Nitrate Reductase Assay for Rapid Detection of Isoniazid, Rifampin, Ethambutol, and Streptomycin Resistance in Mycobacterium tuberculosis: a Systematic Review and Meta-Analysis

Abstract

dColorimetric phenotypic tests recently gained interest because traditional primary drug susceptibility testing of Mycobacterium tuberculosis isolates takes a long time. We used meta-analysis techniques to review the reliability and accuracy of the nitrate reductase assay (NRA), which is one of the most popular colorimetric methods to detect resistance to first-line drugs. Medline, PubMed, ISI Web, Web of Science, and Google Scholar were used to search for studies enrolled in the meta-analysis. The analysis included 35 studies for isoniazid (INH), 38 for rifampin (RIF), and 22 for ethambutol (EMB) and streptomycin (STR). Summary receiver operating characteristic (SROC) curves were applied to summarize diagnostic accuracy. The meta-analyses were performed by the use of Meta-DiSc software (version 1.4) and were focused on sensitivity and specificity values for measurements of accuracy. The pooled sensitivities were 96% for INH, 97% for RIF, 90% for EMB, and 82% for STR. The pooled specificities for INH, RIF, EMB, and STR were 99%, 100%, 98%, and 96%, respectively. The times required to obtain results were between 5 and 28 days by the direct NRA and between 5 and 14 days by the indirect test. In conclusion, the present meta-analysis showed that the NRA is a reliable low-cost rapid colorimetric susceptibility test that can be used for the detection of multidrug-resistant (MDR) tuberculosis, including detection of EMB resistance. However, the test appears to have a relatively low sensitivity for STR and needs further improvement.

Evaluation of the Commercial Kit SIRE Nitratase for detecting resistant Mycobacterium tuberculosis in Brazil

“…The Kit SIRE Nitratase was easy to perform and provided an affordable alternative method for the rapid detection of resistance to first-line antituberculous drugs in the 40 clinical M. tuberculosis strains. The accuracy values determined in this study are similar to those reported by other studies using noncommercial NRA 2,4,8,11 . A recent meta-analysis 11 comprised of 38 studies showed that the SIRE Nitratase method exhibits high sensitivity and specificity in identifying isoniazid and rifampicin resistance 10 .…”

“…The accuracy values determined in this study are similar to those reported by other studies using noncommercial NRA 2,4,8,11 . A recent meta-analysis 11 comprised of 38 studies showed that the SIRE Nitratase method exhibits high sensitivity and specificity in identifying isoniazid and rifampicin resistance 10 . Both the sensitivity and specificity values for ethambutol (variation of 55%-75% and 75%, respectively) and streptomycin (variation of 92-100% and 78%-99%, respectively) 11 were lower in the present study.…”

“…Thus, studies evaluating the direct application of the SIRE Nitratase assay to sputum smear positive samples are necessary and will be performed in the near future. The turnaround time for results in our study (7-10 days) is consistent with the meta-analysis of noncommercial NRA studies conducted by Coban et al 11 , which found that the mean turnaround time for test results ranged from 5 to 14 days.…”

“…A recent meta-analysis 11 comprised of 38 studies showed that the SIRE Nitratase method exhibits high sensitivity and specificity in identifying isoniazid and rifampicin resistance 10 . Both the sensitivity and specificity values for ethambutol (variation of 55%-75% and 75%, respectively) and streptomycin (variation of 92-100% and 78%-99%, respectively) 11 were lower in the present study. Streptomycin and ethambutol have been established as drugs that are difficult to test by conventional methods 12 .…”

Performance of solid and liquid culture media for the detection of Mycobacterium tuberculosis in clinical materials: meta-analysis of recent studies

“…In addition, recent developments were noted during the literature review. For instance, a colourimetric nitrate reductase assay (NRA) performed quite well and with short turnaround times [3,4]. Also, changes of media when resistance testing is involved is worth considering: on Middlebrook 7H11, the detection of isoniazid and rifampicin resistance is more reliable than on LJ [5].…”