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Pumiglia L, Wilson L, Rashidi L. Clostridioides difficile Colitis. Surg Clin North Am 2024; 104:545-556. [PMID: 38677819 DOI: 10.1016/j.suc.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
Clostridioides difficile colitis is an important source of hospital-acquired diarrhea associated with antibiotic use. Symptoms are profuse watery diarrhea, typically following a course of antibiotics; however, some cases of fulminant disease may manifest with shock, ileus, or megacolon. Nonfulminant colitis is treated with oral fidaxomicin. C difficile colitis has a high potential for recurrence, and recurrent episodes are also treated with fidaxomicin. Bezlotoxumab is another medication that may be used in populations at high risk for further recurrence. Fulminant disease is treated with maximal medical therapy and early surgical consultation. Antibiotic stewardship is critical to preventing C difficile colitis.
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Affiliation(s)
- Luke Pumiglia
- Department of General Surgery, Madigan Army Medical Center, 9040 Jackson Avenue, Joint Base Lewis-McChord, WA 98431, USA
| | - Lexi Wilson
- Department of Colorectal Surgery, Swedish Medical Center, 747 Broadway, Seattle, WA 98122, USA
| | - Laila Rashidi
- Department of Surgery, MultiCare Health Care System, Washington State University, 3124 19th Street Suite 220, Tacoma, WA 98405, USA.
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Markantonis JE, Fallon JT, Madan R, Alam MZ. Clostridioides difficile Infection: Diagnosis and Treatment Challenges. Pathogens 2024; 13:118. [PMID: 38392856 PMCID: PMC10891949 DOI: 10.3390/pathogens13020118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/25/2024] Open
Abstract
Clostridioides difficile is the most important cause of healthcare-associated diarrhea in the United States. The high incidence and recurrence rates of C. difficile infection (CDI), associated with high morbidity and mortality, pose a public health challenge. Although antibiotics targeting C. difficile bacteria are the first treatment choice, antibiotics also disrupt the indigenous gut flora and, therefore, create an environment that is favorable for recurrent CDI. The challenge of treating CDI is further exacerbated by the rise of antibiotic-resistant strains of C. difficile, placing it among the top five most urgent antibiotic resistance threats in the USA. The evolution of antibiotic resistance in C. difficile involves the acquisition of new resistance mechanisms, which can be shared among various bacterial species and different C. difficile strains within clinical and community settings. This review provides a summary of commonly used diagnostic tests and antibiotic treatment strategies for CDI. In addition, it discusses antibiotic treatment and its resistance mechanisms. This review aims to enhance our current understanding and pinpoint knowledge gaps in antimicrobial resistance mechanisms in C. difficile, with an emphasis on CDI therapies.
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Affiliation(s)
- John E. Markantonis
- Department of Pathology and Laboratory Medicine, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Greenville, NC 27834, USA; (J.E.M.); (J.T.F.)
| | - John T. Fallon
- Department of Pathology and Laboratory Medicine, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Greenville, NC 27834, USA; (J.E.M.); (J.T.F.)
| | - Rajat Madan
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA;
- Veterans Affairs Medical Center, Cincinnati, OH 45220, USA
| | - Md Zahidul Alam
- Department of Pathology and Laboratory Medicine, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Greenville, NC 27834, USA; (J.E.M.); (J.T.F.)
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Adukauskienė D, Mickus R, Dambrauskienė A, Vanagas T, Adukauskaitė A. Improving Clostridioides difficile Infectious Disease Treatment Response via Adherence to Clinical Practice Guidelines. Antibiotics (Basel) 2024; 13:51. [PMID: 38247610 PMCID: PMC10812669 DOI: 10.3390/antibiotics13010051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/29/2023] [Accepted: 01/02/2024] [Indexed: 01/23/2024] Open
Abstract
Clostridioides difficile (C. difficile) is a predominant nosocomial infection, and guidelines for improving diagnosis and treatment were published in 2017. We conducted a single-center, retrospective 10-year cohort study of patients with primary C. difficile infectious disease (CDID) at the largest referral Lithuanian university hospital, aiming to evaluate the clinical and laboratory characteristics of CDID and their association with the outcomes, as well as implication of concordance with current Clinical Practice Guidelines. The study enrolled a total of 370 patients. Cases with non-concordant CDID treatment resulted in more CDID-related Intensive Care Unit (ICU) admissions (7.5 vs. 1.8%) and higher CDID-related mortality (13.0 vs. 1.8%) as well as 30-day all-cause mortality (61.0 vs. 36.1%) and a lower 30-day survival compared with CDID cases with concordant treatment (p < 0.05). Among cases defined by two criteria for severe CDID, only patients with non-concordant metronidazole treatment had refractory CDID (68.8 vs. 0.0%) compared with concordant vancomycin treatment. In the presence of non-concordant metronidazole treatment for severe CDID, only cases defined by two severity criteria had more CDID-related ICU admissions (18.8 vs. 0.0%) and higher CDID-related mortality (25.0 vs. 2.0%, p < 0.05) compared with cases defined by one criterion. Severe comorbidities and the continuation of concomitant antibiotics administered at CDID onset reduced (p < 0.05) the 30-day survival and increased (p = 0.053) 30-day all-cause mortality, with 57.6 vs. 10.7% and 52.0 vs. 25.0%, respectively. Conclusions: CDID treatment non-concordant with the guidelines was associated with various adverse outcomes. In CDID with leukocytes ≥ 15 × 109/L and serum creatinine level > 133 µmol/L (>1.5 mg/dL), enteral vancomycin should be used to avoid refractory response, as metronidazole use was associated with CDID-related ICU admission and CDID-related mortality. Severe comorbidities worsened the outcomes as they were associated with reduced 30-day survival. The continuation of concomitant antibiotic therapy increased 30-day all-cause mortality; thus, it needs to be reasonably justified, deescalated or stopped.
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Affiliation(s)
- Dalia Adukauskienė
- Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (A.D.); (T.V.)
| | - Rytis Mickus
- Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (A.D.); (T.V.)
| | - Asta Dambrauskienė
- Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (A.D.); (T.V.)
| | - Tomas Vanagas
- Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (A.D.); (T.V.)
| | - Agnė Adukauskaitė
- Department of Cardiology and Angiology, University Hospital of Innsbruck, 6020 Innsbruck, Austria;
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Maestri AC, Nogueira KS, Mialski R, Dos Santos EM, Kraft L, Raboni SM. Laboratory diagnosis of Clostridioides difficile infection in symptomatic patients: what can we do better? Braz J Microbiol 2023; 54:849-857. [PMID: 36991280 PMCID: PMC10234961 DOI: 10.1007/s42770-023-00956-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 03/20/2023] [Indexed: 03/31/2023] Open
Abstract
The laboratory diagnosis of Clostridioides difficile infection (CDI) is challenging since this bacteria may be detected in healthy people and toxin production detection is not sensitive enough to be used alone. Thus, there is no single test with adequate sensitivity and specificity to be used in laboratory diagnosis. We evaluated the performance of tests used in the diagnosis of CDI in symptomatic patients with risk factors in hospitals in southern Brazil. Enzyme immunoassays (EIA) for glutamate dehydrogenase antigen (GDH) and toxins A/B, real-time polymerase chain reaction (qPCR), GeneXpert system, and a two-step algorithm comprising GDH/TOXIN EIA performed simultaneously followed by GeneXpert for outliers were evaluated. Toxigenic strain in stool culture was considered CDI positive (gold standard). Among 400 samples tested, 54 (13.5%) were positive for CDI and 346 (86.5%) were negative. The diagnosis of the two-step algorithm and qPCR had an excellent performance with an accuracy of 94.5% and 94.2%, respectively. The Youden index showed that GeneXpert as a single test (83.5%) and the two-step algorithm (82.8%) were the most effective assays. Diagnosing CDI and non-CDI diarrhea could be successfully attained by the combination of clinical data with accuracy of laboratory tests.
