DOI 10.1186/s13104-016-2328-4 BMC Reserch Notes RESEARCH ARTICLE Open Access Rifmpicin resistnce pttern of Mycobcterium tuberculosis nd ssocited fctors mong presumptive tuberculosis ptients referred to Debre Mrkos Referrl Hospitl, Ethiopi: cross sectionl study Wondemgegn Mulu 1*, Byeh Aber 1, Mult Yimer 1, Tdesse Hilu 1, Himnot Ayele 2 nd Dereje Abte 2 Abstrct Bckground: Previling dt on rifmpicin-resistnt M. tuberculosis is essentil for erly mngement of MDR-TB. Therefore, this study ws conducted to determine the prevlence of rifmpicin-resistnt Mycobcterium tuberculosis nd ssocited fctors mong presumptive TB cses in Debre Mrkos Referrl Hospitl, Ethiopi. Methods: A cross-sectionl study ws conducted from September 2014 to Mrch 2015. Detection of M. tuberculosis nd resistnce to rifmpicin ws performed using Gene Xpert MTB/RIF ssy. Dt ws collected using structured questionnire by fce to fce interview. Logistic regression nlysis ws computed to determine the ssocited fctors of rifmpicin-resistnt M. tuberculosis. Results: A totl of 505 presumptive TB ptients included in the study. The prevlence of M. tuberculosis confirmed cses ws 117 (23.2%) (95% CI 19.7 27%). It ws higher mong mles (27.9%) thn femles (17.9%) (AOR: 2.17; CI 1.35 3.49). Of the 117 M. tuberculosis confirmed cses, 12 (10.3%) (95% CI 6.0 17.1%) were resistnt to rifmpicin. Rifmpicin-resistnt M. tuberculosis ws noticed in 7 previously treted TB ptients (17.1%) nd 5 tretment nive ptients (6.7%) (AOR: 4.16; CI 1.04 16.63). The prevlence of rifmpicin-resistnt M. tuberculosis ws 6 (9.8%) nd 6 (11.3%) in pulmonry nd extr-pulmonry infections, respectively. Of the 30, MTB/HIV co-infection, 3 (10%) were rifmpicin-resistnt M. tuberculosis. Conclusion: Rifmpicin-resistnt M. tuberculosis is prevlent in both pulmonry nd extr-pulmonry tuberculosis ptients. Previous tretment with nti-tb drugs ws significntly ssocited with rifmpicin resistnce. Therefore, the use of Gene Xpert should be scled up cross the country for rpid detection nd mngement of drug resistnt M. tuberculosis. Keywords: M. tuberculosis, Rifmpicin, Resistnce, Gene Xpert MTB/RIF, Ethiopi Bckground Mycobcterium tuberculosis (M. tuberculosis) remins one of the most significnt cuses of deth from n *Correspondence: Wondem_32@yhoo.com 1 Deprtment of Medicl Microbiology, Immunology nd Prsitology, College of Medicine nd Helth Sciences, Bhir Dr University, Bhir Dr, Ethiopi Full list of uthor informtion is vilble t the end of the rticle infectious gent [1]. Tuberculosis (TB) remins mjor public helth problem, ccounting more thn 9.4 million incident cses nd 1.7 million deths every yer, worldwide [2]. World Helth Orgniztion (WHO) estimtes tht 4.5 million people re co-infected with Humn Immunodeficiency Virus (HIV) nd TB globlly [1, 2]. Ethiopi is one of the 22 high burden countries for TB. TB remins one of the leding cuses of mortlity [3]. According to the 2014 WHO report, the prevlence The Author(s) 2017. This rticle is distributed under the terms of the Cretive Commons Attribution 4.0 Interntionl License (http://cretivecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, nd reproduction in ny medium, provided you give pproprite credit to the originl uthor(s) nd the source, provide link to the Cretive Commons license, nd indicte if chnges were mde. The Cretive Commons Public Domin Dediction wiver (http://cretivecommons.org/ publicdomin/zero/1.0/) pplies to the dt mde vilble in this rticle, unless otherwise stted.
