator Tube (MGIT) and microscopic observation drug susceptibility (MODS) assay.

MGIT uses liquid culture to assess whether mycobacteria grow in the absence or presence of various antituberculous drugs. If
growth is detected in the presence of a drug, the organism is resistant to the drug. MGIT results take several days and are available
more rapidly than conventional solid culture.

The MODS assay is a rapid growth-based assay using liquid media for detection of M. tuberculosis complex and drug resistance to
isoniazid and rifampin. The method is relatively labor intense and is not commonly used in laboratories in the United States. Drug-
containing media and drug-free media are inoculated with sputum specimens, and cultures are examined microscopically for
growth [65-69]. Growth of M. tuberculosis on drug-free media reflects a positive culture; growth on both drug-free and drug-
containing media indicates drug resistance. The median turnaround time is seven days. MODS can be used in smear-positive or
smear-negative cases.

Molecular tests — Molecular methods are available for detection of M. tuberculosis complex DNA and common mutations that
are associated with drug resistance. There are two major types of molecular assays: probe-based (non-sequencing) tests and
sequence-based assays.

The chief distinction between these types of assays is that, in general, probe-based tests can detect whether a gene mutation is
present but cannot provide the sequence information for the specific mutation(s). This is important because not all gene mutations
within a given region confer drug resistance; silent or missense mutations may be detected by probe-based assays and signal drug
resistance even though they do not confer drug resistance in culture. In contrast, sequence-based assays can provide information
regarding the nature of a specific mutation and therefore can predict drug resistance with greater accuracy. Therefore, results
obtained from a probe-based assay suggestive of resistance should be confirmed with a sequence-based assay or by culture.
All molecular tests for drug resistance must be confirmed by culture (agar proportion method using solid media is the reference
standard).

Probe-based (NAA) tests — Probe-based tests, also known as nucleic acid amplification (NAA) tests, amplify a specific
nucleic acid sequence that can be detected via a nucleic acid probe. Some NAA tests can detect genes encoding drug resistance;
the information available regarding drug susceptibility depends on the assay used as discussed below.

Nucleic acid amplification testing should be used for rapid diagnosis (24 to 48 hours) of organisms belonging to the M. tuberculosis
complex in patients with suspected TB [3,70]. Two test platforms are approved by the US Food and Drug Administration (FDA) for
use in the United States: the Amplified Mycobacterium tuberculosis Direct (MTD) test and the Xpert MTB/RIF test. NAA is more
sensitive than smear but less sensitive than culture; as few as 1 to 10 organisms/mL may give a positive result [71-75]. NAA testing
has excellent positive predictive value in the setting of AFB smear-positive specimens for distinguishing tuberculous from
nontuberculous mycobacteria (>95 percent), and it can rapidly establish the presence of tuberculosis in 50 to 80 percent of AFB
smear-negative specimens (which would eventually be culture positive) [6]. However, NAA does not replace the roles of AFB smear
and culture in the diagnostic algorithm for tuberculosis; culture is required for confirmation of identification and for drug susceptibility
testing [71].

NAA tests permit amplification of a specific target RNA or DNA sequence that can be detected via a nucleic acid probe [76,77]. In
AFB smear-positive respiratory specimens, the sensitivity and specificity of NAA are 95 and 98 percent, respectively; in smear-
negative specimens, the sensitivity and specificity are about 75 to 88 percent and 95 percent, respectively [78-80]. A positive NAA
result supports the diagnosis of TB in the appropriate clinical and epidemiologic circumstances; smear positivity together with
positive NAA is considered sufficient for diagnosis of tuberculosis [41,72,81]. A negative NAA result is not sufficient to exclude the
presence of active TB or drug resistance [13].

NAA results must be interpreted in conjunction with AFB smear results while mycobacterial culture (the gold standard for laboratory
confirmation) is pending (algorithm 1) [6]. False-positive NAA results can occur in the setting of contamination and laboratory error.
In addition, NAA can detect nucleic acid from dead and live organisms, so the test can remain positive even after appropriate
therapy. Therefore, NAA is appropriate only for initial diagnostic purposes and cannot be used to monitor response to treatment.
The negative predictive value of an NAA test can be useful in deciding to discontinue respiratory isolation [6,14,70,82,83]; it can
also reduce unnecessary treatment and contact investigations [70,81].

Selection of an NAA test should be guided by local availability, the nature of suspected drug resistance, local resistance patterns,
and clinical history (including prior drug susceptibility testing and prior treatment regimens for the patient and the source case, if
available). Resistance to rifampin can be detected by Xpert MTB/RIF or MTBDRplus, resistance to isoniazid can be detected by
MTBDRplus, and resistance to fluoroquinolones and injectable agents can be detected by MTBDRsl. Individuals at risk for
multidrug-resistant tuberculosis with positive nucleic acid amplification test using an assay platform that does not test for drug
resistance (eg, Amplified MTD) should have additional molecular testing for rifampin resistance. (See 'Other assays' below.)

In 2011, the WHO endorsed the Xpert MTB/RIF assay and the MTBDRplus line-probe assay for diagnosis of pulmonary TB for
diagnosis of both pulmonary and extrapulmonary TB [84]. In 2017, the WHO recommended use of Xpert Ultra (where available) as
a replacement for Xpert in all settings [85]. (See 'Xpert MTB/RIF assay' below and 'Xpert MTB/RIF Ultra assay' below.)

The Amplified MTD test is approved for smear-positive or smear-negative respiratory specimens from patients with suspected
pulmonary TB and fewer than seven days of treatment; it detects TB but does not detect drug resistance. The Xpert MTB/RIF
assay is approved for only induced or expectorated sputum from untreated patients or patients on fewer than 3 days' therapy; it
detects TB and rifampin resistance. (See 'Xpert MTB/RIF assay' below.)

NAA tests may be performed for specimens other than respiratory secretions; this is an "off-label" application and is not approved
by the FDA [80,86]. Some laboratories develop, validate, and perform "in-house" NAA testing on these types of samples.

Xpert MTB/RIF assay — The Xpert MTB/RIF assay is a molecular beacon assay for detection of M. tuberculosis and
rifampin-resistance mutations in an 81-bp region (codons 426 to 452) of the rpoB gene known as the rifampicin resistance–
determining region (RRDR) [87-89]. The assay may be used for sputum AFB smear-positive or AFB smear-negative samples
(direct or concentrated specimens, spontaneously produced or induced) from adults with suspected pulmonary TB who have
received fewer than three days of antimycobacterial therapy.

The Xpert MTB/RIF assay received endorsement by the WHO in 2011 and approval by the FDA in 2013 [84,90,91]. In 2017, the
WHO recommended use of Xpert Ultra (where available) as a replacement for Xpert in all settings [85]. (See 'Xpert MTB/RIF Ultra
assay' below.)

The feasibility, diagnostic accuracy, and effectiveness of the Xpert MTB/RIF assay has been demonstrated in low-incidence, high-
resource settings [92,93] as well as in high-incidence, resource-limited settings [88,94,95]. The test has the potential to dramatically
reduce the time to diagnosis (results can be available within two hours) and the time to initiation of effective therapy. The Xpert
MTB/RIF assay is simple to perform with minimal training, is not easily prone to cross-contamination, and requires minimal
biosafety facilities. Results are available in as few as two hours. The assay requires a reliable power supply and operating
temperatures below 30°C. Sputum should be of good quality and concentrated by usual laboratory methods for the best sensitivity,
but unconcentrated sputum may be used.