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Affiliation(s)
- Adriane C Maestri
- , Laboratório de Bacteriologia, Complexo Hospital de Clínicas da Universidade Federal do Paraná, Rua Padre Camargo, 280-Alto da Glória, CEP: 80.062-240, Curitiba, Paraná, Brazil
- Programa de Pós-Graduação em Medicina Interna e Ciências da Saúde, Universidade Federal do Paraná, Rua General Carneiro, 181-Alto da Glória, CEP-80060-900, Curitiba, Paraná, Brazil
| | - Keite S Nogueira
- , Laboratório de Bacteriologia, Complexo Hospital de Clínicas da Universidade Federal do Paraná, Rua Padre Camargo, 280-Alto da Glória, CEP: 80.062-240, Curitiba, Paraná, Brazil
- Departamento de Patologia Básica, Universidade Federal do Paraná, Centro Politecnico, Av. Cel. Francisco H. dos Santos, 100-Jardim das Americas, CEP-81531-980, Curitiba, Paraná, Brazil
| | - Rafael Mialski
- Departamento de Infectologia, Complexo Hospital de Clínicas da Universidade Federal do Paraná, Rua General Carneiro, 181-Alto da Glória, CEP-80060-900, Curitiba, Paraná, Brazil
| | - Erika Medeiros Dos Santos
- Hospital Pequeno Principe, Rua Desembargador Motta, 1070-Agua Verde, Curitiba-PR, 80250-060, Brazil
- Instituto de Pesquisa Pele Pequeno Principe, Av. Silva Jardim, 1632-Agua Verde, Curitiba-PR, 80250-060, Brazil
| | - Leticia Kraft
- Hospital Pequeno Principe, Rua Desembargador Motta, 1070-Agua Verde, Curitiba-PR, 80250-060, Brazil
| | - Sonia M Raboni
- Programa de Pós-Graduação em Medicina Interna e Ciências da Saúde, Universidade Federal do Paraná, Rua General Carneiro, 181-Alto da Glória, CEP-80060-900, Curitiba, Paraná, Brazil.
- Departamento de Infectologia, Complexo Hospital de Clínicas da Universidade Federal do Paraná, Rua General Carneiro, 181-Alto da Glória, CEP-80060-900, Curitiba, Paraná, Brazil.
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Peters H, Iqbal A, Miller E, Khalid S, Rahman O. Outcomes of Continuous Enteral Vancomycin Infusion in Intensive Care Unit Patients: A Novel Treatment Modality for Severe Clostridium Difficile Colitis. Cureus 2022; 14:e22872. [PMID: 35392442 PMCID: PMC8979637 DOI: 10.7759/cureus.22872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background and objective Severe Clostridium difficile (C. difficile) infection (CDI)-related colitis is associated with high morbidity and mortality. Current guidelines recommend oral vancomycin plus intravenous metronidazole as the first-line treatment and early total colectomy in case of medication failure. In critically ill patients at high surgical risk and with multiple comorbidities, loop ileostomy creation and enteral vancomycin infusion have been employed albeit with limited success. We hypothesized that continuous enteral vancomycin (CEV) infusion via a postpyloric feeding tube would provide a less invasive, efficacious, and safer route to treat high surgical risk patients. Methods All adult (>18 years) non-pregnant patients admitted to the ICU for severe CDI from October 2012 to October 2016 and received CEV after the failure of conventional therapy were included. Vancomycin was prepared as a 1-2-mg/ml enteral solution and run continuously through a feeding pump at 42 ml/hour via a post-pyloric feeding tube. The primary efficacy endpoint was clinical improvement defined as (a) decrease in stool output, (b) decreased vasopressor requirement, or (c) improved leukocytosis, and the secondary endpoint was treatment failure defined as the need for total colectomy or death due to severe CDI. Results Our cohort comprised 11 patients in total. The median age of the participants was 64 years, and there were more females (67%) than males (36%). Clinical improvement was seen in seven patients (63%); treatment failure documented as the need for total colectomy was observed in two patients (18%), and death attributable to CDI occurred in three patients (27%). Conclusion CEV resulted in clinical improvement in most patients with severe CDI who were at high surgical risk. Sustained intestinal vancomycin delivery may increase luminal concentration and bactericidal effect. The use of a feeding tube and pump provides an effective and less invasive route of vancomycin delivery in critically ill patients.
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Affiliation(s)
- Haley Peters
- Critical Care Pharmacy, Indiana University Health, Indianapolis, USA
| | - Arslan Iqbal
- Critical Care Medicine, Indiana University School of Medicine, Indianapolis, USA
| | - Emily Miller
- Department of Pharmacy, Indiana University Health, Indianapolis, USA
| | - Sana Khalid
- Critical Care, Indiana University Health, Indianapolis, USA
| | - Omar Rahman
- Pulmonary & Critical Care, Indiana University School of Medicine, Indianapolis, USA
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Phenotypical and Genotypical Comparison of Clostridium difficile Isolated from Clinical Samples: Homebrew DNA Fingerprinting versus Antibiotic Susceptibility Testing (AST) and Clostridial Toxin Genes. CANADIAN JOURNAL OF INFECTIOUS DISEASES AND MEDICAL MICROBIOLOGY 2021; 2021:7386554. [PMID: 34900067 PMCID: PMC8660249 DOI: 10.1155/2021/7386554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 10/30/2021] [Accepted: 11/03/2021] [Indexed: 11/18/2022]
Abstract
Background Clostridium (Clostridioides) difficile is recognized as the major cause of healthcare antibiotic-associated diarrhea. We surveyed a molecular epidemiological correlation between the clinical isolates from two general hospitals in Iran through clustering toxigenic types and antibiotic susceptibility testing (AST) accuracy. Methods Study population included 460 diarrhoeic specimens from inpatients with a history of antibiotic therapy. All samples underwent enriched anaerobic culture, confirmed by detection of gluD gene with PCR. Toxin status and AST were assessed by the disk diffusion method (DDM) and minimal inhibitory concentrations (MICs) of metronidazole, vancomycin, and rifampin. C. difficile outbreak was analyzed through conventional PCR by tracing toxin genes and Homebrew pulsed-field gel electrophoresis (PFGE) for characterizing isolates within our healthcare systems. Results A total of 29 C. difficile strains were isolated by enriched anaerobic culture from the clinical samples. Among them, 22 (4.8%) toxigenic profiles yielded toxins A and B (tcdA, tcdB) and binary toxins (cdtA, cdtB). The minimum inhibitory concentration (MIC) was 18.1% and 9% for vancomycin and metronidazole, and all isolates were susceptible to rifampicin and its minimum inhibitory concentration was at <0.003 μg/mL. The most dominant toxigenic and antibiotic-resistant “pulsotype F” was detected through PFGE combined with multiple Clostridial toxigenic pattern and AST. Conclusions DNA fingerprinting studies represent a powerful tool in surveying hypervirulent C. difficile strains in clinical settings. Resistance to vancomycin and metronidazole, as first-line antibiotics, necessitate accomplishment of proper control strategies and also prescription of tigecycline as a more appropriate option.