Pge 2 of 8 nd incidence of ll forms of TB re 211 nd 224/100,000 popultions, respectively [4]. TB mortlity ws estimted to be 32/100,000 popultions in 2013. Among estimted ll new TB cses, 13% re HIV co-infected [3, 4]. The emergence of drug resistnce to M. tuberculosis hs become significnt obstcle for TB control [5]. The emergence nd spreding of multidrug (MDR) nd extensively (XDR) drug-resistnt M. tuberculosis complex (MTBC) strins poses significnt chllenges to TB control [2]. Ethiopi is one of the highest MDR-TB burden countries [3]. In Ethiopi, 2.3% of new TB cses nd 17.8% of previously treted TB cses were estimted to hve MDR [3]. Studies in Ethiopi reported 4.7 18.3% prevlence of rifmpicin-resistnt M. tuberculosis [6 10]. Muttions in hotspot region of 81 bse pirs (bp) of rpob gene hve been found in bout 96% of rifmpicin (RMP) resistnt M. tuberculosis [6]. Despite low sensitivity in detection of M. tuberculosis, cid-fst stining remins the min dignostic method in resource-limited settings [11, 12]. Mycobcteril culture is the gold stndrd nd the most sensitive method for TB dignosis; however, its use in clinicl prctice is limited due to slow turnround time, biosfety requirements, nd high cost [11, 12]. In 2011, WHO introduced the wide use of Xpert MTB/RIF ssy. It is fully utomted dignostic moleculr test using rel-time polymerse chin rection (PCR) technology to simultneously detect M. tuberculosis nd rifmpicin resistnce muttions in the rpob gene [13]. The Xpert ssy is highly rpid, sensitive nd specific in dignosis of both pulmonry nd extr pulmonry TB [8 14]. Furthermore; it ws shown to be cost-effective for TB dignosis compred to microscopy in low nd middle income settings [14]. In countries with high burden of TB, rpid detection, continuous surveillnce nd regulr monitoring of drug resistnce TB is essentil for disese mngement nd erlier tretment initition. However, there is limited cpcity to perform Xpert ssy, even from ptients suspected of hrboring drug-resistnt strins with TB/HIV co-infection in Ethiopi. Moreover, documented dt on the prevlence of rifmpicin resistnt M. tuberculosis using the newly endorsed method Gene Xpert in our country is limited. Therefore, the im of this study ws to determine the prevlence nd ssocited fctors of rifmpicin-resistnt M. tuberculosis mong ptient s presumptive for either TB or drug resistnt TB (DR TB) in Debre Mrkos Referrl Hospitl. Methods Study design, re nd period A cross-sectionl study ws conducted from September 2014 to Mrch 2015 t Debre Mrkos referrl Hospitl (DMRH). DMRH hs more thn 147 beds offering different specilized services. It receives ptients from the ctchment re nd referred from different res of Est Gojjm zone. The hospitl hs TB/HIV clinic s well s MDR-TB wrd used for dignosis nd tretment of MDR-TB ptients. The Gene Xpert MTB/RIF ssy ws conducted t DMRH tuberculosis lbortory. Smple size The smple size ws determined using single popultion proportion formul considering 50% expected proportion of rifmpicin-resistnt M. tuberculosis using Gene Xpert MTB/RIF ssy, 95% confidence level nd mrginl error of 5%. Assuming 10% non-response rte, the smple size ws: n = 384 + 10% = 384 + 38 = 422. However, 505 ptients provided clinicl specimen dequtely. Any ptients ttending in the TB clinic of DMRH presumptive for either TB or DR TB were the study popultion nd they were enrolled consecutively. Inclusion criteri Ptients presumptive for pulmonry or extr-pulmonry tuberculosis ttending in the TB clinic of DMRH nd volunteered to prticipte in the study were included. Exclusion criteri Presumptive ptients of pulmonry or extr-pulmonry tuberculosis who provided indequte specimen for the lbortory nlysis were excluded from the study. Vribles Rifmpicin-resistnt