The Xpert MTB/RIF assay has greater sensitivity than smear microscopy and very high specificity [87-89,93,94]:

● In one study including 1730 patients in Peru, Azerbaijan, South Africa, and India with suspected TB, Xpert MTB/RIF assay
correctly identified 98 percent of patients with AFB smear-positive tuberculosis and 72 percent of patients with smear-
negative/culture-positive tuberculosis [87]. The accuracy for identification of rifampin resistance was 98 percent.

● In one study including 992 patients in the United States, Brazil, and South Africa, performance of a single test correctly
identified 98 percent of patients with AFB smear-positive tuberculosis and 55 percent of AFB smear-negative/culture-positive
tuberculosis [93].

Detection of rifampin resistance via the Xpert MTB/RIF assay should prompt drug susceptibility testing for second-line drugs to
optimize the treatment regimen and prevent emergence of further resistance [96]. (See 'Drug susceptibility testing' above and
'Sequence-based tests' below.)

The Xpert MTB/RIF assay may be used off-label (in the United States) if validated to estimate the burden of infection via the cycle
threshold value (number of reaction cycles required to obtain a positive result); the cycle threshold value is inversely correlated with
the burden of infection [97].

The Xpert MTB/RIF assay can detect DNA from nonviable bacilli, which may be present in patients with prior tuberculosis or
patients receiving antituberculous therapy. False-positive results have been associated with recent previous infection, high cycle
threshold, and chest radiograph not suggestive of tuberculosis [98]. In addition, false-positive results can occur in regions with low
rates of drug resistance; thus, standard drug susceptibility testing should also be performed.

The Xpert MTB/RIF assay may be used in place of serial AFB sputum smears to aid in decisions regarding whether continued
airborne infection isolation is warranted for patients with suspected tuberculosis. (See "Tuberculosis transmission and control",
section on 'Discontinuing airborne precautions'.)

The Xpert MTB/RIF assay for rifampin resistance may be unreliable in regions where circulating strains contain a mutation outside
the region of rifampin-resistance mutations detected by the assay; in one report from Swaziland, the Xpert MTB/RIF assay was not
able to detect an outbreak strain found to have the rpoB I491F mutation [99].

The Xpert MTB/RIF assay may be useful for diagnosis of extrapulmonary TB in some cases, although its use for this purpose is off-
label. This is discussed further separately. (See "Clinical manifestations, diagnosis, and treatment of miliary tuberculosis", section
on 'Xpert MTB/RIF assay'.)

Xpert MTB/RIF Ultra assay — The Xpert MTB/RIF assay received endorsement by the WHO in 2011 and approval by the
FDA in 2013 [84,90,91]. In 2017, the WHO recommended use of Xpert Ultra (where available) as a replacement for Xpert in all
settings [85].

The Xpert MTB/RIF Ultra was developed to improve the sensitivity of the Xpert MTB/RIF test platform; it uses the same analyzer as
Xpert but employs a new specimen cartridge and new software.

In a study including 462 patients with culture-positive sputum, the sensitivity of Xpert Ultra and Xpert were 88 and 83 percent,
respectively [100]. Among 137 participants with culture-positive sputum who were AFB smear negative, the sensitivities of Xpert
Ultra and Xpert were 63 and 46 percent, respectively. Specificity of Xpert Ultra and Xpert were 96 and 98 percent overall.

In general, Xpert Ultra may be more sensitive than Xpert for detection of MTB in smear-negative culture-positive specimens,
pediatric specimens, extra-pulmonary specimens (notably cerebrospinal fluid) and specimens from HIV-infected individuals [101].

The Xpert Ultra is not approved by the FDA and is available in the United States for off-label (research) use only.

Other assays — Other probe-based (NAA) tests include:

● Investigational assay – An automated cartridge-based molecular assay has been developed using the Xpert platform for
detection of M. tuberculosis with resistance to fluoroquinolones, aminoglycosides, and isoniazid [102]. In a prospective study of
 this investigational diagnostic test including more than 300 patients with positive sputum culture for M. tuberculosis, the
sensitivity of the assay (using phenotypic drug susceptibility as the reference standard) for detection of mutations associated
with resistance to isoniazid, ofloxacin, moxifloxacin, kanamycin, and amikacin was 83, 88, 88, 71, and 71 percent, respectively.
The specificity of was ≥94 percent for all drugs except for moxifloxacin, for which specificity was 84 percent. Using DNA
sequencing as the reference standard, the sensitivity and specificity of this assay for detection of mutations associated with
resistance to isoniazid, fluoroquinolones, kanamycin, and amikacin was >95 percent for all drugs except kanamycin, for which
the sensitivity was 92 percent.

● MTBDR – MTBDR platforms (not FDA approved) include:

• MTBDRplus – The MTBDRplus is a molecular line-probe assay capable of detecting rifampin and isoniazid resistance
mutations (rpoB gene for rifampin resistance; katG and inhA genes for isoniazid resistance). This assay does not have
FDA approval for use in the United States.

In an evaluation of 536 smear-positive specimens from patients at risk for multidrug-resistant TB in South Africa,
MTBDRplus was ≥99 percent sensitive and specific for multidrug TB resistance compared with standard DST; results were
available in one to two days [103]. Since the assay does not depend on culture, it yielded results even in specimens that
were contaminated or had no growth. Molecular testing was successful even when the AFB smear was negative
[104,105].

• MTBDRsl – The MTBDRsl is a molecular line-probe assay capable of detecting resistance to fluoroquinolones and
injectable agents (second-line antituberculous agents; gyrA gene for fluoroquinolone resistance and rrs gene for injectable
agents) [106,107]. This assay does not have FDA approval for use in the United States.

The WHO issued guidance in 2016 recommending use of MTBDRsl for identifying patients with multidrug-resistant TB or
rifampicin-resistant TB who are candidates for treatment with a shortened treatment regimen [108]. The assay may be
used as the initial test for detection of resistance to fluoroquinolones and second-line injectable drugs in place of
phenotypic culture-based DST; however, DST is required to detect resistance to other drugs and to monitor for emergence
of additional drug resistance during treatment. (See "Treatment of drug-resistant pulmonary tuberculosis in adults",
section on 'Shortened regimen'.)

Sequence-based tests — Sequence-based assays can provide the genetic identity of a particular mutation and therefore
can predict drug resistance with greater accuracy than probe-based assays. Methods include pyrosequencing, Sanger sequencing,
and next-generation sequencing.

Sequence-based assays remain investigational and are not approved by the FDA. In the United States, specimens may be
forwarded from state public health TB laboratories to the Centers for Disease Control and Prevention for sequence-based
molecular detection of drug resistance (MDDR) testing [109,110]. The testing identifies genetic mutations associated with rifampin
and isoniazid resistance as well as resistance to second-line drugs including fluoroquinolones and the injectables amikacin,
kanamycin, and capreomycin. Molecular testing results are generally available within days and can be used to guide initial
treatment decisions and inform design of prevention regimens for contacts. Culture-based drug susceptibility testing is also
performed, and these results are reported as they become available.

REPORTING AND PUBLIC HEALTH — Tuberculosis is a reportable disease in the United States [111]. Individuals with confirmed
or suspected tuberculosis must be reported to a state or local public health authority promptly (in many states, this period is 24
hours) [112,113]. Laboratories that process diagnostic specimens for tuberculosis also are required to report the isolation of M.
tuberculosis complex organisms to the provider and to the public health authority.

Case and suspect reporting initiates a series of events by the health department to assist the clinician and patient with additional
diagnostic measures and management of the disease. Public health personnel also initiate activities such as contact notification
and investigation to assess and limit the impact of the infection on the community. This includes new case finding and prevention of
disease in high-risk contacts [114].

