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BACKGROUND: In 2023, an estimated 1.3 million children (aged 0-14 years) became ill with tuberculosis, and 166,000 children (aged 0-15 years) died from the disease. Xpert MTB/RIF Ultra (Xpert Ultra) is a molecular World Health Organization (WHO)-recommended rapid diagnostic test that detects Mycobacterium tuberculosis complex and rifampicin resistance. This is an update of a Cochrane review first published in 2020 and last updated in 2022. Parts of the current update informed the 2024 WHO updated guidance for the diagnosis of tuberculosis. OBJECTIVES: To assess the diagnostic accuracy of Xpert Ultra for detecting pulmonary tuberculosis, tuberculous meningitis, lymph node tuberculosis, and rifampicin resistance in children (aged 0-9 years) with presumed tuberculosis. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, three other databases, and three trial registers without language restrictions to 6 October 2023. SELECTION CRITERIA: For study design, we included cross-sectional and cohort studies and randomized trials that evaluated Xpert Ultra in HIV-positive and HIV-negative children aged birth to nine years. Regarding specimen type, we included studies evaluating sputum, gastric, stool, or nasopharyngeal specimens (pulmonary tuberculosis); cerebrospinal fluid (tuberculous meningitis); and fine needle aspirate or surgical biopsy tissue (lymph node tuberculosis). Reference standards for detection of tuberculosis were microbiological reference standard (MRS; including culture) or composite reference standard (CRS); for stool, we considered Xpert Ultra in sputum or gastric aspirates in addition to culture. Reference standards for detection of rifampicin resistance in sputum were phenotypic drug susceptibility testing or targeted or whole genome sequencing. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed methodological quality using the tailored QUADAS-2 tool, judging risk of bias separately for each target condition and sample type. We conducted separate meta-analyses for detection of pulmonary tuberculosis, tuberculous meningitis, lymph node tuberculosis, and rifampicin resistance. We used a bivariate model to estimate summary sensitivity and specificity with 95% confidence intervals (CIs). We assessed certainty of evidence using the GRADE approach. MAIN RESULTS: This update included 23 studies (including 9 new studies since the previous review) that evaluated detection of pulmonary tuberculosis (21 studies, 9223 children), tuberculous meningitis (3 studies, 215 children), lymph node tuberculosis (2 studies, 58 children), and rifampicin resistance (3 studies, 130 children). Seventeen studies (74%) took place in countries with a high tuberculosis burden. Overall, risk of bias and applicability concerns were low. Detection of pulmonary tuberculosis (microbiological reference standard) Sputum (11 studies) Xpert Ultra summary sensitivity was 75.3% (95% CI 68.9% to 80.8%; 345 children; moderate-certainty evidence), and specificity was 95.9% (95% CI 92.3% to 97.9%; 2645 children; high-certainty evidence). Gastric aspirate (12 studies) Xpert Ultra summary sensitivity was 69.6% (95% CI 60.3% to 77.6%; 167 children; moderate-certainty evidence), and specificity was 91.0% (95% CI 82.5% to 95.6%; 1792 children; moderate-certainty evidence). Stool (10 studies) Xpert Ultra summary sensitivity was 68.0% (95% CI 50.3% to 81.7%; 255 children; moderate-certainty evidence), and specificity was 98.2% (95% CI 96.3% to 99.1%; 2630 children; high-certainty evidence). Nasopharyngeal aspirate (6 studies) Xpert Ultra summary sensitivity was 46.2% (95% CI 34.9% to 57.9%; 94 children; moderate-certainty evidence), and specificity was 97.5% (95% CI 95.1% to 98.7%; 1259 children; high-certainty evidence). Xpert Ultra sensitivity was lower against CRS than against MRS for all specimen types, while the specificities were similar. Extrapulmonary tuberculosis Meta-analysis was not possible for lymph node tuberculosis and tuberculous meningitis due to low study numbers. Interpretation of results For a population of 1000 children, where 100 have pulmonary tuberculosis: In sputum: • 112 would be Xpert Ultra positive, of whom 75 would have pulmonary tuberculosis (true positives) and 37 would not (false positives). • 888 would be Xpert Ultra negative, of whom 863 would not have pulmonary tuberculosis (true negatives) and 25 would have pulmonary tuberculosis (false negatives). In gastric aspirate: • 151 would be Xpert