M. tuberculosis ws the dependent vrible where s demogrphic fctors, HIV infection sttus, tuberculosis nd tretment relted conditions were the independent vribles. Lbortory procedures Ech eligible ptient who signed written consent provided clinicl specimens. From ech ptients presumptive of pulmonry TB, 4 ml of sputum smple ws collected. In the cse of presumptive extr-pulmonry TB, four ml of either pus, CSF, lymph node spirte or peritonel nd pleurl fluid smples were collected. Smples were immeditely processed for Gene Xpert MTB/RIF ssy. Clinicl smples were diluted nd decontminted nd Xpert MTB/RIF ssy (Cepheid) ws performed ccording to mnufcturer s instruction. The Xpert MTB/RIF purifies nd concentrtes M. tuberculosis bcilli from clinicl smples. Genomic mteril isolted from the cptured bcteri by soniction nd subsequently mplifies the genomic DNA by polymerse chin rection (PCR). Furthermore, the process identifies ll the cliniclly relevnt rifmpicin resistnce inducing muttions in the
Pge 3 of 8 RNA polymerse bet (rpob) gene in the M. tuberculosis genome in rel time formt using fluorescent probes clled moleculr becons. HIV testing Testing for HIV ws done ccording to the current ntionl lgorithm recommended by the Federl Ministry of Helth of Ethiopi. Two rpid HIV tests, HIV (1 + 2) rpid test strip (KHB) nd Stt-Pk were run sequentilly. Smples were tested first with KHB. Positive smples were confirmed with Stt-Pk. Discordnt results were resolved using third confirmtory testing kit, HIV-1/2 Unigold Recombinnt ssy. Pre nd post-test HIV counseling ws provided for ll consenting individuls. Using structured questionnire dt ws collected by both fce to fce ptient interviews nd ptients clinicl record review. The min vribles included in the study were ge, sex, residence, reson for dignosis, tretment history, nd ctegory of presumptive DR TB nd site of tuberculosis. Dt nlysis Dt were nlyzed using Sttisticl Pckge for Socil Sciences (SPSS 20, USA). Descriptive sttistics were used to describe the study prticipnts in reltion to relevnt vribles. Chi-squre nd logistic regression nlysis were computed to identify the ssocited fctors of M. tuberculosis nd rifmpicin-resistnce. Most of the vribles were fitted to Chi-squre test. Then ll vribles hving P vlue of 2 in the Chisqure test were further entered into logistic regression model. In the multivrite nlysis, bckwrd step wise logistic regression techniques were fitted nd confounding were controlled. Vribles hving P vlue <0.05 in the multivrite nlysis were tken s sttisticlly significnt. Adjusted odds rtios with their 95% confidence intervls were clculted. The Hosmer nd Lemshow grdens-of-fit test ws used to ssess whether the necessry ssumptions for the ppliction of multiple regressions were fulfilled nd P vlue >0.05 ws considered s good fit. Qulity ssurnce Both SPC nd PCC internl controls used during Gene Xpert MTB/RIF ssy. The specimen ws excluded from the nlysis if it ws n invlid smple for Xpert ssy or smple error ccording to Cepheid pckge insert. All procedures were done using stndrd operting methods. Results Ptient chrcteristics A totl of 505 presumptive TB or DRTB ptients prticipted in the study. Of whom, 188 (37.2%) were presumptive DR TB. Most 265 (52.4%) were mles. The ge rnge of prticipnts ws 6/12 month to 92 yers with men ge of 35.5 yer. Mjority (55.7%) of prticipnts were urbn dwellers. Of the totl, 323 (64%) were presumptive for pulmonry TB while 182 (36%) were presumptive for extr-pulmonry TB. Four presumptive DRTB ctegories were involved in this study: 101 (52.1%) relpse, 62 (32%) new, 26 (13.4%) tretment filure nd 4 (2.1%) MDR contct. Prevlence of HIV ws 183 (36%) mong study prticipnts (Tble 1). Prevlence of tuberculosis The prevlence of M. tuberculosis