Clinical Relevance of Trace-Positive Results in Xpert MTB/RIF Ultra for Tuberculosis Diagnosis in a High-Burden Setting: A Retrospective Cohort Study

<b>Background</b>: The introduction of the "trace" category in the Xpert MTB/RIF Ultra assay has significantly improved the sensitivity of molecular tuberculosis diagnostics. While it enhances sensitivity, especially in paucibacillary and extrapulmonary cases, its specificity remains debatable, making its interpretation outside select populations a topic of clinical uncertainty. <b>Objectives</b>: This study evaluates the diagnostic and clinical significance of trace-positive results obtained with the Xpert MTB/RIF Ultra assay in the context of a high-incidence TB setting, examining their association with clinical, imaging, and microbiological findings. <b>Methods</b>: A retrospective analysis was conducted on 65 samples with trace-positive Xpert Ultra results, collected over a six-year period from 59 distinct patients in a general hospital in Romania. Correlations were assessed with microscopy, culture, clinical features, imaging, treatment initiation, and prior TB history. A composite reference standard was used for diagnostic accuracy evaluation. <b>Results</b>: Of the 65 trace-positive samples, 29 (44.6%) were culture-positive and 5 (7.7%) were smear-positive. A high proportion of patients, 56 (94.9%), presented with TB-compatible symptoms, and 47 (79.6% of those with imaging) had highly suggestive radiological findings. Based on the composite reference standard, 47 patients (79.7%) were ultimately diagnosed with active TB. Anti-TB treatment was initiated in 44 patients (74.5%). Trace positivity was observed across various specimen types, including sputum, pleural fluid, and cerebrospinal fluid. <b>Conclusions</b>: In high TB burden environments, trace-positive Xpert Ultra results frequently reflect true disease when interpreted within the appropriate clinical and imaging framework. Our findings indicate that, in regions with high tuberculosis incidence such as Romania, trace-positive Xpert Ultra results may contribute meaningfully to clinical decision-making when interpreted alongside clinical and radiological findings, in alignment with current WHO guidance.