The public health authority can provide a link to expert medical consultation for diagnosis or management; this may be especially
useful in regions with limited local expertise or where TB is not common. In the United States, the Centers for Disease Control and
Prevention also sponsors regional training and medical consultation centers [115].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Diagnosis and treatment of tuberculosis".)

SUMMARY AND RECOMMENDATIONS

● The diagnosis of pulmonary tuberculosis (TB) should be suspected in patients with relevant clinical manifestations (cough >2
to 3 weeks' duration, lymphadenopathy, fevers, night sweats, weight loss) and relevant epidemiologic factors (history of prior
TB infection or disease, known or possible TB exposure, and/or past or present residence in or travel to an area where TB is
endemic). (See 'General diagnostic approach' above.)

● The diagnosis of pulmonary TB is definitively established by isolation of Mycobacterium tuberculosis from a bodily secretion
(eg, culture of sputum, bronchoalveolar lavage, or pleural fluid) or tissue (pleural biopsy or lung biopsy). Additional diagnostic
tools include sputum acid-fast bacilli (AFB) smear and nucleic acid amplification (NAA) testing; positive NAA test (with or
without AFB smear positivity) is considered sufficient for diagnosis of tuberculosis. (See 'General diagnostic approach' above.)

● The approach to diagnosis of TB begins with a history and physical examination to assess the patient's risk for TB (table 1).
Patients meeting clinical criteria should undergo chest radiography; if imaging suggests TB of the lungs or airways, three
sputum specimens (obtained via cough or induction at least eight hours apart and including at least one early-morning
specimen) should be submitted for AFB smear, mycobacterial culture, and NAA testing (algorithm 1). (See 'General diagnostic
approach' above.)

● In addition, a tuberculin skin test (TST) or interferon-gamma release assay (IGRA) should be performed. These are tools
designed for diagnosis of latent TB infection; a positive result supports (but cannot be used to establish) a diagnosis of active
TB disease, and a negative result does not rule out active TB disease. (See 'General diagnostic approach' above.)

● Establishing a definitive laboratory diagnosis of TB may not be possible in some circumstances. In such cases, a presumptive
clinical diagnosis may be based on epidemiologic exposure together with physical findings, radiographic findings, positive TST
or IGRA, analysis of sputum or bronchoscopy specimens, and/or histopathology. In the setting of high clinical suspicion for
tuberculosis, initiation of empiric therapy based on these findings is appropriate. (See 'General diagnostic approach' above.)

● Drug-resistant TB should be suspected in the setting of relevant risk factors; these include prior episode of TB treatment,
progressive clinical and/or radiographic findings while on TB therapy, residence in or travel to a region with high prevalence of
drug-resistant TB, and/or exposure to an individual with known or suspected infectious drug-resistant TB. Definitive diagnosis
of drug-resistant TB is established via laboratory identification of M. tuberculosis in sputum (or other clinical specimen), with
drug susceptibility testing (DST) demonstrating resistance to one or more antituberculous agents. (See 'Suspected drug-
resistant TB' above.)

● Sputum may be obtained spontaneously (by coughing) or it may be induced by inhalation of aerosolized hypertonic saline
generated by a nebulizer. Bronchoscopy with bronchoalveolar lavage and brushings should be reserved for the circumstances
described above. Tissue biopsy may establish a definitive diagnosis of tuberculosis when other diagnostic techniques are not
diagnostic. (See 'Obtaining clinical specimens' above.)

● Laboratory tools for drug susceptibility testing include culture-based testing (which provides phenotypic information) and
molecular testing (which provides genotypic information). Culture-based testing is the gold standard for diagnosis of drug-
resistant TB; it allows comparison of growth on drug-containing medium with growth on control medium to establish presence
or absence of drug resistance, but it may take at least a month to perform. Molecular tests have faster turnaround time (results
available within hours to days) and are useful for guiding initial decisions regarding therapy until definitive culture-based DST is
available. (See 'Microbiologic testing' above.)

● There are two major types of molecular assays: probe-based (non-sequencing) tests and sequence-based assays. Probe-
based tests, also known as nucleic acid amplification tests, amplify a specific nucleic acid sequence that can be detected via a
nucleic acid probe; some NAA tests can detect genes encoding drug resistance. Sequence-based assays remain
investigational and are not approved by the US Food and Drug Administration (FDA). (See 'Molecular tests' above.)

● Two NAA test platforms are approved by the FDA for use in the United States: the Amplified Mycobacterium tuberculosis Direct
(MTD) test and the Xpert MTB/RIF test. The Amplified MTD test is approved for smear-positive or smear-negative respiratory
specimens from patients with suspected pulmonary TB and fewer than seven days of treatment; it detects TB but does not
detect drug resistance. The Xpert MTB/RIF assay is approved for only induced or expectorated sputum from untreated patients
or patients on fewer than three days' therapy; it detects TB and rifampin resistance. (See 'Probe-based (NAA) tests' above.)

● Individuals with confirmed or suspected tuberculosis must be reported to a public health authority promptly. Such reporting
facilitates diagnostic and treatment support as well as contact investigation to assess and limit the impact of the infection on
the community. (See 'Reporting and public health' above.)
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REFERENCES