confirmed TB ws 117 (23.2%) (95% CI 19.7 27%). The proportion of M. tuberculosis ws 74 (27.9%) in mles nd 43 (17.9%) in femles. The proportion of M. tuberculosis ws 48 (15.1%) nd 69 (36.7%) mong ptients presumptive of TB nd DR TB, respectively. From 188 presumptive DRTB cses, M. tuberculosis ws noticed in 28 new (45.2%), 26 relpse (25.7%) nd 14 tretment filure (53.8%) cses. M. tuberculosis ws detected in 64 pulmonry (19.8%) nd 53 extr-pulmonry TB cses (29.1%). The rte of MTB/HIV co-infection ws 30 (16.6%) (Tble 1). Rifmpicin resistnt M. tuberculosis Of the 117 M. tuberculosis cses, 12 (10.3%) were resistnt to rifmpicin. The proportion of rifmpicin-resistnt M. tuberculosis ws 7 (17.1%) mong previously treted TB ptients nd 5 (6.7%) mong tretment nïve ptients. Of the 69 presumptive DR TB ptients, rifmpicin resistnt M. tuberculosis ws detected in 3 new (10.7%), 5 relpse (19.2%) nd 2 tretment filure (14.3%) cses. Five rifmpicin-resistnt M. tuberculosis ws noticed from ll ptients with MTB/HIV co-infection (17.9%). Rifmpicin resistnce ws noticed in 6 pulmonry (9.5%) nd 6 extrpulmonry tuberculosis cses (11.3%) (Tble 2). Associted fctors Multivrite nlysis showed tht M. tuberculosis infection ws significntly ssocited with mle (AOR = 2.17; CI 1.35 3.49), younger ge (AOR = 3.2, CI 1.23 8.21), previous TB therpy (AOR = 2, CI 1.03 3.96) nd site of TB infection (AOR = 2.19, CI 1.36 3.51). On the other hnd, rifmpicin-resistnt M. tuberculosis ws significntly ssocited with previous TB therpy (AOR = 4.16, CI 1.04 16.6). Mle ptients were 2.17 times more likely to hve M. tuberculosis infection. TB ptients who hd previous history of TB therpy were 2 times more likely to hve M. tuberculosis infection thn tretment nïve ptients. Moreover, TB ptients who were previously treted by nti-tb drugs were 4.2 times more likely to develop rifmpicin-resistnt M. tuberculosis compred to tretment nïve ptients (Tbles 3, 4).
Pge 4 of 8 Tble 1 Prevlence of M. tuberculosis mong presumptive TB ptients referred to DMRH using Gene Xpert MTB/RIF ssy, 2015 Chrcters M. tuberculosis Totl N (%) Detected Not detected N (%) N (%) P vlue Age, yers 10 9 (23.7) 29 (76.3) 38 (7.5) 0.017 11 17 7 (29.2) 17 (70.8) 24 (4.8) 18 30 46 (34.3) 88 (65.7) 134 (26.7) 31 40 25 (18.7) 109 (81.3) 134 (26.5) 41 50 15 (15.1) 82 (84.5) 97 (19.2) 51 60 9 (18) 41 (82) 50 (9.9) 61 95 6 (21.4) 22 (79.6) 28 (5.5) Sex Mle 74 (27.9) 191 (72.1) 265 (52.4) 0.008 Femle 43 (17.9) 197 (82.1) 240 (47.6) Residence Urbn 57 (20.2) 225 (79.8) 282 (55.7) 0.007 Rurl 60 (26.9) 163 (73.1) 223 (44.3) HIV infection Positive 30 (16.6) 153 (83.4) 183 (36) 0.008 Negtive 87 (26.9) 235 (73.1) 322 (64) Reson for dignosis Presumptive TB 48 (15.1) 269 (84.8) 317 (62.8) <0.001 Presumptive DR TB 69 (36.7) 119 (63.3) 188 (37.2) Tretment history with nti-tb drugs Previously treted 41 (31.6) 91 (68.9) 132 (26.2) 0.013 Previously untreted 76 (20.4) 297 (79.6) 372 (73.8) Presumptive DRTB New 28 (45.2) 34 (54.8) 62 (32) 0.024 Relpse 26 (25.7) 75 (74.3) 101 (52.1) Filure 14 (92.3) 12 (7.7) 26 (13.4) Lost to follow-up 0 1 1 (0.5) MDR-contct 1 (25) 3 (75) 4 (2.1) Site of presumptive TB Pulmonry 64 (19.8) 259 (80.2) 323 (64) 0.013 Extr-pulmonry 53 (29.1) 129 (70.9) 182 (36) Type of specimen Respirtory (sputum) 64 (19.8) 259 (80.2) 323 (64) 0.007 Non-respirtory 53 (29.1) 129 (70.9) 182 (36) Type of non-respirtory specimen Pus 46 (35.1) 85 (64.9) 131 (26) Peritonel fluid 2 (11.8) 15 (88.2) 17 (3.4) Lymph node 1 (7.1) 13 (92.9) 14 (2.8) spirte Pleurl fluid 3 (23.1) 10 (76.9) 13 (2.6) Other 1 (14.3) 6 (83.7) 7 (1.2) Totl 117 (23.2) 388 (76.8%) 505 (100) Tble 2 Prevlence of rifmpicin-resistnt M. tuberculosis in ech vrible mong the totl M. tuberculosis cses using Gene Xpert MTB/RIF ssy, DMRH, 2015 Vribles