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Markovic S, Jankovic M, Kalaba A, Zogovic B, Sreckovic SS. Infliximab Rescue in Acute Severe Ulcerative Colitis Complicated by Clostridium Difficile Infection: A Case Series. Cureus 2021; 13:e19019. [PMID: 34824934 PMCID: PMC8611478 DOI: 10.7759/cureus.19019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2021] [Indexed: 11/05/2022] Open
Abstract
Relapses in inflammatory bowel disease (IBD) complicated by Clostridium difficile infection (CDI) are associated with significant morbidity and mortality. CDI can exacerbate the course of IBD and may result in prolonged hospitalizations, admissions to intensive care, surgical interventions, or even death. Early detection and aggressive treatment with systemic corticosteroids or biologics such as infliximab are often needed in severe presentations. Five cases of relapsed ulcerative colitis complicated by fulminant CDI were retrospectively reviewed. Biological therapy with infliximab was initiated upon multidisciplinary team assessment as the cases were resistant to standard IBD therapy. All five patients improved clinically and avoided early surgical intervention. Some required prolonged therapy with infliximab to achieve remission. Early recognition of CDI and aggressive therapy with biologics may be required to avoid complications in the IBD patients experiencing a relapse. Infliximab therapy should be considered early on, especially where the disease is resistant to standard therapy.
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Affiliation(s)
- Srdjan Markovic
- Gastroenterology and Hepatology, University Hospital Medical Center "Zvezdara", Belgrade, SRB
| | - Marijana Jankovic
- Gastroenterology and Hepatology, University Hospital Medical Center "Zvezdara", Belgrade, SRB
| | - Ana Kalaba
- Gastroenterology and Hepatology, University Hospital Medical Center "Zvezdara", Belgrade, SRB
| | - Branimir Zogovic
- Department of General Surgery, Royal Prince Alfred Hospital, New South Wales, AUS
| | - Slobodan S Sreckovic
- Gastroenterology and Hepatology, University Hospital Medical Center "Zvezdara", Belgrade, SRB
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Clinical Significance of Toxigenic Clostridioides difficile Growth in Stool Cultures during the Era of Nonculture Methods for the Diagnosis of C. difficile Infection. Microbiol Spectr 2021; 9:e0079921. [PMID: 34668727 PMCID: PMC8528117 DOI: 10.1128/spectrum.00799-21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The importance of the detection of relevant toxins or toxin genes to diagnose Clostridioides difficile infection (CDI) or the prediction of clinical outcomes of CDI has been emphasized in recent years. Although stool culture of C. difficile is not routinely recommended in the era of nonculture methods as the preferred tools for CDI diagnosis, the clinical significance of toxigenic C. difficile growth (tCdG) in stool cultures was analyzed. A clinical study was conducted in medical wards of Tainan Hospital, Ministry of Health and Welfare, in southern Taiwan. Diarrheal adults with fecal glutamate dehydrogenase and C. difficile toxin between January 2013 and April 2020 were included. Of the 209 patients with CDI, 158 (75.6%) had tCdG found in stool cultures, and the rest (51, 24.4%) had no tCdG in stool. Only prior ceftazidime or ceftriaxone therapy was independently associated with no tCdG in stool (odds ratio [OR] 2.17, P = 0.02). Compared to the patients with tCDG in stool, those without tCdG in stool experienced treatment success more often (97.1% versus 67.0%, P < 0.001) if treated with metronidazole or vancomycin but had a similar in-hospital mortality or recurrence rate. In the multivariate analysis among 114 patients with CDI treated with metronidazole or vancomycin, treatment success was independently associated with no tCdG in stool (OR 12.7, P = 0.02). Despite the limited utility of stool cultures in CDI diagnoses, no tCdG in stool culture heralds a favorable therapeutic outcome among adults with CDI treated with metronidazole or vancomycin. IMPORTANCE The importance of detecting toxins or toxin genes when diagnosing Clostridioides difficile infections (CDIs) or predicting the severity and outcomes of CDI has been emphasized in recent years. Although the yielding of C. difficile from stool cultures might implicate higher bacterial loads in fecal samples, in an era of nonculture methods for the standard diagnosis of CDIs, clinical significance of positive stool cultures of toxigenic C. difficile was analyzed in this study. Despite the limited ability of stool cultures in CDI diagnoses, no yielding of C. difficile growth might predict the successful CDI therapy.
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Bouza E, Aguado JM, Alcalá L, Almirante B, Alonso-Fernández P, Borges M, Cobo J, Guardiola J, Horcajada JP, Maseda E, Mensa J, Merchante N, Muñoz P, Pérez Sáenz JL, Pujol M, Reigadas E, Salavert M, Barberán J. Recommendations for the diagnosis and treatment of Clostridioides difficile infection: An official clinical practice guideline of the Spanish Society of Chemotherapy (SEQ), Spanish Society of Internal Medicine (SEMI) and the working group of Postoperative Infection of the Spanish Society of Anesthesia and Reanimation (SEDAR). REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2020; 33:151-175. [PMID: 32080996 PMCID: PMC7111242 DOI: 10.37201/req/2065.2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/26/2020] [Indexed: 12/12/2022]
Abstract
This document gathers the opinion of a multidisciplinary forum of experts on different aspects of the diagnosis and treatment of Clostridioides difficile infection (CDI) in Spain. It has been structured around a series of questions that the attendees considered relevant and in which a consensus opinion was reached. The main messages were as follows: CDI should be suspected in patients older than 2 years of age in the presence of diarrhea, paralytic ileus and unexplained leukocytosis, even in the absence of classical risk factors. With a few exceptions, a single stool sample is sufficient for diagnosis, which can be sent to the laboratory with or without transportation media for enteropathogenic bacteria. In the absence of diarrhoea, rectal swabs may be valid. The microbiology laboratory should include C. difficile among the pathogens routinely searched in patients with diarrhoea. Laboratory tests in different order and sequence schemes include GDH detection, presence of toxins, molecular tests and toxigenic culture. Immediate determination of sensitivity to drugs such as vancomycin, metronidazole or fidaxomycin is not required. The evolution of toxin persistence is not a suitable test for follow up. Laboratory diagnosis of CDI should be rapid and results reported and interpreted to clinicians immediately. In addition to the basic support of all diarrheic episodes, CDI treatment requires the suppression of antiperistaltic agents, proton pump inhibitors and antibiotics, where possible. Oral vancomycin and fidaxomycin are the antibacterials of choice in treatment, intravenous metronidazole being restricted for patients in whom the presence of the above drugs in the intestinal lumen cannot be assured. Fecal material transplantation is the treatment of choice for patients with multiple recurrences but uncertainties persist regarding its standardization and safety. Bezlotoxumab is a monoclonal antibody to C. difficile toxin B that should be administered to patients at high risk of recurrence. Surgery is becoming less and less necessary and prevention with vaccines is under research. Probiotics have so far not been shown to be therapeutically or preventively effective. The therapeutic strategy should be based, rather than on the number of episodes, on the severity of the episodes and on their potential to recur. Some data point to the efficacy of oral vancomycin prophylaxis in patients who reccur CDI when systemic antibiotics are required again.
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Affiliation(s)
- E Bouza
- Emilio Bouza MD, PhD, Instituto de Investigación Sanitaria Gregorio Marañón, Servicio de Microbiología Clínica y E. Infecciosas C/ Dr. Esquerdo, 46 - 28007 Madrid, Spain.
