{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,22]],"date-time":"2026-01-22T06:58:21Z","timestamp":1769065101415,"version":"3.49.0"},"reference-count":35,"publisher":"Oxford University Press (OUP)","issue":"11","license":[{"start":{"date-parts":[[2025,10,14]],"date-time":"2025-10-14T00:00:00Z","timestamp":1760400000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,10,30]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>The World Health Organization (WHO) recommends stool as an alternative respiratory sample (RS) for diagnosing pulmonary tuberculosis (PTB) in children &amp;lt;10 years. This study assessed stool-Xpert-Ultra diagnostic performance against microbiologically confirmed (MC-PTB) cases identified based on the composite reference standard (CRS) in children &amp;lt;15 years, stratified by age and nutritional status.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Children &amp;lt;15 years with presumptive PTB were assessed at 2 tertiary-care hospitals in Pakistan. Stools and RS were tested using Xpert MTB\/RIF-Ultra (Xpert-Ultra) and culture. Using the CRS, PTB cases were MC-PTB or clinically confirmed. Nutritional status was classified using WHO criteria. Stool-Xpert-Ultra diagnostic performance was assessed against MC-PTB or positive RS-Xpert-Ultra. Logistic regression identified predictors of microbiological yields.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among 650 children, we obtained 587 RS, 258 stool and 195 both stool and RS. Of 650, 264 (41%) had MC and 136 (21%) had clinically confirmed PTB. Stool-Xpert-Ultra had sensitivity, specificity, and accuracy of 47%, 88%, 77%, and 72%, 73%, 72% against MC-PTB in children &amp;lt;10 and \u226510, respectively. Stool-Xpert-Ultra performed similarly against RS-Xpert-Ultra in each age group. Stool-Xpert-Ultra detected 11% additional MC-PTB cases when RS was negative or unavailable. Stool-Xpert-Ultra had high sensitivity (64%) in severely acute malnourished (SAM) children. Age \u226510, female, SAM and TB-consistent chest X-rays were strongly associated with stool and RS microbiological positivity.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Stool-Xpert-Ultra demonstrated moderate sensitivity against MC-PTB in &amp;lt;10. It identified additional MC-PTB cases when RS was unavailable or\/negative, making it a valuable noninvasive alternative, especially in children \u226510 and with SAM, where it missed fewer cases.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/ofid\/ofaf641","type":"journal-article","created":{"date-parts":[[2025,10,13]],"date-time":"2025-10-13T13:04:24Z","timestamp":1760360664000},"source":"Crossref","is-referenced-by-count":1,"title":["Evaluation of the Performance of Stool Samples to Diagnose Pediatric Pulmonary Tuberculosis in Routine Care: A Cohort Study From Pakistan"],"prefix":"10.1093","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5449-5147","authenticated-orcid":false,"given":"Brekhna","family":"Aurangzeb","sequence":"first","affiliation":[{"name":"Centre of International Health, Department of Global Public Health and Primary Care, University of Bergen , Bergen ,","place":["Norway"]},{"name":"Children's Hospital, Pakistan Institute of Medical Sciences , Islamabad ,","place":["Pakistan"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2165-4444","authenticated-orcid":false,"given":"Atiqa","family":"Ambreen","sequence":"additional","affiliation":[{"name":"Department of Microbiology, Gulab Devi Teaching Hospital , Lahore ,","place":["Pakistan"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-2114-1748","authenticated-orcid":false,"given":"Iqbal","family":"Bano","sequence":"additional","affiliation":[{"name":"Department of Pediatric Pulmonology, University of Child Health Sciences, the Children's Hospital , Lahore ,","place":["Pakistan"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0826-7485","authenticated-orcid":false,"given":"Huda","family":"Sarwar","sequence":"additional","affiliation":[{"name":"Department of Health Sciences, University of York , York ,","place":["UK"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-5426-6105","authenticated-orcid":false,"given":"Aneela","family":"Shaheen","sequence":"additional","affiliation":[{"name":"Department of Pediatric Medicine, Gulab Devi Teaching Hospital , Lahore ,","place":["Pakistan"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zunaira","family":"Rao","sequence":"additional","affiliation":[{"name":"Department of Microbiology, Gulab Devi Teaching Hospital , Lahore ,","place":["Pakistan"]},{"name":"Department of Primary and Secondary Health Care, Provincial TB Control Program Punjab , Lahore ,","place":["Pakistan"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Muhammad","family":"Usama","sequence":"additional","affiliation":[{"name":"Department of Microbiology, Gulab Devi Teaching Hospital , Lahore ,","place":["Pakistan"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-0419-3158","authenticated-orcid":false,"given":"Zaheer","family":"Akhtar","sequence":"additional","affiliation":[{"name":"Department of Pulmonology, Gulab Devi Teaching Hospital , Lahore ,","place":["Pakistan"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9720-5699","authenticated-orcid":false,"given":"Yasir Bin","family":"Nisar","sequence":"additional","affiliation":[{"name":"Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization , Geneva ,","place":["Switzerland"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9822-1191","authenticated-orcid":false,"given":"Tehmina","family":"Mustafa","sequence":"additional","affiliation":[{"name":"Centre of International Health, Department of Global Public Health and Primary Care, University of Bergen , Bergen ,","place":["Norway"]},{"name":"Department of Thoracic Medicine, Haukeland University Hospital , Bergen ,","place":["Norway"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2025,10,14]]},"reference":[{"key":"2025110312512361000_ofaf641-B1","volume-title":"Global tuberculosis report 2024","author":"World Health Organization","year":"2024"},{"key":"2025110312512361000_ofaf641-B2","doi-asserted-by":"crossref","first-page":"e898","DOI":"10.1016\/S2214-109X(17)30289-9","article-title":"The global burden of tuberculosis mortality in children: a mathematical modelling study","volume":"5","author":"Dodd","year":"2017","journal-title":"Lancet Glob Health"},{"key":"2025110312512361000_ofaf641-B3","doi-asserted-by":"crossref","first-page":"e16","DOI":"10.1016\/S2214-109X(23)00496-5","article-title":"Global, regional, and national causes of death in children and adolescents younger than 20 years: an open data portal with estimates for 2000\u201321","volume":"12","author":"Villavicencio","year":"2024","journal-title":"Lancet Glob Health"},{"key":"2025110312512361000_ofaf641-B4","first-page":"1","article-title":"Xpert MTB\/RIF ultra assay for tuberculosis disease and rifampicin resistance in children","author":"Kay","year":"2022","journal-title":"Cochrane Database Syst Rev"},{"key":"2025110312512361000_ofaf641-B5","doi-asserted-by":"crossref","first-page":"76","DOI":"10.1016\/S1473-3099(17)30691-6","article-title":"Xpert MTB\/RIF ultra for detection of Mycobacterium tuberculosis and rifampicin resistance: a prospective multicentre diagnostic accuracy study","volume":"18","author":"Dorman","year":"2018","journal-title":"Lancet Infect Dis"},{"key":"2025110312512361000_ofaf641-B6","volume-title":"WHO Operational handbook on tuberculosis. 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