1. Dheda K, Barry CE 3rd, Maartens G. Tuberculosis. Lancet 2016; 387:1211.

2. World Health Organization. Global Tuberculosis Report, 2016. WHO, Geneva 2016. http://apps.who.int/iris/bitstream/10665/2
50441/1/9789241565394-eng.pdf?ua=1 (Accessed on November 08, 2016).
3. Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of
America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and
Children. Clin Infect Dis 2017; 64:e1.
4. Pai M, Behr MA, Dowdy D, et al. Tuberculosis. Nat Rev Dis Primers 2016; 2:16076.
5. Pai M, Nicol MP, Boehme CC. Tuberculosis Diagnostics: State of the Art and Future Directions. Microbiol Spectr 2016; 4.
6. Centers for Disease Control and Prevention (CDC). Updated guidelines for the use of nucleic acid amplification tests in the
diagnosis of tuberculosis. MMWR Morb Mortal Wkly Rep 2009; 58:7.
7. Pai M, Menzies D. Interferon-gamma release assays: what is their role in the diagnosis of active tuberculosis? Clin Infect Dis
2007; 44:74.
8. Dewan PK, Grinsdale J, Kawamura LM. Low sensitivity of a whole-blood interferon-gamma release assay for detection of
active tuberculosis. Clin Infect Dis 2007; 44:69.
9. Taylor Z, Marks SM, Ríos Burrows NM, et al. Causes and costs of hospitalization of tuberculosis patients in the United States.
Int J Tuberc Lung Dis 2000; 4:931.
10. Centers for Disease Control and Prevention. Reported Tuberculosis in the United States: Tuberculosis Cases and Percentage
s by Case Verification Criterion and Site of Disease: United States, 1993–2015. https://www.cdc.gov/tb/statistics/reports/2015/
pdfs/2015_surveillance_report_fullreport.pdf (Accessed on February 15, 2017).
11. Khan MS, Dar O, Sismanidis C, et al. Improvement of tuberculosis case detection and reduction of discrepancies between
men and women by simple sputum-submission instructions: a pragmatic randomised controlled trial. Lancet 2007; 369:1955.
12. Diagnostic Standards and Classification of Tuberculosis in Adults and Children. This official statement of the American
Thoracic Society and the Centers for Disease Control and Prevention was adopted by the ATS Board of Directors, July 1999.
This statement was endorsed by the Council of the Infectious Disease Society of America, September 1999. Am J Respir Crit
Care Med 2000; 161:1376.
13. Centers for Disease Control and Prevention: Tuberculosis (TB) http://www.cdc.gov/tb/amplification_tests/amplification_tests.p
df (Accessed on January 20, 2008).
14. Consensus statement on the use of Cepheid Xpert MTB/RIF® assay in making decisions to discontinue airborne infection isol
ation in healthcare settings. NTCA APHL, April 2016. http://www.tbcontrollers.org/docs/resources/NTCA_APHL_GeneXpert_C
onsensus_Statement_Final.pdf (Accessed on April 27, 2016).
15. Nelson SM, Deike MA, Cartwright CP. Value of examining multiple sputum specimens in the diagnosis of pulmonary
tuberculosis. J Clin Microbiol 1998; 36:467.
16. Craft DW, Jones MC, Blanchet CN, Hopfer RL. Value of examining three acid-fast bacillus sputum smears for removal of
patients suspected of having tuberculosis from the "airborne precautions" category. J Clin Microbiol 2000; 38:4285.
17. Rieder HL, Chiang CY, Rusen ID. A method to determine the utility of the third diagnostic and the second follow-up sputum
smear examinations to diagnose tuberculosis cases and failures. Int J Tuberc Lung Dis 2005; 9:384.
18. Al Zahrani K, Al Jahdali H, Poirier L, et al. Yield of smear, culture and amplification tests from repeated sputum induction for
the diagnosis of pulmonary tuberculosis. Int J Tuberc Lung Dis 2001; 5:855.
19. Davis JL, Cattamanchi A, Cuevas LE, et al. Diagnostic accuracy of same-day microscopy versus standard microscopy for
pulmonary tuberculosis: a systematic review and meta-analysis. Lancet Infect Dis 2013; 13:147.
20. Lee E, Holzman RS. Evolution and current use of the tuberculin test. Clin Infect Dis 2002; 34:365.
21. Schoch OD, Rieder P, Tueller C, et al. Diagnostic yield of sputum, induced sputum, and bronchoscopy after radiologic
tuberculosis screening. Am J Respir Crit Care Med 2007; 175:80.
22. Brown M, Varia H, Bassett P, et al. Prospective study of sputum induction, gastric washing, and bronchoalveolar lavage for
the diagnosis of pulmonary tuberculosis in patients who are unable to expectorate. Clin Infect Dis 2007; 44:1415.
23. Anderson C, Inhaber N, Menzies D. Comparison of sputum induction with fiber-optic bronchoscopy in the diagnosis of
tuberculosis. Am J Respir Crit Care Med 1995; 152:1570.
24. Conde MB, Soares SL, Mello FC, et al. Comparison of sputum induction with fiberoptic bronchoscopy in the diagnosis of

tuberculosis: experience at an acquired immune deficiency syndrome reference center in Rio de Janeiro, Brazil. Am J Respir
Crit Care Med 2000; 162:2238.
25. McWilliams T, Wells AU, Harrison AC, et al. Induced sputum and bronchoscopy in the diagnosis of pulmonary tuberculosis.
Thorax 2002; 57:1010.
26. Somu N, Swaminathan S, Paramasivan CN, et al. Value of bronchoalveolar lavage and gastric lavage in the diagnosis of
pulmonary tuberculosis in children. Tuber Lung Dis 1995; 76:295.
27. Malekmohammad M, Marjani M, Tabarsi P, et al. Diagnostic yield of post-bronchoscopy sputum smear in pulmonary
tuberculosis. Scand J Infect Dis 2012; 44:369.
28. George PM, Mehta M, Dhariwal J, et al. Post-bronchoscopy sputum: improving the diagnostic yield in smear negative
pulmonary TB. Respir Med 2011; 105:1726.
29. Pathology of Tuberculosis. The Internet Pathology Laboratory for Medical Education. Available at: http://www-medlib.med.uta
h.edu/WebPath/TUTORIAL/MTB/MTB.html (Accessed on March 23, 2006).
30. Steingart KR, Henry M, Laal S, et al. A systematic review of commercial serological antibody detection tests for the diagnosis
of extrapulmonary tuberculosis. Thorax 2007; 62:911.
31. Dowdy DW, Steingart KR, Pai M. Serological testing versus other strategies for diagnosis of active tuberculosis in India: a
cost-effectiveness analysis. PLoS Med 2011; 8:e1001074.
32. Steingart KR, Flores LL, Dendukuri N, et al. Commercial serological tests for the diagnosis of active pulmonary and
extrapulmonary tuberculosis: an updated systematic review and meta-analysis. PLoS Med 2011; 8:e1001062.
33. World Health Organization. Commercial serodiagnostic tests for diagnosis of tuberculosis: Policy statement. World Health Org
anization, Geneva, Switzerland 2011. http://whqlibdoc.who.int/publications/2011/9789241502054_eng.pdf (Accessed on Dece
mber 16, 2016).
34. Broger T, Basu Roy R, Filomena A, et al. Diagnostic Performance of Tuberculosis-Specific IgG Antibody Profiles in Patients
with Presumptive Tuberculosis from Two Continents. Clin Infect Dis 2017; 64:947.
35. Meyer M, Clarke P, O'Regan AW. Utility of the lateral chest radiograph in the evaluation of patients with a positive tuberculin
skin test result. Chest 2003; 124:1824.
36. Geng E, Kreiswirth B, Burzynski J, Schluger NW. Clinical and radiographic correlates of primary and reactivation tuberculosis:
a molecular epidemiology study. JAMA 2005; 293:2740.
37. Radiographic Manifestations of Tuberculosis: A Primer for Clinicians, 2nd Edition, Francis, J (Ed). Curry National TB Center, 2
006. Available at: http://www.nationaltbcenter.edu/radiographic/ (Accessed on May 18, 2010).
38. Khan MA, Kovnat DM, Bachus B, et al. Clinical and roentgenographic spectrum of pulmonary tuberculosis in the adult. Am J
Med 1977; 62:31.
39. Restrepo CS, Katre R, Mumbower A. Imaging Manifestations of Thoracic Tuberculosis. Radiol Clin North Am 2016; 54:453.
40. Perlman DC, el-Sadr WM, Nelson ET, et al. Variation of chest radiographic patterns in pulmonary tuberculosis by degree of
human immunodeficiency virus-related immunosuppression. The Terry Beirn Community Programs for Clinical Research on
AIDS (CPCRA). The AIDS Clinical Trials Group (ACTG). Clin Infect Dis 1997; 25:242.
41. Havlir DV, Barnes PF. Tuberculosis in patients with human immunodeficiency virus infection. N Engl J Med 1999; 340:367.
42. Jones BE, Young SM, Antoniskis D, et al. Relationship of the manifestations of tuberculosis to CD4 cell counts in patients with
human immunodeficiency virus infection. Am Rev Respir Dis 1993; 148:1292.
43. Stumpe KD, Dazzi H, Schaffner A, von Schulthess GK. Infection imaging using whole-body FDG-PET. Eur J Nucl Med 2000;
27:822.
44. Goo JM, Im JG, Do KH, et al. Pulmonary tuberculoma evaluated by means of FDG PET: findings in 10 cases. Radiology
2000; 216:117.
45. Hara T, Kosaka N, Suzuki T, et al. Uptake rates of 18F-fluorodeoxyglucose and 11C-choline in lung cancer and pulmonary
tuberculosis: a positron emission tomography study. Chest 2003; 124:893.
46. Vorster M, Maes A, Van de Wiele C, Sathekge MM. 68Ga-citrate PET/CT in Tuberculosis: A pilot study. Q J Nucl Med Mol
Imaging 2014.
47. De Backer AI, Mortelé KJ, De Keulenaer BL, Parizel PM. Tuberculosis: epidemiology, manifestations, and the value of
medical imaging in diagnosis. JBR-BTR 2006; 89:243.
48. Palomino JC. Newer diagnostics for tuberculosis and multi-drug resistant tuberculosis. Curr Opin Pulm Med 2006; 12:172.