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Kraft CS, Parrott JS, Cornish NE, Rubinstein ML, Weissfeld AS, McNult P, Nachamkin I, Humphries RM, Kirn TJ, Dien Bard J, Lutgring JD, Gullett JC, Bittencourt CE, Benson S, Bobenchik AM, Sautter RL, Baselski V, Atlas MC, Marlowe EM, Miller NS, Fischer M, Richter SS, Gilligan P, Snyder JW. A Laboratory Medicine Best Practices Systematic Review and Meta-analysis of Nucleic Acid Amplification Tests (NAATs) and Algorithms Including NAATs for the Diagnosis of Clostridioides ( Clostridium) difficile in Adults. Clin Microbiol Rev 2019; 32:32/3/e00032-18. [PMID: 31142497 PMCID: PMC6589859 DOI: 10.1128/cmr.00032-18] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The evidence base for the optimal laboratory diagnosis of Clostridioides (Clostridium) difficile in adults is currently unresolved due to the uncertain performance characteristics and various combinations of tests. This systematic review evaluates the diagnostic accuracy of laboratory testing algorithms that include nucleic acid amplification tests (NAATs) to detect the presence of C. difficile The systematic review and meta-analysis included eligible studies (those that had PICO [population, intervention, comparison, outcome] elements) that assessed the diagnostic accuracy of NAAT alone or following glutamate dehydrogenase (GDH) enzyme immunoassays (EIAs) or GDH EIAs plus C. difficile toxin EIAs (toxin). The diagnostic yield of NAAT for repeat testing after an initial negative result was also assessed. Two hundred thirty-eight studies met inclusion criteria. Seventy-two of these studies had sufficient data for meta-analysis. The strength of evidence ranged from high to insufficient. The uses of NAAT only, GDH-positive EIA followed by NAAT, and GDH-positive/toxin-negative EIA followed by NAAT are all recommended as American Society for Microbiology (ASM) best practices for the detection of the C. difficile toxin gene or organism. Meta-analysis of published evidence supports the use of testing algorithms that use NAAT alone or in combination with GDH or GDH plus toxin EIA to detect the presence of C. difficile in adults. There is insufficient evidence to recommend against repeat testing of the sample using NAAT after an initial negative result due to a lack of evidence of harm (i.e., financial, length of stay, or delay of treatment) as specified by the Laboratory Medicine Best Practices (LMBP) systematic review method in making such an assessment. Findings from this systematic review provide clarity to diagnostic testing strategies and highlight gaps, such as low numbers of GDH/toxin/PCR studies, in existing evidence on diagnostic performance, which can be used to guide future clinical research studies.
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Affiliation(s)
| | - J Scott Parrott
- Department of Interdisciplinary Studies, School of Health Professions, Rutgers University, Newark, New Jersey, USA
- Department of Epidemiology, School of Public Health, Rutgers University, Piscataway, New Jersey, USA
| | - Nancy E Cornish
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | - Peggy McNult
- American Society for Microbiology, Washington, DC, USA
| | - Irving Nachamkin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Thomas J Kirn
- Department of Interdisciplinary Studies, School of Health Professions, Rutgers University, Newark, New Jersey, USA
- Department of Epidemiology, School of Public Health, Rutgers University, Piscataway, New Jersey, USA
| | - Jennifer Dien Bard
- Children's Hospital Los Angeles, Los Angeles, California, USA
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | | | - Jonathan C Gullett
- Kaiser Permanente (Southern California Permanente Medical Group) Regional Reference Laboratories, Greater Los Angeles, Los Angeles, California, USA
| | | | - Susan Benson
- PathWest Laboratory Medicine, Perth, Western Australia, Australia
- University of Western Australia, Perth, Western Australia, Australia
| | - April M Bobenchik
- Rhode Island Hospital/Lifespan Academic Medical Center, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | | | - Vickie Baselski
- University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Michel C Atlas
- Kornhauser Health Sciences Library, University of Louisville, Louisville, Kentucky, USA
| | | | - Nancy S Miller
- Boston Medical Center, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
| | | | | | - Peter Gilligan
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - James W Snyder
- Kornhauser Health Sciences Library, University of Louisville, Louisville, Kentucky, USA
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Miller JM, Binnicker MJ, Campbell S, Carroll KC, Chapin KC, Gilligan PH, Gonzalez MD, Jerris RC, Kehl SC, Patel R, Pritt BS, Richter SS, Robinson-Dunn B, Schwartzman JD, Snyder JW, Telford S, Theel ES, Thomson RB, Weinstein MP, Yao JD. A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2018 Update by the Infectious Diseases Society of America and the American Society for Microbiology. Clin Infect Dis 2018; 67:e1-e94. [PMID: 29955859 PMCID: PMC7108105 DOI: 10.1093/cid/ciy381] [Citation(s) in RCA: 286] [Impact Index Per Article: 47.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 04/28/2018] [Indexed: 12/12/2022] Open
Abstract
The critical nature of the microbiology laboratory in infectious disease diagnosis calls for a close, positive working relationship between the physician/advanced practice provider and the microbiologists who provide enormous value to the healthcare team. This document, developed by experts in laboratory and adult and pediatric clinical medicine, provides information on which tests are valuable and in which contexts, and on tests that add little or no value for diagnostic decisions. This document presents a system-based approach rather than specimen-based approach, and includes bloodstream and cardiovascular system infections, central nervous system infections, ocular infections, soft tissue infections of the head and neck, upper and lower respiratory infections, infections of the gastrointestinal tract, intra-abdominal infections, bone and joint infections, urinary tract infections, genital infections, and other skin and soft tissue infections; or into etiologic agent groups, including arthropod-borne infections, viral syndromes, and blood and tissue parasite infections. Each section contains introductory concepts, a summary of key points, and detailed tables that list suspected agents; the most reliable tests to order; the samples (and volumes) to collect in order of preference; specimen transport devices, procedures, times, and temperatures; and detailed notes on specific issues regarding the test methods, such as when tests are likely to require a specialized laboratory or have prolonged turnaround times. In addition, the pediatric needs of specimen management are also emphasized. There is intentional redundancy among the tables and sections, as many agents and assay choices overlap. The document is intended to serve as a guidance for physicians in choosing tests that will aid them to quickly and accurately diagnose infectious diseases in their patients.
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Affiliation(s)
| | - Matthew J Binnicker
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | | | - Karen C Carroll
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | | | - Peter H Gilligan
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill
| | - Mark D Gonzalez
- Department of Pathology, Children’s Healthcare of Atlanta, Georgia
| | - Robert C Jerris
- Department of Pathology, Children’s Healthcare of Atlanta, Georgia
| | | | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Bobbi S Pritt
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | | | - Barbara Robinson-Dunn
- Department of Pathology and Laboratory Medicine, Beaumont Health, Royal Oak, Michigan
| | | | - James W Snyder
- Department of Pathology and Laboratory Medicine, University of Louisville, Kentucky
| | - Sam Telford
- Department of Infectious Disease and Global Health, Tufts University, North Grafton, Massachusetts
| | - Elitza S Theel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Richard B Thomson
- Department of Pathology and Laboratory Medicine, NorthShore University HealthSystem, Evanston, Illinois
| | - Melvin P Weinstein
- Departments of Medicine and Pathology & Laboratory Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Joseph D Yao
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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Krehelova M, Nyč O, Sinajová E, Krutova M. The predominance and clustering of Clostridioides (Clostridium) difficile PCR ribotype 001 isolates in three hospitals in Eastern Slovakia, 2017. Folia Microbiol (Praha) 2018; 64:49-54. [PMID: 29971567 DOI: 10.1007/s12223-018-0629-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/27/2018] [Indexed: 12/20/2022]
Abstract
This study aimed to implement a toxigenic culture as an optional third diagnostic step for glutamate dehydrogenase (GDH)-positive and toxin A/B-negative diarrheal stool samples into a diagnostic algorithm for Clostridioides (Clostridium) difficile infection (CDI), and to characterise C. difficile isolates for epidemiological purposes. During the 5-month study, 481 diarrhoeal stool samples from three Slovak hospitals were investigated and 66 non-duplicated GDH-positive stool samples were found. Of them, 36 were also toxin A/B-positive. Twenty-three GDH-positive and toxin A/B-negative stool samples were shown subsequently to be positive following toxigenic culture (TC). Molecular characterisation of C. difficile isolates showed the predominance of PCR ribotype (RT) 001 (n = 37, 56.1%) and the occurrence of RT 176 (n = 3, 4.5%). C. difficile RT 001 isolates clustered to eight clonal complexes (CCs) using multiple-locus variable-number tandem repeats analysis (MLVA). Interestingly, one third of RT 001 isolates clustering in these CCs were cultured from toxin A/B-negative stool samples. Our observations highlight the need of use multiple step diagnostic algorithm in CDI diagnosis in order to detect all CDI cases and to avoid the spread of C. difficile in healthcare settings.
