Analysis of time-to-positivity data in tuberculosis treatment studies: Identifying a new limit of quantification

Abstract

AbstractThe BACTEC Mycobacteria Growth Indicator Tube (MGIT) machine is the standard globally for detecting viable mycobacteria in patients’ sputum. Samples are observed for no longer than 42 days, at which point the sample is declared “negative” for tuberculosis (TB). This time to detection of bacterial growth, referred to as time-to-positivity (TTP), is increasingly of interest not solely as a diagnostic tool, but as a continuous biomarker wherein change in TTP over time can be used for comparing the bactericidal activity of different TB treatments. However, as a continuous measure, there are oddities in the distribution of TTP values observed, particularly at higher values. We explored whether there is evidence to suggest setting an upper limit of quantification (ULOQM) lower than the diagnostic limit of detection (LOD) using data from several TB-PACTS randomized clinical trials and PanACEA MAMS-TB. Across all trials, less than 7.1% of all weekly samples returned TTP measurements between 25 and 42 days. Further, the relative absolute prediction error (%) was highest in this range. When modeling with ULOQMs of 25 and 30 days, the precision in estimation improved for 23 of 25 regimen-level slopes as compared to models using the diagnostic LOD while also improving the discrimination between regimens based on Bayesian posteriors. While TTP measurements between 25 days and the diagnostic LOD may be important for diagnostic purposes, TTP values in this range may not contribute meaningfully to its use as a quantitative measure, particularly when assessing treatment response, and may lead to under-powered clinical trials.HighlightsThe BACTEC Mycobacteria Growth Indicator Tube (MGIT) machine is the STAND, PaMZard globally for the detection and diagnosis of tuberculosis.As MGIT machine use becomes more ubiquitous, its time-to-positivity (TTP) measures are increasingly of interest as a continuous biomarker for evaluating bactericidal activity of TB treatment regimens.Using data from seven previously published trials, this work highlights the evidence for setting a limit of quantification for quantitative analyses that is below the diagnostic limit of detection. TTP values near the upper limit of detection appear to be noisier and sparser, with precision improving for estimation of 23 of 25 regimen-specific rates of change in TTP when analyzed with a lower limit of quantification.While TTP measurements between 25 days and the diagnostic LOD may be important for diagnostic purposes, TTP values in this range may not contribute meaningfully to its use as a quantitative measure, particularly when assessing early treatment response.