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Xpert MTB/RIF
R
GXMTB/RIF-10
PROPRIETARY NAME
Xpert® MTB/RIF Assay
A. INTENDED USE
The Xpert MTB/RIF Assay for use with the Cepheid GeneXpert® system is a semi-quantitative,
nested real-time PCR in-vitro diagnostic test for the detection of:
• Mycobacterium tuberculosis complex DNA in sputum samples or concentrated sediments prepared
from induced or expectorated sputa that are either acid-fast bacilli (AFB) smear positive or
negative
• Rifampin-resistance associated mutations of the rpoB gene in samples from patients at risk for
rifampin resistance
The Xpert MTB/RIF Assay is intended for use with specimens from untreated patients for whom
there is clinical suspicion of tuberculosis (TB). Use of the Xpert MTB/RIF Assay for the detection of
M. tuberculosis (MTB) or determination of rifampin susceptibility has not been validated for patients
who are receiving treatment for tuberculosis.
Molecular detection of MTB and rpoB gene mutations associated with RIF resistance speeds the
diagnosis of both drug-susceptible and MDR-TB. With the Xpert MTB/RIF Assay, this can be
accomplished in fresh sputum samples and in prepared sediments in less than 2.5 hours. The rapid
detection of MTB and RIF resistance allows the physician to make critical patient management
decisions regarding therapy during the same medical encounter.
Note: The Sample Reagent (SR) solution is clear, ranging from colorless to golden yellow.
Note: The bovine serum albumin (BSA) in the beads within this product was produced exclusively from bovine
plasma sourced in the United States. The manufacturing of the BSA is also performed in the United
States. No ruminant protein or other animal protein was fed to the animals; the animals passed ante- and
post-mortem testing. During processing, there was no commingling of the material with other animal
materials.
Note: The transfer pipettes have a single mark representing the minimum volume of sample necessary to transfer
to the GX cartridge. Use only for this purpose. All other pipettes must be provided by the laboratory.
Fresh sputum 1 mL 2 mL
Note: To obtain an adequate fresh sputum specimen, follow the instructions in this section. The patient should
be seated or standing.
H. ASSAY PROCEDURE(S)
H.1 SPUTUM SEDIMENTS PROCEDURE
Note: Reject specimens with obvious food particles or other solid particulates.
Volume Requirements: Sputum sediments prepared according to the method of Kent and
Kubica8 and re-suspended in 67mM Phosphate/H2O buffer) can be tested using Xpert MTB/
RIF Assay. After resuspension, keep at least 0.5 mL of the resuspended sediment for the Xpert
MTB/RIF Assay.
1. Label each Xpert MTB/RIF cartridge with the sample ID.
Note: Write on the sides of the cartridge or affix an ID label. Do not put the label on the lid of the cartridge or
cover the existing 2D barcode on the cartridge.
2. Transfer at least 0.5 mL of the total resuspended pellet to a conical, screw-capped tube for
the Xpert MTB/RIF using a transfer pipette. Alternatively, the entire sample can be
processed in the original tube.
Note: Store re-suspended sediments at 2 to 8 °C if they are not immediately processed. Do not store for more
than 12 hours.
3. Transfer 1.5 mL of Xpert MTB/RIF Sample Reagent (SR) to 0.5 mL of resuspended
sediment using a transfer pipette.
Note: Write on the sides of the cartridge or affix an ID label. Do not put the label on the lid of the cartridge or
cover the existing 2D barcode on the cartridge.
B. Pour approximately 2 times the volume of the SR to the sputum (2:1 dilution,
SR:sputum).
Example 1 Example 2
8 mL SR:4 mL sputum 2 mL SR:1 mL sputum
Note: Discard the leftover SR
and the bottle in a chemical
3 mL line
waste container.
1 mL sputum
3. Transfer the sample into the sample chamber of the Xpert MTB/RIF cartridge. Dispense
the sample slowly to minimize the risk of aerosol formation. See Figure 5.
Figure 5. Dispensing decontaminated liquefied sample into the sample chamber of the cartridge
Important: Be sure to load the cartridge into the GeneXpert Dx instrument and start the
test within 5 hours of preparing the cartridge.
Important: Before you start the test, make sure that the system is running GX 4.0 software
or higher and that the Xpert MTB/RIF assay definition file is imported into the
software.
This section lists the basic steps for running the test. For detailed instructions, see the
GeneXpert Dx System Operator Manual or the GeneXpert Infinity System Operator Manual,
depending on the model that is being used.
Note: The steps you follow can be different if the system administrator changed the default workflow of the
system.
1. Turn on the GeneXpert instrument:
• If using the GeneXpert Dx instrument, first turn on the GX Dx instrument, and then
turn on the computer. The GeneXpert software will launch automatically.
or
• If using the GeneXpert Infinity instrument, power up the instrument. On the
Windows® desktop, double-click the Software shortcut icon.
2. Log on to the GeneXpert Dx System software using your user name and password.
3. In the GeneXpert Dx System window, click Create Test. The Scan Sample ID dialog box
appears.