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Affiliation(s)
| | - Otakar Nyč
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Uvalu 84, 150 06, Prague 5, Czech Republic
| | - Eva Sinajová
- Department of Microbiology, Medirex Group, Kosice, Slovakia
| | - Marcela Krutova
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Uvalu 84, 150 06, Prague 5, Czech Republic.
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13
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Garvey MI, Bradley CW, Wilkinson MAC, Holden E. Can a toxin gene NAAT be used to predict toxin EIA and the severity of Clostridium difficile infection? Antimicrob Resist Infect Control 2017; 6:127. [PMID: 29270290 PMCID: PMC5735516 DOI: 10.1186/s13756-017-0283-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 11/23/2017] [Indexed: 12/17/2022] Open
Abstract
Background Diagnosis of C. difficile infection (CDI) is controversial because of the many laboratory methods available and their lack of ability to distinguish between carriage, mild or severe disease. Here we describe whether a low C. difficile toxin B nucleic acid amplification test (NAAT) cycle threshold (CT) can predict toxin EIA, CDI severity and mortality. Methods A three-stage algorithm was employed for CDI testing, comprising a screening test for glutamate dehydrogenase (GDH), followed by a NAAT, then a toxin enzyme immunoassay (EIA). All diarrhoeal samples positive for GDH and NAAT between 2012 and 2016 were analysed. The performance of the NAAT CT value as a classifier of toxin EIA outcome was analysed using a ROC curve; patient mortality was compared to CTs and toxin EIA via linear regression models. Results A CT value ≤26 was associated with ≥72% toxin EIA positivity; applying a logistic regression model we demonstrated an association between low CT values and toxin EIA positivity. A CT value of ≤26 was significantly associated (p = 0.0262) with increased one month mortality, severe cases of CDI or failure of first line treatment. The ROC curve probabilities demonstrated a CT cut off value of 26.6. Discussions Here we demonstrate that a CT ≤26 indicates more severe CDI and is associated with higher mortality. Samples with a low CT value are often toxin EIA positive, questioning the need for this additional EIA test. Conclusions A CT ≤26 could be used to assess the potential for severity of CDI and guide patient treatment.
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Affiliation(s)
- Mark I Garvey
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, B15 2WB, Edgbaston, Birmingham, UK.,Institute of Microbiology and Infection, The University of Birmingham, Edgbaston, Birmingham, UK
| | - Craig W Bradley
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, B15 2WB, Edgbaston, Birmingham, UK
| | - Martyn A C Wilkinson
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, B15 2WB, Edgbaston, Birmingham, UK
| | - Elisabeth Holden
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, B15 2WB, Edgbaston, Birmingham, UK
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14
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A Decade of Development of Chromogenic Culture Media for Clinical Microbiology in an Era of Molecular Diagnostics. Clin Microbiol Rev 2017; 30:449-479. [PMID: 28122803 DOI: 10.1128/cmr.00097-16] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
In the last 25 years, chromogenic culture media have found widespread application in diagnostic clinical microbiology. In the last decade, the range of media available to clinical laboratories has expanded greatly, allowing specific detection of additional pathogens, including Pseudomonas aeruginosa, group B streptococci, Clostridium difficile, Campylobacter spp., and Yersinia enterocolitica. New media have also been developed to screen for pathogens with acquired antimicrobial resistance, including vancomycin-resistant enterococci, carbapenem-resistant Acinetobacter spp., and Enterobacteriaceae with extended-spectrum β-lactamases and carbapenemases. This review seeks to explore the utility of chromogenic media in clinical microbiology, with particular attention given to media that have been commercialized in the last decade. The impact of laboratory automation and complementary technologies such as matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) is also assessed. Finally, the review also seeks to demarcate the role of chromogenic media in an era of molecular diagnostics.
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Simeunovic G, Sharma M, Riederer K, Khatib R. Relevance of indeterminate Clostridium difficile screening tests with detectable toxin genes: colonization or C. difficile disease? Infect Dis (Lond) 2017; 49:471-473. [DOI: 10.1080/23744235.2017.1279746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Gordana Simeunovic
- Department of Medicine, Ascension St John Hospital and Medical Center, Grosse Pointe Woods, MichiganMI, USA
| | - Mamta Sharma
- Department of Medicine, Ascension St John Hospital and Medical Center, Grosse Pointe Woods, MichiganMI, USA
| | - Kathleen Riederer
- Department of Medicine, Ascension St John Hospital and Medical Center, Grosse Pointe Woods, MichiganMI, USA
| | - Riad Khatib
- Department of Medicine, Ascension St John Hospital and Medical Center, Grosse Pointe Woods, MichiganMI, USA
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Mentula S, Kotila SM, Lyytikäinen O, Ibrahem S, Ollgren J, Virolainen A. Clostridium difficile infections in Finland, 2008–2015: trends, diagnostics and ribotypes. Eur J Clin Microbiol Infect Dis 2017; 36:1939-1945. [DOI: 10.1007/s10096-017-3017-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 05/15/2017] [Indexed: 02/06/2023]
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17
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Seo JY, Jeong JH, Kim KH, Ahn JY, Park PW, Seo YH. Laboratory diagnosis of Clostridium difficile infection: Comparison of Techlab C. diff Quik Chek Complete, Xpert C. difficile, and multistep algorithmic approach. J Clin Lab Anal 2017; 31. [PMID: 28177534 DOI: 10.1002/jcla.22135] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 12/13/2016] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Clostridium difficile is a major pathogen responsible for nosocomial infectious diarrhea. We explored optimal laboratory strategies for diagnosis of C. difficile infection (CDI) in our clinical settings, a 1400-bed tertiary care hospital. METHODS Using 191 fresh stool samples from adult patients, we evaluated the performance of Xpert C. difficile (Xpert CD), C. diff Quik Chek Complete (which simultaneously detects glutamate dehydrogenase [GDH] and C. difficile toxins [CDT]), toxigenic culture, and a two-step algorithm composed of GDH/CDT as a screening test and Xpert CD as a confirmatory test. RESULTS Clostridium difficile was detected in 35 samples (18.3%), and all isolates were toxigenic strains. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value of each assay for detecting CDI were as follows: Quik Chek Complete CDT (45.7%, 100%, 100%, 89.1%), Quik Chek Complete GDH (97.1%, 99.4%, 97.1%, 99.4%), Xpert CD (94.3%, 100%, 100%, 98.7%), and toxigenic culture (91.4%, 100%, 100%, 98.1%). A two-step algorithm performed identically with Xpert CD assay. CONCLUSION Our data showed that most C. difficile isolates from adult patients were toxigenic. We demonstrated that a two-step algorithm based on GDH/CDT assay followed by Xpert CD assay as a confirmatory test was rapid, reliable, and cost effective for diagnosis of CDI in an adult patient setting with high prevalence of toxigenic C. difficile.
