In many high TB burden settings, sputum-smear microscopy remains the primary diagnostic technique for evaluating individuals presenting with the signs and symptoms of TB. However, sputum-smear microscopy is a relatively insensitive test, with a limit of detection (LoD) of 5000-10 000 bacilli per millilitre of sputum. Furthermore, sputum-smear microscopy cannot distinguish drug-susceptible strains from drug-resistant strains. WHO recommends that TB programmes transition to replacing microscopy as the initial diagnostic test with mWRDs that detect MTBC.
The current gold standard method for the bacteriological confirmation of TB is culture using commercially available liquid media. However, culture is not used as a primary diagnostic test in many high-burden countries because of the cost, the infrastructure requirements (biosafety level 3 [BSL-3] or TB containment laboratory) and the long time required to generate results (1-3 weeks for a positive result and up to 6 weeks for a negative result). Nonetheless, conventional microscopy and culture remain necessary to monitor a patient's response to treatment. Culture is still important in the diagnosis of paediatric and extrapulmonary TB from paucibacillary samples, and in the differential diagnosis of non-tuberculous mycobacteria (NTM) infection.