4. In the Sample ID box, scan or type the sample ID. Make sure you type the correct sample
ID (sample ID is associated with the test results and is shown in the View Results window
and all the reports). The Scan Cartridge Barcode dialog box appears.
5. Scan the barcode on the Xpert MTB/RIF cartridge. The Create Test window appears.
Using the barcode information, the software automatically fills the boxes for the following
fields: Select Assay, Reagent Lot ID, Cartridge SN, and Expiration Date.
6. Click Start Test. Enter your password if requested.
7. Open the instrument module door with the blinking green light and load the cartridge.
8. Close the door. The test starts and the green light stops blinking. When the test is finished,
the light turns off.
9. Wait until the system releases the door lock at the end of the run, then open the module
door and remove the cartridge.
I. QUALITY CONTROL
Each test includes a Sample Processing Control (SPC) and Probe Check Control (PCC).
SPC: Ensures the sample was correctly processed. The SPC contains noninfectious spores in the
form of a dry spore cake that is included in each cartridge to verify adequate processing of MTB. The
SPC verifies that lysis of MTB has occurred if the organisms are present and verifies that specimen
processing is adequate. Additionally, this control detects specimen-associated inhibition of the real-
time PCR assay.
The SPC should be positive in a negative sample and can be negative or positive in a positive sample.
The SPC passes if it meets the validated acceptance criteria. The test result will be “Invalid” if the
SPC is not detected in a negative test.
PCC: Before the start of the PCR reaction, the GeneXpert Dx System measures the fluorescence
signal from the probes to monitor bead rehydration, reaction-tube filling, probe integrity and dye
stability. PCC passes if it meets the assigned acceptance criteria.
J. INTERPRETATION OF RESULTS
The GeneXpert Instrument system generates the results from measured fluorescent signals and
embedded calculation algorithms. The results can be seen in the View Results window. See Figures
6, 7, and 8 for specific examples, and see Table 2 for a list of all possible results.
Figure 6. MTB DETECTED MEDIUM; Rif Resistance DETECTED (Privileged User View)
Figure 7. MTB DETECTED LOW; Rif Resistance NOT DETECTED (Privileged User View)
Result Interpretation
The MTB target is present within the sample:
MTB DETECTED;
• A mutation in the rpoB gene has been detected that falls within the valid delta Ct
Rif Resistance DETECTED setting.
• SPC: NA (not applicable). An SPC signal is not required because MTB
amplification can compete with this control.
• Probe Check: PASS. All probe check results pass.
The MTB target is present within the sample:
MTB DETECTED;
• No mutation in the rpoB gene has been detected.
Rif Resistance NOT DETECTED • SPC: NA (not applicable). An SPC signal is not required because MTB
amplification can compete with this control.
• Probe Check: PASS. All probe check results pass.
The MTB target is present within the sample:
MTB DETECTED;
• RIF resistance could not be determined due to insufficient signal detection.
Rif Resistance INDETERMINATE • SPC: NA (not applicable). An SPC signal is not required because MTB
amplification can compete with this control.
• Probe Check: PASS. All probe check results pass.
The MTB target is not detected within the sample:
MTB Not Detected
• SPC: PASS. The SPC met the acceptance criteria.
• Probe Check: PASS. All probe check results pass.
The presence or absence of MTB cannot be determined. The SPC does not meet the
INVALID
acceptance criteria, the sample was not properly processed, or PCR was inhibited. Repeat
the test. See the Retest Procedure section of this document.
• MTB INVALID: The presence or absence of MTB DNA cannot be determined.
• SPC: FAIL. The MTB target result is negative, and the SPC Ct is not within valid
range.
• Probe Check: PASS. All probe check results pass.
The presence or absence of MTB cannot be determined. Repeat the test. See the Retest
ERROR
Procedure section of this document.
• MTB: NO RESULT
• SPC: NO RESULT
• Probe Check: FAIL. All or one of the probe check results failed.
Note: If the probe check passed, the error is caused by a system component failure.
The presence or absence of MTB cannot be determined. Repeat the test. See the Retest
NO RESULT
Procedure section of this document. A NO RESULT indicates that insufficient data was
collected. For example, the operator stopped a test that was in progress.
• MTB: NO RESULT
• SPC: NO RESULT
• Probe Check: NA (not applicable)
K. LIMITATIONS
The performance of the Xpert MTB/RIF was validated using the procedures provided in this
package insert. Modifications to these procedures may alter the performance of the test. Results from
the Xpert MTB/RIF should be interpreted in conjunction with other laboratory and clinical data
available to the clinician.
Because the detection of MTB is dependent on the number of organisms present in the sample,
reliable results are dependent on proper specimen collection, handling, and storage. Erroneous test
results might occur from improper specimen collection, failure to follow the recommended sample
collection procedure, handling or storage, technical error, sample mix-up, or an insufficient
concentration of starting material. Careful compliance to the instructions in this insert is necessary to
avoid erroneous results.
A positive test result does not necessarily indicate the presence of viable organisms. It is however,
presumptive for the presence of MTB and RIF resistance.