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Affiliation(s)
- Ja Young Seo
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Ji Hun Jeong
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Kyung Hee Kim
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jeong-Yeal Ahn
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Pil-Whan Park
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Yiel-Hea Seo
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
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Reigadas E, Alcalá L, Marín M, Martín A, Bouza E. C. difficile PCR-ribotype 023 might go undetected when using ChromId C. difficile agar. Anaerobe 2017; 44:34-35. [PMID: 28108388 DOI: 10.1016/j.anaerobe.2017.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 01/10/2017] [Accepted: 01/14/2017] [Indexed: 01/05/2023]
Abstract
We compared the performance of the new chromogenic medium ChromID C. difficile with that of CLO agar. ChromID C. difficile agar is a sensitive medium that can accelerate the presumptive identification of C. difficile, however ribotype 023 might go undetected when using this chromogenic medium.
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Affiliation(s)
- E Reigadas
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.
| | - L Alcalá
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - M Marín
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - A Martín
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - E Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain.
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Chen S, Gu H, Sun C, Wang H, Wang J. Rapid detection of Clostridium difficile toxins and laboratory diagnosis of Clostridium difficile infections. Infection 2016; 45:255-262. [PMID: 27601055 DOI: 10.1007/s15010-016-0940-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 08/11/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Clostridium difficile is an anaerobic, spore-forming and Gram-positive bacillus. It is the major cause of antibiotic-associated diarrhea prevailing in hospital settings. The morbidity and mortality of C. difficile infection (CDI) has increased significantly due to the emergence of hypervirulent strains. Because of the poor clinical different between CDI and other causes of hospital-acquired diarrhea, laboratory test for C. difficile is an important intervention for diagnosis of CDI. OBJECTIVE Laboratory tests for CDI can broadly detect either the organisms or its toxins. Currently, several laboratory tests are used for diagnosis of CDI, including toxigenic culture, glutamate dehydrogenase detection, nucleic acid amplification testing, cell cytotoxicity assay, and enzyme immunoassay towards toxin A and/or B. This review focuses on the rapid testing of C. difficile toxins and currently available methods for diagnosis of CDI, giving an overview of the role that the toxins rapid detecting plays in clinical diagnosis of CDI.
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Affiliation(s)
- Shuyi Chen
- School of Bioscience and Bioengineering, South China University of Technology, Guangzhou, China
| | - Huawei Gu
- School of Bioscience and Bioengineering, South China University of Technology, Guangzhou, China
| | - Chunli Sun
- School of Bioscience and Bioengineering, South China University of Technology, Guangzhou, China
| | - Haiying Wang
- School of Bioscience and Bioengineering, South China University of Technology, Guangzhou, China
| | - Jufang Wang
- School of Bioscience and Bioengineering, South China University of Technology, Guangzhou, China.
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20
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Crobach MJT, Planche T, Eckert C, Barbut F, Terveer EM, Dekkers OM, Wilcox MH, Kuijper EJ. European Society of Clinical Microbiology and Infectious Diseases: update of the diagnostic guidance document for Clostridium difficile infection. Clin Microbiol Infect 2016; 22 Suppl 4:S63-81. [PMID: 27460910 DOI: 10.1016/j.cmi.2016.03.010] [Citation(s) in RCA: 362] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 03/02/2016] [Accepted: 03/10/2016] [Indexed: 12/14/2022]
Abstract
In 2009 the first European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guideline for diagnosing Clostridium difficile infection (CDI) was launched. Since then newer tests for diagnosing CDI have become available, especially nucleic acid amplification tests. The main objectives of this update of the guidance document are to summarize the currently available evidence concerning laboratory diagnosis of CDI and to formulate and revise recommendations to optimize CDI testing. This update is essential to improve the diagnosis of CDI and to improve uniformity in CDI diagnosis for surveillance purposes among Europe. An electronic search for literature concerning the laboratory diagnosis of CDI was performed. Studies evaluating a commercial laboratory test compared to a reference test were also included in a meta-analysis. The commercial tests that were evaluated included enzyme immunoassays (EIAs) detecting glutamate dehydrogenase, EIAs detecting toxins A and B and nucleic acid amplification tests. Recommendations were formulated by an executive committee, and the strength of recommendations and quality of evidence were graded using the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system. No single commercial test can be used as a stand-alone test for diagnosing CDI as a result of inadequate positive predictive values at low CDI prevalence. Therefore, the use of a two-step algorithm is recommended. Samples without free toxin detected by toxins A and B EIA but with positive glutamate dehydrogenase EIA, nucleic acid amplification test or toxigenic culture results need clinical evaluation to discern CDI from asymptomatic carriage.
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Affiliation(s)
- M J T Crobach
- Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - T Planche
- Department of Medical Microbiology, St. George's Hospital, London, UK
| | - C Eckert
- National Reference Laboratory for Clostridium difficile, Paris, France
| | - F Barbut
- National Reference Laboratory for Clostridium difficile, Paris, France
| | - E M Terveer
- Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - O M Dekkers
- Departments of Clinical Epidemiology and Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands; Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - M H Wilcox
- Department of Microbiology, Leeds Teaching Hospitals & University of Leeds, Leeds, UK
| | - E J Kuijper
- Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands.
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21
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Han S, Shannahan S, Pellish R. Fecal Microbiota Transplant. J Intensive Care Med 2016; 31:577-86. [DOI: 10.1177/0885066615594344] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 05/14/2015] [Indexed: 12/16/2022]
Abstract
Clostridium difficile infection (CDI) has steadily increased in incidence since the 1990s, with an associated increase in recurrence and severity, which has in turn lead to more intensive care unit (ICU) admissions. The development of recurrent CDI, in particular, has been associated with increasing patient morbidity and mortality as well as an immense financial burden on the health care system. Recently, fecal microbiota transplantation (FMT) has received much publicity as an effective means of treatment for recurrent CDI. The goal of this review is to provide evidence-based recommendations for the diagnosis and management of CDI, with a particular focus on FMT and its utilization in the ICU.
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Affiliation(s)
- Samuel Han
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Sarah Shannahan
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Randall Pellish
- University of Massachusetts Medical School, Worcester, MA, USA
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22
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Olling A, Leidinger H, Hoffmann R. Comparison of enzyme immunoassays and rapid diagnostic tests for clostridium difficile glutamate dehydrogenase and toxin a + B to toxinogenic culture on a highly selective chromogenic medium. Eur J Clin Microbiol Infect Dis 2016; 35:1655-9. [PMID: 27323765 DOI: 10.1007/s10096-016-2706-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 06/06/2016] [Indexed: 12/18/2022]
Abstract
To compare Clostridium. (C.) difficile toxin A/B and glutamate dehydrogenase (GDH) enzyme immunoassays or rapid diagnostic tests to toxinogenic culture on recently described highly selective agar plates. Five hundred consecutive samples sent in for C. difficile diagnostics were tested by toxin A/B enzyme immunoassay (EIA) and rapid diagnostic test (RDT), GDH EIA and RDT, and culture on chromID C. difficile plates for 48 hrs, with toxin testing from culture if the toxin EIA from feces was negative. Samples with discordant results from EIA and RDT were submitted to C. difficile-specific 16S rRNA gene and tcdB PCR. Ninety-two, 88, 31, and 37 samples were positive by GDH EIA, GDH RDT, toxin A/B EIA, and toxin A/B RDT respectively. Seventy-four samples were positive by culture, 54 culture-positive samples were subjected to repeat toxin testing, with an additional 29 samples positive. Thus, there were 60 C. difficile toxin A/B positive samples in total (12 %). Single-step screening with GDH EIA, GDH RDT, toxin A/B EIA, and toxin A/B RDT would have missed seven (12 %), 11 (18 %), 29 (48 %) or 27 (45 %) of all positive samples respectively. Single-step screening with GDH or toxin A/B tests from feces misses a significant proportion of patients compared to toxinogenic culture, putting these patients at risk from undiagnosed C. difficile infection. More data are needed to establish the clinical significance of a positive toxinogenic culture result in the absence of detectable toxin A/B in feces.