Resistnce pttern P vlue Resistnce N (%) Sensitive N (%) Age, yers 10 2 (22.2) 7 (77.8) 0.02 11 17 1(14.3) 6 (83.6) 18 30 3 (6.7) 43 (93.3) 31 40 0 25 (100) 41 50 5 (33.3) 10 (66.7) 51 60 0 9 (100) 61 92 1 (16.7) 5 (83.3) Sex Mle 8 (11.3) 64 (88.7) 0.77 Femle 4 (8.9) 41 (91.1) Residence Urbn 5 (17.9) 53 (91.2) 0.76 Rurl 7 (11.9) 52 (88.1) HIV infection Positive 5 (17.9) 24 (82.1) 0.17 Negtive 7 (8) 81 (92) Reson for dignosis Presumptive TB 3 (5.9) 49 (94.1) 0.22 Presumptive DR TB 9 (13.8) 56 (86.2) Tretment history with nti-tb drugs Previously treted 7 (17.1) 34 (82.9) 0.11 Previously untreted 5 (6.7) 71 (93.3) Presumptive DR TB New 3 (10.7) 25 (89.3) 0.87 Relpse 5 (19.2) 21 (80.8) Filure 2 (14.3) 12 (91.7) MDR-contct 0 1 Site of presumptive TB Pulmonry 6 (9.4) 58 (90.6) 0.77 Extr pulmonry 6 (11.3) 47 (88.7) Specimen type Respirtory (sputum) 6 (9.5) 58 (90.6) 0.67 Non-respirtory 6 (11.3) 47 (88.7) Type of non-respirtory specimen Pus 4 (8.5) 43 (91.5) Peritonel fluid 0 2 Lymph node spirte 0 1 Pleurl fluid 2 1 Totl 12 (10.3) 105 (89.7) RIF rifmpicin resistnt, MTB M. tuberculosis, DR TB drug resistnt tuberculosis MTB M. tuberculosis, DR TB drug resistnt tuberculosis
Pge 5 of 8 Tble 3 Multivrite nlysis showing the ssocited predictors of M. tuberculosis in DMRH, 2015 Vribles Gene expert result M. tuberculosis AOR (95% CI) P vlue Detected Not detected Residence Urbn 57 225 1.35 (0.86 2.13) 0.19 Rurl 60 163 Sex Mle 74 191 2.17 (1.35 3.49) 0.001 Femle 43 197 Age, yers 10 9 29 3.2 (1.23 8.21) 0.02 11 17 7 17 3.3 (1.08 10.08) 0.036 18 30 46 88 4.6 (1.63 12.71) 0.004 31 40 25 109 2.76 (0.77 9.91) 0.12 41 50 15 82 1.1 (0.46 2.70) 0.82 51 60 9 41 1.2 (0.36 4.02) 0.77 61 92 6 22 HIV infection Positive 30 153 1.36 (0.80 2.3) 0.25 Negtive 87 235 Reson for exmintion Presumptive 48 269 TB Presumptive DR TB 69 119 6.83 (3.55 13.15) <0.001 Tretment history with nti-tb drugs Previously 41 91 2.02 (1.03 3.96) 0.04 treted Previously 76 297 untreted Site of TB infection Pulmonry 64 259 2.19 (1.36 3.51) 0.001 Extr-pulmonry 53 129 MTB M. tuberculosis, RIF rifmpicin, AOR djusted odds rtio Reference ctegory, Hosmer Lemeshow test = 0.92, Person Chisqure = 2.55, clssifiction tble = 77.4 Discussion In the present study, the prevlence of M. tuberculosis infection ws similr with reports of South Afric (26%) [15], Northern Nigeri (23%) [16] nd Indi (27.6%) [17]. However, it ws lower compred to reports in Nigeri (31.4%) [18] nd Pkistn (37%) [19]. The lower proportion rte of confirmed M. tuberculosis in the present study compred to other studies is due to the fct tht we included presumptive cses to identify M. tuberculosis while other studies included identified cses of M. tuberculosis to check gene Xpert technique. In contrst, it is higher thn studies conducted in other prts of Ethiopi Tble 4 Multivrite nlysis showing the ssocited predictors of rifmpicin resistnt M. tuberculosis in DMRH, 2015 Vribles Resistnce pttern AOR (95% CI) P vlue Resistnce Sensitive Age, yers 0 10 2 7 2.3 (0.15 37.67) 0.55 11 17 1 6 1.84 (0.08 44.6) 0.71 18 30 3 43 0.55 (0.04 6.80) 0.64 31 40 0 25 41 50 5 10 4.3 (0.34 54.99) 0.23 51 60 0 9 61 92 1 5 HIV infection Positive 5 24 3.2 (0.69 14.96) 0.14 Negtive 7 81 Reson for exmintion Presumptive TB 3 49 Presumptive DR TB 9 56 0.41 (10.04 4.21) 0.45 Tretment history with nti-tb drugs Previously treted 7 34 4.16 (1.04 16.63) 0.04 Previously untreted 5 71 DR TB drug resistnt tuberculosis, AOR djusted odds rtio, CI confidence intervl Reference ctegory, Hosmer Lemeshow test = 0.99, Person Chisqure = 0.91, clssifiction tble = 89.7 [20 22] nd Indi [23]. The discrepncy might be due to difference in methods of detection of M. tuberculosis, community nd geogrphicl re. In this study, the detection rte of