49. Curry International Tuberculosis Center. Drug-Resistant Tuberculosis: A Survival Guide for Clinicians, Third Edition. CITC, Wa
shington, DC 2016. http://www.currytbcenter.ucsf.edu/sites/default/files/tb_sg3_book.pdf (Accessed on July 12, 2016).
50. Hobby GL, Holman AP, Iseman MD, Jones JM. Enumeration of tubercle bacilli in sputum of patients with pulmonary
tuberculosis. Antimicrob Agents Chemother 1973; 4:94.
51. Steingart KR, Henry M, Ng V, et al. Fluorescence versus conventional sputum smear microscopy for tuberculosis: a
systematic review. Lancet Infect Dis 2006; 6:570.
52. Harries AD, Maher D, Nunn P. An approach to the problems of diagnosing and treating adult smear-negative pulmonary
tuberculosis in high-HIV-prevalence settings in sub-Saharan Africa. Bull World Health Organ 1998; 76:651.
53. Perlman DC, El-Helou P, Salomon N. Tuberculosis in patients with human immunodeficiency virus infection. Semin Respir
Infect 1999; 14:344.
54. Shingadia D, Novelli V. Diagnosis and treatment of tuberculosis in children. Lancet Infect Dis 2003; 3:624.
55. Prince DS, Peterson DD, Steiner RM, et al. Infection with Mycobacterium avium complex in patients without predisposing
conditions. N Engl J Med 1989; 321:863.
56. du Moulin GC, Sherman IH, Hoaglin DC, Stottmeier KD. Mycobacterium avium complex, an emerging pathogen in
Massachusetts. J Clin Microbiol 1985; 22:9.
57. Morgan MA, Horstmeier CD, DeYoung DR, Roberts GD. Comparison of a radiometric method (BACTEC) and conventional
culture media for recovery of mycobacteria from smear-negative specimens. J Clin Microbiol 1983; 18:384.
58. Ichiyama S, Shimokata K, Takeuchi J. Comparative study of a biphasic culture system (Roche MB Check system) with a
conventional egg medium for recovery of mycobacteria. Aichi Mycobacteriosis Research Group. Tuber Lung Dis 1993;
74:338.
59. Centers for Disease Control and Prevention. Tuberculosis: Drug Susceptibility Testing. http://www.cdc.gov/tb/topic/laboratory/
drug_testing.htm (Accessed on May 26, 2016).
60. Shinnick TM, Good RC. Diagnostic mycobacteriology laboratory practices. Clin Infect Dis 1995; 21:291.
61. Kent PT, Kubica GP. Public Health Mycobacteriology: A guide for the Level III Laboratory., Centers for Disease Control and Pr
evention, Atlanta 1985.
62. Saleeb PG, Drake SK, Murray PR, Zelazny AM. Identification of mycobacteria in solid-culture media by matrix-assisted laser
desorption ionization-time of flight mass spectrometry. J Clin Microbiol 2011; 49:1790.
63. Hettick JM, Kashon ML, Slaven JE, et al. Discrimination of intact mycobacteria at the strain level: a combined MALDI-TOF MS
and biostatistical analysis. Proteomics 2006; 6:6416.
64. Association of Public Health Laboratories. Infectious Diseases. http://www.aphl.org/programs/infectious_disease/Pages/defaul
t.aspx (Accessed on June 17, 2016).
65. Iseman MD, Heifets LB. Rapid detection of tuberculosis and drug-resistant tuberculosis. N Engl J Med 2006; 355:1606.
66. Shiferaw G, Woldeamanuel Y, Gebeyehu M, et al. Evaluation of microscopic observation drug susceptibility assay for
detection of multidrug-resistant Mycobacterium tuberculosis. J Clin Microbiol 2007; 45:1093.
67. Moore DA, Evans CA, Gilman RH, et al. Microscopic-observation drug-susceptibility assay for the diagnosis of TB. N Engl J
Med 2006; 355:1539.
68. Arias M, Mello FC, Pavón A, et al. Clinical evaluation of the microscopic-observation drug-susceptibility assay for detection of
tuberculosis. Clin Infect Dis 2007; 44:674.
69. Minion J, Leung E, Menzies D, Pai M. Microscopic-observation drug susceptibility and thin layer agar assays for the detection
of drug resistant tuberculosis: a systematic review and meta-analysis. Lancet Infect Dis 2010; 10:688.
70. Marks SM, Cronin W, Venkatappa T, et al. The health-system benefits and cost-effectiveness of using Mycobacterium
tuberculosis direct nucleic acid amplification testing to diagnose tuberculosis disease in the United States. Clin Infect Dis
2013; 57:532.
71. Cheng VC, Yew WW, Yuen KY. Molecular diagnostics in tuberculosis. Eur J Clin Microbiol Infect Dis 2005; 24:711.
72. Catanzaro A, Perry S, Clarridge JE, et al. The role of clinical suspicion in evaluating a new diagnostic test for active
tuberculosis: results of a multicenter prospective trial. JAMA 2000; 283:639.
73. Conaty SJ, Claxton AP, Enoch DA, et al. The interpretation of nucleic acid amplification tests for tuberculosis: do rapid tests
change treatment decisions? J Infect 2005; 50:187.
74. Lim TK, Mukhopadhyay A, Gough A, et al. Role of clinical judgment in the application of a nucleic acid amplification test for

the rapid diagnosis of pulmonary tuberculosis. Chest 2003; 124:902.