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Affiliation(s)
- A Olling
- R-Biopharm, An der neuen Bergstraße 17, 64297, Darmstadt, Germany
| | - H Leidinger
- R-Biopharm, An der neuen Bergstraße 17, 64297, Darmstadt, Germany
| | - R Hoffmann
- Institut für Labormedizin und Mikrobiologie, Klinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany.
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Diagnostic yield of repeat sampling with immunoassay, real-time PCR, and toxigenic culture for the detection of toxigenic Clostridium difficile in an epidemic and a non-epidemic setting. Eur J Clin Microbiol Infect Dis 2015; 34:2325-30. [PMID: 26377204 PMCID: PMC4655006 DOI: 10.1007/s10096-015-2484-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 08/27/2015] [Indexed: 12/18/2022]
Abstract
Current international guidelines lack definite conclusions regarding repeat stool sampling for the detection of toxigenic Clostridium difficile. We assessed the value of repeat sampling and compared the diagnostic yield in an epidemic to a non-epidemic setting. Consecutive fecal samples obtained during two time frames were analyzed using direct stool immunoassay toxin testing (enzyme immunoassay [EIA]), direct stool real-time PCR toxin gene testing, and toxigenic culture. Samples collected within 7 days of the initial sample were considered repeat tests. In the epidemic setting 989 patients were analyzed, and in the non-epidemic setting 1,015. In the epidemic setting 204 patients had two or more specimens included for analysis and in the non-epidemic setting 287 patients. In the epidemic setting 136 samples yielded a positive results, either by EIA or toxigenic culture; of these, 108 were positive according to EIA and 123 according to toxigenic culture. In the first test round 98 (90.7%, 95% CI 85.3 to 96.2), 114 (92.7%, 88.1 to 97.3), and 126 (92.6%, 88.3 to 97.0) positives were detected. Subsequent test rounds yielded 10 (9.3%, 3.8 to 14.7), 9 (7.3%, 2.7 to 11.9), and 10 (7.4%, 3.0 to 11.7) extra positives. In the non-epidemic setting EIA, toxigenic culture and PCR detected 33, 66, and 83 positives. The three tests combined 93 detected positives. In the first test round 30 (90.9%, 81.1 to 100.7), 63 (95.5%, 90.4 to 110.5), 76 (91.6%, 85.6 to 97.5), and 87 (93.5%, 88.6 to 98.5) positives were detected. Subsequent test rounds yielded 3 (9.1%, -0.7 to 18.9), 3 (4.5%, -0.5 to 9.6), 7 (8.4%, 2.5 to 14.4), and 6 (6.5%, 1.5 to 11.4) extra positives. In conclusion, repeat testing resulted in 4.5% to 9.3% extra positives. No significant difference between the settings studied could be demonstrated. Repeat sampling and multimodality testing may be chosen in an outbreak situation to detect all cases, effectively controlling nosocomial spread.
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Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, Pepin J, Wilcox MH. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2015; 31:431-55. [PMID: 20307191 DOI: 10.1086/651706] [Citation(s) in RCA: 2180] [Impact Index Per Article: 242.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Since publication of the Society for Healthcare Epidemiology of America position paper onClostridium difficileinfection in 1995, significant changes have occurred in the epidemiology and treatment of this infection.C. difficileremains the most important cause of healthcare-associated diarrhea and is increasingly important as a community pathogen. A more virulent strain ofC. difficilehas been identified and has been responsible for more-severe cases of disease worldwide. Data reporting the decreased effectiveness of metronidazole in the treatment of severe disease have been published. Despite the increasing quantity of data available, areas of controversy still exist. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, and infection control and environmental management.
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Affiliation(s)
- Stuart H Cohen
- Department of Internal Medicine, Division of Infectious and Immunologic Diseases, University of California Davis Medical Center, Sacramento, California, USA
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Shimizu H, Mori M, Yoshimoto N. Clostridium difficile Infection Is More Severe When Toxin Is Detected in the Stool than When Detected Only by a Toxigenic Culture. Intern Med 2015; 54:2155-9. [PMID: 26328639 DOI: 10.2169/internalmedicine.54.4641] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Clostridium difficile infection (CDI) is the major cause of antibiotic-associated diarrhea in hospital inpatients. Rapid testing for the toxins in stool specimens is inconclusive due to its low sensitivity. Therefore, a two-step method is recommended as the most appropriate approach. The purpose of the present study was to evaluate the differences in the disease severity score between the patients who were glutamate dehydrogenase (GDH)-positive/enzyme immunoassays (EIA) toxin-positive (group A) and those who were GDH-positive/EIA toxin-negative, but who were nonetheless finally confirmed to be toxin-positive by toxigenic culture testing (group B). METHODS A rapid detection EIA for GDH and toxin A/B were simultaneously performed for initial screening. Subsequently, the toxin production by bacterial colonies in culture was retested with the same rapid test kit when necessitated by an equivocal result of the initial screening. RESULTS A total of 334 fecal specimens were evaluated. Group A consisted of 25 specimens (from 16 patients) and group B consisted of 27 specimens (from 12 patients). The severity score (based on a number of factors, including age, body temperature, serum albumin level and white cell count) of group A and B was 2.2±0.7 and 1.4±0.5, respectively (p=0.002). CONCLUSION The cases of CDI in which the toxins were detected by the initial screening test were more severe than those where the toxins were not detected at the initial screening but were identified by the toxigenic culture. In addition, the most significant factors affecting the severity score were an older age and a lower serum albumin level.