M. tuberculosis ws significntly higher in mles thn femles. Likewise, reports from WHO [24], Ethiopi [7] nd Northest Chin [25] supports this finding. The reson for this might be due to socil nd helth seeking behvior difference nd higher exposure of mles to outer environment, smoking nd lcoholism [24]. The highest proportion of Gene Xpert positive M. tuberculosis cses were seen in the ge group of 18 30 yers. This is consistent with previous reports in Ethiopi [20 22, 26]. This might be due to more exposure to the outer environment, high work lod nd wide rnge of mobility of young people to cquire the TB bcilli s young people hve. In the present study, the proportion of M. tuberculosis ws significntly higher in presumptive DRTB compred to presumptive TB ptients (P < 0.001). This might be due to tretment filure nd cquiring of resistnt bcilli from drug resistnt TB contcts. Moreover, significntly higher proportion of M. tuberculosis ws found mong ptients treted with nti-tb drugs compred to tretment nïve
Pge 6 of 8 ptients in the present study. This finding ws comprble to study conducted in Zimbbwe [27]. Rifmpicin-resistnt M. tuberculosis is serious helth problem in the study popultion. The prevlence of rifmpicin-resistnt M. tuberculosis in this study ws in keeping with previous studies in Nigeri [28], North Indi [29], Irn [30] nd Northest Chin [25]. However, it ws higher thn studies observed in Ethiopi [8, 9, 31, 32], Keny [33], Nigeri [34], Ugnd [35] nd South of Irq [36]. In contrst, the proportion of rifmpicin-resistnt M. tuberculosis ws lower thn reports in other prts of Ethiopi [7, 36] nd Chile [37]. The vrition could be due to difference in risk for HIV cquisition, exposure to nti-tb drugs nd ntionl TB control progrm. The reltive higher proportion of rifmpicin-resistnt M. tuberculosis in our study could be due to the use of rifmpicin to tret other conditions. Moreover, rifmpicin hs severl dverse effects which could result in ptient non-dherence nd hence my led to the selection of resistnt strins. In the present study, the proportion of rifmpicinresistnt M. tuberculosis ws significntly higher mong previously treted ptients compred to tretment nive ptients which might be due to filure from previous tretment nd contct with drug resistnt TB ptients [26, 38 43]. However, the level of rifmpicin resistnce mong previously untreted cses (6.7%) in the nlysis close to the reported prevlence of rifmpicin- resistnt MTB (10.4%). This finding is significnt relevnce in the current globl nd regionl efforts to ccurtely nd timely dignose MDR-TB with the scle up of moleculr technology like Gene Xpert MTB/RIF, providing quick results of rifmpicin resistnce s proxy to MDR-TB. In this study, high prevlence of rifmpicin-resistnt M. tuberculosis ws detected mong HIV positive cses which re in ccordnce with study done in other prt of Ethiopi [26] nd Cmbodi [44]. However, in the present study, there ws lck of ssocition between HIV infection nd development of ctive tuberculosis s well s rifmpicin resistnce. This ws consistent with the results of erlier studies in Ethiopi [39], Tnzni [42], Clbr Nigeri [35] nd Brzil [45]. In the present study, the proportion of extr-pulmonry tuberculosis ws significntly higher compred to pulmonry tuberculosis; in ddition the proportion of rifmpicin-resistnt M. tuberculosis ws higher in nonrespirtory specimens compred to sputum. This conforms to study in Cmbodi [44]. This demonstrtes tht rifmpicin-resistnt extr-pulmonry M. tuberculosis infection is mjor helth problem in resource-limited settings. The mjor strength of this study ws detection of M. tuberculosis nd rifmpicin resistnce using the newly endorsed method Gene Xpert MTB/RIF ssy from sputum nd non-respirtory specimens. However, the