75. Wiener RS, Della-Latta P, Schluger NW. Effect of nucleic acid amplification for Mycobacterium tuberculosis on clinical
decision making in suspected extrapulmonary tuberculosis. Chest 2005; 128:102.
76. Cohen RA, Muzaffar S, Schwartz D, et al. Diagnosis of pulmonary tuberculosis using PCR assays on sputum collected within
24 hours of hospital admission. Am J Respir Crit Care Med 1998; 157:156.
77. Centers for Disease Control and Prevention (CDC). Nucleic acid amplification tests for tuberculosis. MMWR Morb Mortal Wkly
Rep 1996; 45:950.
78. Rapid diagnostic tests for tuberculosis: what is the appropriate use? American Thoracic Society Workshop. Am J Respir Crit
Care Med 1997; 155:1804.
79. Perry S, Catanzaro A. Use of clinical risk assessments in evaluation of nucleic acid amplification tests for HIV/tuberculosis. Int
J Tuberc Lung Dis 2000; 4:S34.
80. Laraque F, Griggs A, Slopen M, Munsiff SS. Performance of nucleic acid amplification tests for diagnosis of tuberculosis in a
large urban setting. Clin Infect Dis 2009; 49:46.
81. Campos M, Quartin A, Mendes E, et al. Feasibility of shortening respiratory isolation with a single sputum nucleic acid
amplification test. Am J Respir Crit Care Med 2008; 178:300.
82. Chaisson LH, Roemer M, Cantu D, et al. Impact of GeneXpert MTB/RIF assay on triage of respiratory isolation rooms for
inpatients with presumed tuberculosis: a hypothetical trial. Clin Infect Dis 2014; 59:1353.
83. Lippincott CK, Miller MB, Popowitch EB, et al. Xpert MTB/RIF assay shortens airborne isolation for hospitalized patients with
presumptive tuberculosis in the United States. Clin Infect Dis 2014; 59:186.
84. World Health Organization. Automated real-time nucleic acid amplification technology for rapid and simultaneous detection of
tuberculosis and drug-resistant tuberculosis: policy statement. Geneva, Switzerland: WHO 2011.
85. http://who.int/tb/features_archive/Xpert-Ultra/en/ (Accessed on December 07, 2017).
86. Dinnes J, Deeks J, Kunst H, et al. A systematic review of rapid diagnostic tests for the detection of tuberculosis infection.
Health Technol Assess 2007; 11:1.
87. Boehme CC, Nabeta P, Hillemann D, et al. Rapid molecular detection of tuberculosis and rifampin resistance. N Engl J Med
2010; 363:1005.
88. Steingart KR, Sohn H, Schiller I, et al. Xpert® MTB/RIF assay for pulmonary tuberculosis and rifampicin resistance in adults.
Cochrane Database Syst Rev 2013; :CD009593.
89. Steingart KR, Schiller I, Horne DJ, et al. Xpert® MTB/RIF assay for pulmonary tuberculosis and rifampicin resistance in
adults. Cochrane Database Syst Rev 2014; :CD009593.
90. Centers for Disease Control and Prevention (CDC). Availability of an assay for detecting Mycobacterium tuberculosis,
including rifampin-resistant strains, and considerations for its use - United States, 2013. MMWR Morb Mortal Wkly Rep 2013;
62:821.
91. World Health Organization. Automated real-time nucleic acid amplification technology for rapid and simultaneous detection of
tuberculosis and rifampicin resistance: Xpert MTB/RIF assay for the diagnosis of pulmonary and extrapulmonary TB in adults
and children, Policy update. WHO, Geneva 2013. http://apps.who.int/iris/bitstream/10665/112472/1/9789241506335_eng.pdf?
ua=1 (Accessed on May 17, 2016).
92. Sohn H, Aero AD, Menzies D, et al. Xpert MTB/RIF testing in a low tuberculosis incidence, high-resource setting: limitations in
accuracy and clinical impact. Clin Infect Dis 2014; 58:970.
93. Luetkemeyer AF, Firnhaber C, Kendall MA, et al. Evaluation of Xpert MTB/RIF Versus AFB Smear and Culture to Identify
Pulmonary Tuberculosis in Patients With Suspected Tuberculosis From Low and Higher Prevalence Settings. Clin Infect Dis
2016; 62:1081.
94. Boehme CC, Nicol MP, Nabeta P, et al. Feasibility, diagnostic accuracy, and effectiveness of decentralised use of the Xpert
MTB/RIF test for diagnosis of tuberculosis and multidrug resistance: a multicentre implementation study. Lancet 2011;
377:1495.
95. O'Grady J, Bates M, Chilukutu L, et al. Evaluation of the Xpert MTB/RIF assay at a tertiary care referral hospital in a setting
where tuberculosis and HIV infection are highly endemic. Clin Infect Dis 2012; 55:1171.
96. Jacobson KR, Barnard M, Kleinman MB, et al. Implications of Failure to Routinely Diagnose Resistance to Second-Line Drugs
 in Patients With Rifampicin-Resistant Tuberculosis on Xpert MTB/RIF: A Multisite Observational Study. Clin Infect Dis 2017;
64:1502.

97. Hanrahan CF, Theron G, Bassett J, et al. Xpert MTB/RIF as a measure of sputum bacillary burden. Variation by HIV status
and immunosuppression. Am J Respir Crit Care Med 2014; 189:1426.
98. Theron G, Venter R, Calligaro G, et al. Xpert MTB/RIF Results in Patients With Previous Tuberculosis: Can We Distinguish
True From False Positive Results? Clin Infect Dis 2016; 62:995.
99. Sanchez-Padilla E, Merker M, Beckert P, et al. Detection of drug-resistant tuberculosis by Xpert MTB/RIF in Swaziland. N
Engl J Med 2015; 372:1181.
100. Dorman SE, Schumacher SG, Alland D, et al. Xpert MTB/RIF Ultra for detection of Mycobacterium tuberculosis and rifampicin
resistance: a prospective multicentre diagnostic accuracy study. Lancet Infect Dis 2017.
101. http://www.who.int/tb/publications/2017/XpertUltra/en/ (Accessed on December 07, 2017).
102. Xie YL, Chakravorty S, Armstrong DT, et al. Evaluation of a Rapid Molecular Drug-Susceptibility Test for Tuberculosis. N Engl
J Med 2017; 377:1043.
103. Barnard M, Albert H, Coetzee G, et al. Rapid molecular screening for multidrug-resistant tuberculosis in a high-volume public
health laboratory in South Africa. Am J Respir Crit Care Med 2008; 177:787.
104. Jacobson KR, Theron D, Kendall EA, et al. Implementation of genotype MTBDRplus reduces time to multidrug-resistant
tuberculosis therapy initiation in South Africa. Clin Infect Dis 2013; 56:503.
105. Kipiani M, Mirtskhulava V, Tukvadze N, et al. Significant clinical impact of a rapid molecular diagnostic test (Genotype
MTBDRplus assay) to detect multidrug-resistant tuberculosis. Clin Infect Dis 2014; 59:1559.
106. Theron G, Peter J, Richardson M, et al. The diagnostic accuracy of the GenoType(®) MTBDRsl assay for the detection of
resistance to second-line anti-tuberculosis drugs. Cochrane Database Syst Rev 2014; :CD010705.
107. Theron G, Peter J, Richardson M, et al. GenoType(®) MTBDRsl assay for resistance to second-line anti-tuberculosis drugs.
Cochrane Database Syst Rev 2016; 9:CD010705.
108. World Health Organization. The use of molecular line probe assays for the detection of resistance to second-line antituberculo
sis drugs: Policy guidance. WHO, Geneva 2016. http://www.who.int/tb/WHOPolicyStatementSLLPA.pdf?ua=1 (Accessed on
May 23, 2016).
109. Centers for Disease Control and Prevention. Tuberculosis: Laboratory Information. http://www.cdc.gov/tb/topic/laboratory/ (Ac
cessed on June 16, 2016).
110. Centers for Disease Control and Prevention. Reference Laboratory Division of TB Elimination Laboratory User Guide for U.S.
Public Health Laboratories: Molecular Detection of Drug Resistance (MDDR) in Mycobacterium tuberculosis Complex by DNA
Sequencing (Version 2.0), June 2012. CDC, Atlanta, GA 2012. http://www.cdc.gov/tb/topic/laboratory/mddrusersguide.pdf (Ac
cessed on June 16, 2016).
111. Tuberculosis control laws--United States, 1993. Recommendations of the Advisory Council for the Elimination of Tuberculosis
(ACET). MMWR Recomm Rep 1993; 42:1.
112. Sotir MJ, Parrott P, Metchock B, et al. Tuberculosis in the inner city: impact of a continuing epidemic in the 1990s. Clin Infect
Dis 1999; 29:1138.
113. Centers for Disease Control and Prevention: State TB Control Offices http://www.cdc.gov/tb/links/tboffices.htm (Accessed on
May 18, 2010).
114. Taylor Z, Nolan CM, Blumberg HM, et al. Controlling tuberculosis in the United States. Recommendations from the American
Thoracic Society, CDC, and the Infectious Diseases Society of America. MMWR Recomm Rep 2005; 54:1.
115. Centers for Disease Control and Prevention. Regional Training and Medical Consultation Centers (RTMCCs). Available at: htt
p://www.cdc.gov/tb/education/rtmc/default.htm (Accessed on May 21, 2010).