Test results might be affected by antecedent or concurrent antibiotic therapy. Therefore, therapeutic
success or failure cannot be assessed using this test because DNA might persist following
antimicrobial therapy.
Mutations or polymorphisms in primer or probe binding regions may affect detection of new or
unknown MDR-MTB or RIF-resistant strains resulting in a false negative result.
L. PERFORMANCE CHARACTERISTICS
This section lists the performance characteristics and limitations of the Xpert MTB/RIF Assay.
• Drug susceptibility testing (DST) on L-J proportion or on MGIT covering at least four
first-line drugs.
• Standard NAAT tests (Gen-Probe Amplified Mycobacterium TB Direct Test and Roche
AMPLICOR® MTB Test) when performed
Samples included sputum specimens collected for routine testing from patients suspected of
tuberculosis infection and at risk for multi-drug resistant TB.
When considering only a single direct sputum sample, the Xpert MTB/RIF Assay sensitivity
was 97.8% (545/557) in S+C+ patients and 73.1% (122/167) in S-C+ patients. The specificity
was 99.0% (605/611) in non-TB patients.
When considering only a single direct sputum sample, the Xpert MTB/RIF Assay sensitivity
for RIF resistance detection was 97.2% (141/145) in RIF-resistant patients. The specificity in
RIF sensitive cases was 98.3% (412/419). See Table 5.
The Xpert MTB/RIF Assay results on specimens from those sites where a NAAT test was
also performed are shown in Table . The NAAT test result is shown for comparison.
Table 6. Comparison of Xpert MTB/RIF Assay and Alternative NAAT Performance on Sputum Speciments
Of the Xpert MTB/RIF Assays runs performed in conjunction with this study, 96.5% (4327/
4484) were successful on the first attempt. The remaining 157 gave indeterminate results on
the first attempt. One hundred eight of the 157 specimens yielded valid results with retest.
The overall assay success rate was 98.9% (4435/4484).
Under the conditions of the study, all of the NTM isolates were reported MTB negative.
Additionally, in order to determine if high concentrations of NTM would interfere with the
detection of low levels of TB, the strains listed in Table 7 were mixed with the TB strain
H37Rv in sputum to a final concentration of 106 CFU/mL NTM and 200 CFU/mL H37Rv.
GeneXpert Result
MTB Positive
RIF Resistance 37 0 0
MTB +
0 42 0
Reference RIF Sensitive
MTB 0 0 52
M. REFERENCES
1. WHO report 20081. http://www.who.int/tb/publications/global_report/2008
2. Anti-tuberculosis resistance in the world: fourth global report. WHO/HTM/TB/
2008.394
3. Morris SL, Bai G, Suffys P, Portillo-Gomez L, Fairchok M, Rouse D. Molecular
mechanisms of multidrug resistance in clinical lisolates of Mycobacterium tuberculosis. J Infect
Dis 1995; 171:954-60.
4. Ashok Rattan, Awdhesh Kalia, and Nishat Ahmad. Multidrug-Resistant Mycobacterium
tuberculosis: Molecular Perspectives, Emerging Infectious Diseases, Vol.4 No.2, http://
www.cdc.gov/ncidod/EID/vol4no2/rattan.htm
5. Francis J. Curry National Tuberculosis Center and California Department of Public
Health, 2008: Drug-Resistant Tuberculosis, A Survival Guide for Clinicians, Second Edition.
6. Centers for Disease Control and Prevention. Biosafety in microbiological and biomedical
laboratories. Richmond JY and McKinney RW (eds) (1993). HHS Publication number
(CDC) 93-8395.
7. Clinical and Laboratory Standards Institute (formerly National Committee for Clinical
Laboratory Standards). Protection of laboratory workers from occupationally acquired
infections; Approved Guideline. Document M29 (refer to latest edition).
8. Kent PT, Kubica GP 1985. Public Health Mycobacteriology—A Guide for Level III
Laboratory, Centers of Disease Control, Atlanta, Publication no. PB 86-216546.
9. Laboratory Services in Tuberculosis Control: Part II, Microscopy WHO/TB/98.258;
p 1-61.
10. Laboratory Services in Tuberculosis control: Part III Culture. WHO/TB/98.258. p 1- 74.
11. NCCLS, Susceptibility testing of Mycobacteria, Nocardia, and other Aerobic
Actinomycetes: Approved Standard. NCCLS document M24-A (ISBN 1- 56238-500-3).
NCCLS, 940 West Valley Road, Suite 1400, Wayne, Pennsylvania 19087 – 1898, USA.
2003.
12. Boehme CC, Nabeta P, Hillemann D, Nicol MP, et al. Rapid Molecular Detection of
Tuberculosis and Rifampin Resistance. N Engl J Med 2010;363:1005-15.
N. ASSISTANCE
Before contacting Cepheid Technical Support, collect the following information:
• Product name
• Lot number
• Serial number of the instrument
• Error messages (if any)
• Software version and, if applicable, Computer Service Tag number
TABLE OF SYMBOLS
Symbol Meaning
European conformity
Catalog number
Batch code
Do not reuse
Manufacturer
Control
Temperature limitation
Biological risks
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