Ultra positive, of whom 70 would have pulmonary tuberculosis (true positives) and 81 would not (false positives). • 849 would be Xpert Ultra negative, of whom 819 would not have pulmonary tuberculosis (true negatives) and 30 would have pulmonary tuberculosis (false negatives). In stool: • 85 would be Xpert Ultra positive, of whom 68 would have pulmonary tuberculosis (true positives) and 17 would not (false positives). • 915 would be Xpert Ultra negative, of whom 883 would not have pulmonary tuberculosis (true negatives) and 32 would have pulmonary tuberculosis (false negatives). In nasopharyngeal aspirate: • 68 would be Xpert Ultra positive, of whom 46 would have pulmonary tuberculosis (true positives) and 22 would not (false positives). • 932 would be Xpert Ultra negative, of whom 878 would not have pulmonary tuberculosis (true negatives), and 54 would have pulmonary tuberculosis (false negatives). Detection of rifampicin resistance Three studies with 76 children evaluated detection of rifampicin resistance (sputum only); two of these studies reported no cases and one reported rifampicin resistance in two children. AUTHORS' CONCLUSIONS: Xpert Ultra sensitivity was moderate in sputum, gastric aspirate, and stool specimens. Nasopharyngeal aspirate had the lowest sensitivity. Xpert Ultra specificity was high against both MRS and CRS. We were unable to determine the accuracy of Xpert Ultra for detecting tuberculous meningitis, lymph node tuberculosis, and rifampicin resistance due to a paucity of data. FUNDING: This update was funded through WHO. REGISTRATION: The protocol for this review was originally published through Cochrane in 2019. The protocol for this update was a generic protocol that consolidated previously published Cochrane protocols of Xpert Ultra for tuberculosis detection and can be accessed at https://osf.io/26wg7/. Protocol (2019) DOI: 10.1002/14651858.CD013359 Original review (2020) DOI: 10.1002/14651858.CD013359.pub2 Review update (2022) DOI: 10.1002/14651858.CD013359.pub3.

BACKGROUND: Every year, an estimated one million children and young adolescents become ill with tuberculosis, and around 226,000 of those children die. Xpert MTB/RIF Ultra (Xpert Ultra) is a molecular World Health Organization (WHO)-recommended rapid diagnostic test that simultaneously detects Mycobacterium tuberculosis complex and rifampicin resistance. We previously published a Cochrane Review 'Xpert MTB/RIF and Xpert MTB/RIF Ultra assays for tuberculosis disease and rifampicin resistance in children'. The current review updates evidence on the diagnostic accuracy of Xpert Ultra in children presumed to have tuberculosis disease. Parts of this review update informed the 2022 WHO updated guidance on management of tuberculosis in children and adolescents. OBJECTIVES: To assess the diagnostic accuracy of Xpert Ultra for detecting: pulmonary tuberculosis, tuberculous meningitis, lymph node tuberculosis, and rifampicin resistance, in children with presumed tuberculosis. Secondary objectives To investigate potential sources of heterogeneity in accuracy estimates. For detection of tuberculosis, we considered age, comorbidity (HIV, severe pneumonia, and severe malnutrition), and specimen type as potential sources. To summarize the frequency of Xpert Ultra trace results. SEARCH METHODS: We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, three other databases, and three trial registers without language restrictions to 9 March 2021. SELECTION CRITERIA: Cross-sectional and cohort studies and randomized trials that evaluated Xpert Ultra in HIV-positive and HIV-negative children under 15 years of age. We included ongoing studies that helped us address the review objectives. We included studies evaluating sputum, gastric, stool, or nasopharyngeal specimens (pulmonary tuberculosis), cerebrospinal fluid (tuberculous meningitis), and fine needle aspirate or surgical biopsy tissue (lymph node tuberculosis). For detecting tuberculosis, reference standards were microbiological (culture) or composite reference standard; for stool, we also included Xpert Ultra performed on a routine respiratory specimen. For detecting rifampicin resistance, reference standards were drug susceptibility testing or MTBDRplus. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and, using QUADAS-2, assessed methodological quality judging risk of bias separately for each target condition and reference standard. For each target condition, we used the bivariate model to estimate summary sensitivity and specificity with 95% confidence intervals (CIs). We stratified all analyses by type of reference standard. We summarized the frequency of Xpert Ultra trace results; trace represents detection of a very low quantity of Mycobacterium tuberculosis DNA. We assessed certainty of evidence using GRADE. MAIN RESULTS: We identified 14 studies (11 new studies since the previous review). For detection of pulmonary tuberculosis, 335 data sets (25,937 participants) were available for analysis. We did not identify any studies that evaluated Xpert Ultra accuracy for tuberculous meningitis or lymph node tuberculosis. Three studies evaluated Xpert Ultra for detection of rifampicin resistance. Ten studies (71%) took place in countries with a high tuberculosis burden based on WHO classification. Overall, risk of bias was low. Detection of pulmonary tuberculosis Sputum, 5 studies Xpert Ultra summary sensitivity verified by culture was 75.3% (95% CI 64.3 to 83.8; 127 participants; high-certainty evidence), and specificity was 97.1% (95% CI 94.7 to 98.5; 1054 participants; high-certainty evidence). Gastric aspirate, 7 studies Xpert Ultra summary sensitivity verified by culture was 70.4% (95% CI 53.9 to 82.9; 120 participants; moderate-certainty evidence), and specificity was 94.1% (95% CI 84.8 to 97.8; 870 participants; moderate-certainty evidence). Stool, 6 studies Xpert Ultra summary sensitivity verified by culture was 56.1% (95% CI 39.1 to 71.7; 200 participants; moderate-certainty evidence), and specificity was 98.0% (95% CI 93.3 to 99.4; 1232 participants; high certainty-evidence). Nasopharyngeal aspirate, 4 studies Xpert Ultra summary sensitivity verified by culture was 43.7% (95% CI 26.7 to 62.2; 46 participants; very low-certainty evidence), and specificity was 97.5% (95% CI 93.6 to 99.0; 489 participants; high-certainty evidence). Xpert Ultra sensitivity was lower against a composite than a culture reference standard for all specimen types other than nasopharyngeal aspirate, while specificity was similar against both reference standards. Interpretation of results In theory, for a population of 1000 children: • where 100 have pulmonary tuberculosis in sputum (by culture): - 101 would be Xpert Ultra-positive, and of these, 26 (26%) would not have pulmonary tuberculosis (false positive); and - 899 would be Xpert Ultra-negative, and of these, 25 (3%) would have tuberculosis (false negative). • where 100 have pulmonary tuberculosis in gastric aspirate (by culture): - 123 would be Xpert Ultra-positive, and of these, 53 (43%) would not have pulmonary tuberculosis (false positive); and - 877 would be Xpert Ultra-negative, and of these, 30 (3%) would have tuberculosis (false negative). • where 100 have pulmonary tuberculosis in stool (by culture): - 74 would be Xpert Ultra-positive, and of these, 18 (24%) would not have pulmonary tuberculosis (false positive); and - 926 would be Xpert Ultra-negative, and of these, 44 (5%) would have tuberculosis (false negative). • where 100 have pulmonary tuberculosis in nasopharyngeal aspirate (by culture): - 66 would be Xpert Ultra-positive, and of these, 22 (33%) would not have pulmonary tuberculosis (false positive); and - 934 would be Xpert Ultra-negative, and of these, 56 (6%) would have tuberculosis (false negative). Detection of rifampicin resistance Xpert Ultra sensitivity was 100% (3 studies, 3 participants; very low-certainty evidence), and specificity range was 97% to 100% (3 studies, 128 participants; low-certainty evidence). Trace results Xpert Ultra trace results, regarded as positive in children by WHO standards, were common. Xpert Ultra specificity remained high in children, despite the frequency of trace results. AUTHORS' CONCLUSIONS: We found Xpert Ultra sensitivity to vary by specimen type, with sputum having the highest sensitivity, followed by gastric aspirate and stool. Nasopharyngeal aspirate had the lowest sensitivity. Xpert Ultra specificity was high against both microbiological and composite reference standards. However, the evidence base is still limited, and findings may be imprecise and vary by study setting. Although we found Xpert Ultra accurate for detection of rifampicin resistance, results were based on a very small number of studies that included only three children with rifampicin resistance. Therefore, findings should be interpreted with caution. Our findings provide support for the use of Xpert Ultra as an initial rapid molecular diagnostic in children being evaluated for tuberculosis.