Topic 111683 Version 10.0

GRAPHICS

Guidelines for the evaluation of pulmonary tuberculosis in adults in five clinical scenarios

Patient and setting Recommended evaluation

Any patient with a cough of ≥2 to 3 weeks' duration, with at least Chest radiograph: If suggestive of TB*, collect three sputum
one additional symptom, including fever, night sweats, weight specimens for AFB smear microscopy and culture. At least one
loss, or hemoptysis specimen should also be tested using an NAA test.

Any patient at high risk for TB ¶ with an unexplained illness, Chest radiograph: If suggestive of TB*, collect three sputum
including respiratory symptoms, of ≥2 to 3 weeks' duration specimens for AFB smear microscopy and culture. At least one
specimen should also be tested using an NAA test.

Any patient with HIV infection and unexplained cough and fever Chest radiograph, and collect three sputum specimens for AFB
smear microscopy and culture. At least one specimen should also
be tested using an NAA test.

Any patient at high risk for TB ¶ with a diagnosis of community- Chest radiograph, and collect three sputum specimens for AFB
acquired pneumonia who has not improved after seven days of smear microscopy and culture. At least one specimen should also
treatment be tested using an NAA test.

Any patient at high risk for TB ¶ with incidental findings on chest Review of previous chest radiographs if available, three sputum
radiograph suggestive of TB even if symptoms are minimal or specimens for AFB smear microscopy and culture. At least one
absent Δ specimen should also be tested using an NAA test.

TB: tuberculosis; AFB: acid-fast bacilli; NAA: nucleic acid amplification.

* Infiltrates with or without cavitation in the upper lobes or the superior segments of the lower lobes.
¶ Patients with one of the following characteristics: recent exposure to a person with a case of infectious TB; history of a positive test result
for Mycobacterium tuberculosis; HIV infection; injection or noninjection drug use; foreign birth and immigration ≤5 years from a region in
which incidence is high; residents and employees of high-risk congregate settings; membership in a medically underserved, low-income
population; or a medical risk factor for TB (including diabetes mellitus, conditions requiring prolonged corticosteroid and other
immunosuppressive therapy, chronic renal failure, certain hematological malignancies and carcinomas, weight >10 percent below ideal body
weight, silicosis, gastrectomy, or jejunoileal bypass).
Δ Chest radiograph performed for any reason, including targeted testing for latent TB infection and screening for TB disease.

Adapted from: Controlling tuberculosis in the United States. Recommendations from the American Thoracic Society, CDC, the Infectious
Diseases Society of America. MMWR Recomm Rep 2005; 54(RR-12):1. Daley CL, Gotway MB, Jasmer RM. Radiographic manifestations of
tuberculosis: a primer for clinicians. San Francisco, CA: Francis J Curry National Tuberculosis Center; 2003: 1-30, and Updated guidelines for
the use of nucleic acid amplification tests in the diagnosis of tuberculosis. MMWR Morb Mortal Wkly Rep 2009; 58:7.

Graphic 80879 Version 5.0

Approach to interpretation of sputum AFB smear and NAA test for diagnosis of pulmonary
tuberculosis disease in adults

AFB: acid-fast bacilli; NAA: nucleic acid amplification; TB: tuberculosis; NTM: nontuberculous mycobacteria.
* A negative NAA result should be accompanied by a negative test for inhibitors that may limit amplification (if the Enhanced Amplified
Mycobacterium Tuberculosis Direct Test [E-MTD] assay was used). The Xpert MTB/RIF assay contains a positive control that signals an invalid
result if an inhibitor is detected.
¶ An invalid NAA result indicates failure of the assay. An invalid result is usually reported after the test has been repeated using the same
specimen. Receipt of an invalid NAA result should prompt a repeat test using a new specimen.
Δ TB remains possible; the organism burden may be too low to meet the sensitivity threshold for detection via NAA or smear.
Data from: ​
1. Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for
Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children. Clin Infect Dis 2017; 64:e1.
2. World Health Organization. Global Tuberculosis Report, 2016. WHO, Geneva 2016. Available at:
http://apps.who.int/iris/bitstream/10665/250441/1/9789241565394-eng.pdf?ua=1 (Accessed on March 9, 2017).
3. Centers for Disease Control and Prevention (CDC). Updated guidelines for the use of nucleic acid amplification tests in the diagnosis of
tuberculosis. MMWR Morb Mortal Wkly Rep 2009; 58:7.

Graphic 112251 Version 1.0

Risk factors for drug-resistant tuberculosis

Patients with history of tuberculosis

Persistent or progressive clinical and/or radiographic findings while on antituberculous therapy

Lack of conversion of cultures to negative during first three months of antituberculous therapy

Incomplete adherence to prescribed antituberculous therapy

Lack of directly observed therapy or poorly supervised antituberculous therapy

Documented treatment failure or relapse

History of an inappropriate treatment regimen, including too few effective drugs or inadequate drug dosing

Patients without prior history of tuberculosis

Exposure to an individual with known or suspected drug-resistant TB

Residence in or travel to a region with high prevalence of drug-resistant tuberculosis

Residence in or work in an institution or setting with documented drug-resistant tuberculosis

Among foreign-born individuals: Emigration within the previous two years

TB: tuberculosis.

Data from: Curry International Tuberculosis Center and California Department of Public Health, 2016: Drug-Resistant Tuberculosis: A
Survival Guide for Clinicians, Third Edition.

Graphic 108729 Version 1.0

Distribution of percentage of new tuberculosis cases with multidrug-
resistant tuberculosis (MDR-TB)

Figures are based on the most recent year for which data have been reported, which varies among
countries.
Reproduced, with the permission of the publisher, from the Global Tuberculosis Report 2013. Geneva, World
Health Organization, 2013. (Figure 4.2,
http://apps.who.int/iris/bitstream/10665/91355/1/9789241564656_eng.pdf, Accessed on November 18,
2013.)

Graphic 83859 Version 2.0

Percentage of previously treated tuberculosis patients with multidrug-
resistant tuberculosis (MDR-TB)

Figures are based on the most recent year for which data have been reported, which varies
among countries. The high percentages of previously treated tuberculosis cases with multidrug-
resistant tuberculosis in Bahrain, Bonaire - Saint Eustatius and Saba, Cook Islands, Iceland, Sao
Tome and Principe, and Lebanon refer to only a small number of notified cases (<10).

Reproduced, with the permission of the publisher, from the Global Tuberculosis Report 2013. Geneva,
World Health Organization, 2013. (Figure 4.3,
http://apps.who.int/iris/bitstream/10665/91355/1/9789241564656_eng.pdf, Accessed on November 18,
2013.)
Graphic 83860 Version 2.0
Nebulized sputum induction for tuberculosis

Purpose
To obtain sputum specimens for AFB smear microscopy and culture from a patient who has a dry, non-productive cough.
Ensure that the patient is placed in an appropriate negative air pressure room with the door shut. The air in the
negative air pressure room should be drawn out of the room and vented outside of the building.

Materials and equipment required

Sterile, filtered water or normal saline (150 to 250 mL)
Hand-held nebulizer with mouthpiece and 15 mL vial of 3% saline
NOTE: A mask may be used if a patient absolutely cannot use the mouthpiece; 3% saline may be available from the pharmacy
if not available in department stock.