mjor limittion of this study ws determintion of the smple size using single popultion formul which my overwhelm some of the ssocited fctors. This study could not do the level of resistnce to other nti-tb drugs nd the finding of Gene Xpert ws not compred to cid fst bcilli microscopy. Thus the finding of this study should be interpreted with these limittions. Conclusions Rifmpicin-resistnt M. tuberculosis is prevlent both in pulmonry nd extr-pulmonry tuberculosis cses in the study re. Previous tretment with nti-tb drugs ws significntly ssocited with rifmpicin resistnce. The strong ssocition of rifmpicin resistnce with previous tretment suggests tht improved monitoring of tretment to limit the emergence of drug resistnt M. tuberculosis. Hence, the use of Gene Xpert should be scled up cross the country for rpid dignosis, mngement nd expnded surveillnce of drug-resistnt M. tuberculosis. Authors contributions WM conceived nd designed the study, involved in Gene Xpert MTB/RIF ssy, interpret the result, performed the sttisticl nlysis nd wrote the mnuscript, HA nd DA performed the gene Xpert MTB/RIF ssy, nd revised the mnuscript, BA, MY nd TH, criticlly revised the mnuscript. All uthors red nd pproved the finl mnuscript. Author detils 1 Deprtment of Medicl Microbiology, Immunology nd Prsitology, College of Medicine nd Helth Sciences, Bhir Dr University, Bhir Dr, Ethiopi. 2 Deprtment of Microbiology Lbortory, Debre Mrkos Referrl Hospitl, Debre Mrkos, Ethiopi. Acknowledgements We would like to cknowledge DMRH for giving permission to conduct the study. We would like lso to thnk Mr. Belchew Mulu, Medicl Lbortory technicin t DMRH for his contribution in ssisting the dt collection process. Competing interests The uthors declre tht they hve no competing interests. Avilbility of dt nd mterils The finding of this study is generted from the dt collected nd nlyzed bsed on the stted methods nd mterils. All the dt re lredy found in the mnuscript nd there re no supplementry files. The originl dt supporting this finding will be vilble t ny time upon request. Consent for publiction Consent to publish is not pplicble for this mnuscript becuse there is no individul dt detils like imges or videos. Ethics pprovl nd consent to prticipte Ethicl pprovl ws secured from the reserch ethics committee of DMRH. We followed ll chins of commnd to get support letter from leglly uthorized representtives for dt collection. Written consent ws obtined from ech study prticipnts. Moreover, ll prents of prticipnts under 18 gve written consent to prticipte in this study. The results from lbortory nlysis were communicted to the responsible physicin for erly initition of nti- TB tretment. Confidentility of the result ws lso mintined nonymously nd not communicted for other purposes.
Pge 7 of 8 Funding Funding is not pplicble for this study becuse the reserch project ws not funded by ny orgniztion. Received: 5 Jnury 2016 Accepted: 8 December 2016 References 1. Zek AN, Tsbkn S, Cvusoglu C. Evlution of the Gene Xpert MTB/RIF ssy for rpid dignosis of tuberculosis nd detection of rifmpin resistnce in pulmonry nd extr pulmonry specimens. J Clin Microbiol. 2011;49(12):4138 41. 2. Ionnidis P, Ppventsis D, Krbel S, Nikolou S, Pngi M, Rftopoulou E, et l. Cepheid Gene Xpert MTB/RIF ssy for Mycobcterium tuberculosis detection nd rifmpin resistnce identifiction in ptients with substntil clinicl indictions of tuberculosis nd smer-negtive microscopy results. J Clin Microbiol. 2011;49(8):3068 70. 3. World Helth Orgniztion. Tuberculosis Progress. WHO/HTM/TB 2014. Genev: WHO; 2015. 4. World Helth Orgniztion. Globl Tuberculosis Report. WHO/HTM/TB 2014. Genev: WHO; 2014. 5. World Helth Orgniztion. 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