N95 mask (particulate respirator) for AFB

Gloves
Box of tissues
Sterile specimen container approved by the laboratory for sputum collection and transport

Procedure
Preparation

1. Assure that the patient is NPO for three hours prior to sputum induction.
NOTE: Three hours NPO reduces the potential risk of vomiting and aspiration.

2. Instruct the patient to gently brush his/her teeth, gingival margins, tongue, and buccal surfaces using sterile, filtered water or
normal saline to rinse.
Do not use toothpaste, commercial mouth wash preparations, nose drops, or any medications containing alcohol, or oil.
Instruct the patient to avoid taking oral antibiotics immediately before the sputum collection procedure.

3. Instruct the patient to gargle several times with sterile, filtered water or normal saline after brushing.
Do not use tap water or bottled water, as it may contain nontuberculous mycobacteria that may alter findings.

Sputum collection

1. Observe standard precautions at all times.

NOTE: N95 masks must worn by healthcare personnel for AFB cough-producing procedures.
 2. The patient must be in an appropriate negative air pressure room.
3. Place approximately 5 mL of 3% saline into the hand-held nebulizer. Set the flow at 6 to 8 L/min and nebulize saline for 7 to
10 minutes or until sputum is expectorated. The maximum nebulization time is 20 minutes.
NOTE: More saline may be added to the nebulizer if more than 10 minutes is needed to produce an adequate cough.

4. Ask the patient to inhale the nebulized 3% saline deeply 2 to 3 times followed by a vigorous cough. This will assist in
expectorating quality sputum. Collect the sputum into a sterile specimen container.
NOTE: Coaching the patient is very important in order to get quality results in a timely manner.
NOTE: High-quality sputum is required for smear, culture, and NAA testing. For AFB NAA testing alone, a minimum of 1 mL
of raw sputum (or 0.5 mL of sputum sediment) is needed. It is preferred to collect 5 to 10 mL of raw sputum.

5. Label the specimen with time and date of its collection and place it in a specimen bag. Attach a laboratory request form, if
applicable.
6. Document the procedure in the appropriate flow sheet or medical record.
NOTE: Documentation also is required for unsuccessful procedures.

AFB: acid-fast bacilli; NPO: nothing by mouth; NAA: nucleic acid amplification.

Reproduced with permission from: National Tuberculosis Controllers Association. Consensus statement on the use of Cepheid Xpert MTB/RIF
assay in making decisions to discontinue airborne infection isolation in healthcare settings, April 2016. Copyright © 2016 National TB
Controllers Association. Available at: http://www.tbcontrollers.org/docs/resources/NTCA_APHL_GeneXpert_Consensus_Statement_Final.pdf
(Accessed on June 21, 2016).

Graphic 108732 Version 1.0

Spontaneously produced sputum collection for tuberculosis

Purpose
To obtain sputum specimens for AFB smear microscopy and culture from a patient who has a productive cough.
Ensure that the patient is outdoors or placed in an airborne isolation room or negative-pressure sputum collection
booth with the door shut. The air in the negative-pressure room or booth should be drawn out of the space and vented
outside of the building.

Materials and equipment required

Sterile, filtered water or normal saline (150 to 250 mL)
N95 mask (particulate respirator) for AFB
Gloves
Box of tissues
Sterile specimen container approved by the laboratory for sputum collection and transport

Procedure
Preparation

1. Instruct the patient to gently brush his/her teeth, gingival margins, tongue, and buccal surfaces using sterile, filtered water or
normal saline to rinse.
Do not use toothpaste, commercial mouth wash preparations, nose drops, any medications containing alcohol, or oil.
Instruct the patient to avoid taking oral antibiotics immediately before the sputum collection procedure.

2. Instruct the patient to gargle several times with sterile, filtered water or normal saline after brushing.
Do not use tap water or bottled water, as it may contain nontuberculous mycobacteria that may alter findings.

Sputum collection

1. Observe standard precautions at all times.

NOTE: N95 masks must worn by healthcare personnel for AFB cough-producing procedures.

2. The patient must be outdoors or in an appropriate negative air pressure room or booth.
3. Coach the patient and supervise the first sputum collection, at a minimum, in order to obtain a good quality sputum sample
that represents secretions from the lower respiratory tract.
NOTE: The patient should understand that sputum is material that is brought up from the lungs and that nasal secretions
and saliva or spit are not acceptable.

4. Instruct the patient to inhale deeply, as far as possible, and then exhale slowly three times.
5. After the third breath, direct the patient to inhale completely and try to cough hard to produce sputum from deep in the lungs.
The patient may feel a rattle or tickle as the sputum moves up from the lungs into the throat.
6. Instruct the patient to expectorate the sputum into a sterile specimen container.
7. When there is at least 5 mL (1 teaspoon) of sputum, replace the lid on the container and tighten it so it does not leak.
NOTE: High-quality sputum is required for smear, culture, and NAA testing. For AFB NAA testing alone, a minimum of 1 mL
of raw sputum (or 0.5 mL of sputum sediment) is needed. It is preferred to collect 5 to 10 mL of raw sputum.

8. If the patient is in a negative air pressure room or booth, ask the patient remain in the booth or room until cleared to leave.
9. Label the specimen with time and date of its collection and place it in a specimen bag. Attach a laboratory request form, if
applicable.
10. Document the procedure in the appropriate flow sheet or medical record.
NOTE: Documentation also is required for unsuccessful procedures.

AFB: acid-fast bacilli; NAA: nucleic acid amplification.

Reproduced with permission from: National Tuberculosis Controllers Association. Consensus statement on the use of Cepheid Xpert MTB/RIF
assay in making decisions to discontinue airborne infection isolation in healthcare settings, April 2016. Copyright © 2016 National TB
Controllers Association. Available at: http://www.tbcontrollers.org/docs/resources/NTCA_APHL_GeneXpert_Consensus_Statement_Final.pdf
(Accessed on June 21, 2016).

Graphic 108733 Version 1.0

Classic adult tuberculosis posterior-anterior view case I

Chest radiograph, posterior-anterior view, of an 18-year-old high school student

exposed four years earlier to an infectious pulmonary tuberculosis patient. She was
noncompliant with isoniazid prophylaxis. She now presents with cough for one month,
fever, and night sweats. Posterior-anterior radiograph shows right upper lobe apical
and posterior segment infiltrate with cavitation. This radiograph is "classic" for adult-
type reactivation tuberculosis.

Courtesy of John Bernardo, MD.

Graphic 74846 Version 4.0

Classic adult TB lateral view

18-year-old high school student, chest radiograph, lateral view.

Courtesy of John Bernardo, MD.

Graphic 70220 Version 4.0
Classic adult tuberculosis posterior-anterior view case II

A 40-year-old automobile mechanic from the Dominican Republic, in the United

States eight years, presented to the urgent care clinic with four months of
productive cough, fevers, progressive hoarseness, and a 40 pound weight loss.
A chest radiograph (posterior-anterior view) demonstrates diffuse parenchymal
disease with multiple cavities and bulla formation on the left. Sputum smear
was positive for acid-fast bacilli.

Courtesy of John Bernardo, MD.

Graphic 54807 Version 4.0

Classic adult TB case 2 lateral

A 40-year-old automobile mechanic with pulmonary tuberculosis, chest radiograph

lateral view.

Courtesy of John Bernardo, MD.

Graphic 56912 Version 4.0

Contributor Disclosures
John Bernardo, MD Nothing to disclose C Fordham von Reyn, MD Grant/Research/Clinical Trial Support: Oxford Immunotec
[Tuberculosis (vaccine)]. Elinor L Baron, MD, DTMH Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting
through a multi-level review process, and through requirements for references to be provided to support the content.
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