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Affiliation(s)
- Hiroyuki Shimizu
- Pediatrics General Medical Center, Yokohama City University Medical Center, Japan
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An B, Kim H, Lee K. Evaluation of the Selective Enrichment Culture to Recover Clostridium difficile. KOREAN JOURNAL OF CLINICAL LABORATORY SCIENCE 2014. [DOI: 10.15324/kjcls.2014.46.4.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Byoungrak An
- Department of Laboratory Medicine, Yongin Severance Hospital, Yongin, 449-930, Korea
| | - Heejung Kim
- Department of Laboratory Medicine, Yongin Severance Hospital, Yongin, 449-930, Korea
- Departments of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul 120-752, Korea
| | - Kyungwon Lee
- Departments of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul 120-752, Korea
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Comparative performance of the GeneXpert C. difficile PCR assay and C. diff Quik Chek Complete kit assay for detection of Clostridium difficile antigen and toxins in symptomatic community-onset infections. Int J Infect Dis 2014; 29:244-8. [DOI: 10.1016/j.ijid.2014.10.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 09/12/2014] [Accepted: 10/06/2014] [Indexed: 11/22/2022] Open
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Qu HQ, Jiang ZD. Clostridium difficile infection in diabetes. Diabetes Res Clin Pract 2014; 105:285-94. [PMID: 25015315 DOI: 10.1016/j.diabres.2014.06.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 01/26/2014] [Accepted: 06/13/2014] [Indexed: 01/08/2023]
Abstract
Diabetes-related hospitalization and hospital utilization is a serious challenge to the health care system, a situation which may be further aggravated by nosocomial Clostridium difficile (C. difficile) infection (CDI). Studies have demonstrated that diabetes increases the risk of recurrent CDI with OR (95% CI) 2.99 (1.88, 4.76). C. difficile is a gram-positive, spore-forming anaerobic bacterium which is widely distributed in the environment. Up to 7% of healthy adults and up to 45% of infants may have asymptomatic intestinal carriage of C. difficile. A large number of strains of C. difficile have been identified. A number of PCR or sequence-based molecular typing methods are available for typing C. difficile isolates. C. difficile virulence evolved independently in the highly epidemic lineages, associated with the expression of toxin genes and other virulence factors. This article briefly reviews recent progresses in the bateriology of C. difficile and highlights the limited knowledge of potential mechanisms for the increased risk of CDI in diabetes which warrants further research.
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Affiliation(s)
- Hui-Qi Qu
- Human Genetics Center, The University of Texas School of Public Health, Houston, TX, USA.
| | - Zhi-Dong Jiang
- Center for Infectious Diseases, Division of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas School of Public Health, Houston, TX, USA
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Han SB, Chang J, Shin SH, Park KG, Lee GD, Park YG, Park YJ. Performance of chromID Clostridium difficile agar compared with BBL C. difficile selective agar for detection of C. difficile in stool specimens. Ann Lab Med 2014; 34:376-9. [PMID: 25187891 PMCID: PMC4151007 DOI: 10.3343/alm.2014.34.5.376] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 12/19/2013] [Accepted: 06/16/2014] [Indexed: 02/06/2023] Open
Abstract
We evaluated the performance of a new chromogenic medium for detection of Clostridium difficile, chromID C. difficile agar (CDIF; bioMérieux, France), by comparison with BBL C. difficile Selective Agar (CDSA; Becton Dickinson and Company, USA). After heat pre-treatment (80℃, 5 min), 185 diarrheal stool samples were inoculated onto the two media types and incubated anaerobically for 24 hr and 48 hr for CDIF and for 48 hr and 72 hr for CDSA. All typical colonies on each medium were examined by Gram staining, and the gram-positive rods confirmed to contain the tpi gene by PCR were identified as C. difficile. C. difficile was recovered from 36 samples by using a combination of the two media. The sensitivity with CDIF 48 hr was highest (100%) and was significantly higher than that with CDIF 24 hr (58.3%; P<0.001), because samples with a low burden of C. difficile tended to require prolonged incubation up to 48 hr (P<0.001). The specificity of CDIF 24 hr and CDIF 48 hr (99.3% and 90.6%, respectively) was significantly higher than that of CDSA 48 hr and CDSA 72 hr (72.5% and 67.1%, respectively; P<0.001). CDIF was effective for detecting C. difficile in heat-pretreated stool specimens, thus reducing unnecessary testing for toxin production in non-C. difficile isolates and turnaround time.
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Affiliation(s)
- Sang Bong Han
- Department of Laboratory Medicine, Yeouido St. Mary's Hospital, Seoul, Korea
| | - Jiyoung Chang
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, Seoul, Korea
| | - Sang Hyun Shin
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, Seoul, Korea
| | - Kang Gyun Park
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, Seoul, Korea
| | - Gun Dong Lee
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, Seoul, Korea
| | - Yong Gyu Park
- Department of Biostatistics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yeon-Joon Park
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, Seoul, Korea
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Kim H, Kim WH, Kim M, Jeong SH, Lee K. Evaluation of a rapid membrane enzyme immunoassay for the simultaneous detection of glutamate dehydrogenase and toxin for the diagnosis of Clostridium difficile infection. Ann Lab Med 2014; 34:235-9. [PMID: 24790912 PMCID: PMC3999323 DOI: 10.3343/alm.2014.34.3.235] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 11/14/2013] [Accepted: 03/03/2014] [Indexed: 12/15/2022] Open
Abstract
We evaluated the new C. DIFF QUIK CHEK COMPLETE (CD COMPLETE; TechLab, USA), which is a rapid membrane enzyme immunoassay that uses a combination of glutamate dehydrogenase (GDH) antigen and toxin A and B detection. A total of 608 consecutive loose stool specimens collected from the patients with suspected Clostridium difficile infection (CDI) from August to December 2012 were subjected to the CD COMPLETE and VIDAS Clostridium difficile A & B (VIDAS CDAB; bioMérieux, France). Their performances were compared with a toxigenic culture as a reference. Stool specimens that were culture-negative and CD COMPLETE- or VIDAS CDAB-positive were analyzed by using an enrichment procedure. In comparison to the toxigenic cultures, sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV) were 63.6%, 98.0%, 76.1%, and 96.4%, respectively, for the CD COMPLETE-toxin and 75.5%, 97.4%, 72.5%, and 97.8%, respectively, for the VIDAS CDAB. In comparison to the enriched C. difficile cultures, the sensitivity, specificity, PPV, and NPV for the CD COMPLETE-GDH were 91.0%, 92.4%, 70.5%, and 98.1%, respectively. The CD COMPLETE is a reliable method for the diagnosis of CDI and provides greater sensitivity than toxin enzyme immunoassay alone. Furthermore, the CD COMPLETE-GDH has advantages over direct culture in detecting C. difficile.
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Affiliation(s)
- Heejung Kim
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea
| | - Wan Hee Kim
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea
| | - Myungsook Kim
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea
| | - Seok Hoon Jeong
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea
| | - Kyungwon Lee
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea
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A cost-effective approach for detection of toxigenic Clostridium difficile: toxigenic culture using ChromID Clostridium difficile agar. J Clin Microbiol 2013; 52:671-3. [PMID: 24478510 DOI: 10.1128/jcm.03113-13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
We evaluated the performance and the cost of toxigenic culture using a commercial chromogenic medium (CDIF) for 538 stool specimens. Compared with real-time PCR, this method was found to detect an additional 9% of positive specimens and result in 61% reduction in material costs, with a trade-off increase in turnaround time of 1 day.
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Denys GA. Portrait Toxigenic Clostridium difficile assay, an isothermal amplification assay detects toxigenic C. difficile in clinical stool specimens. Expert Rev Mol Diagn 2013; 14:17-26. [PMID: 24308336 DOI: 10.1586/14737159.2014.864239] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The Portrait Toxigenic Clostridium difficile assay is a rapid, qualitative assay for the detection of the tcdB gene of C. difficile in stool specimens from patients suspected of C. difficile infections, and received 510(k) clearance by the US FDA in March 2012. The Portrait Toxigenic C. difficile assay combines novel blocked-primer-mediated helicase-dependent multiplex amplification (bpHDA) technology and chip-based detection in an automated sample-to-result format. The assay requires minimal sample preparation and results are available within 90 min. In a multicenter evaluation, the Portrait Toxigenic C. difficile assay had a sensitivity of 98.2% and specificity of 92.8% compared with toxigenic culture. A comparative study between the Portrait Toxigenic C. difficile assay and three FDA-cleared molecular assays for the detection of toxigenic C. difficile exhibited a high degree of agreement (93.8-97.5%). The Portrait Toxigenic C. difficile assay provides a simple, cost-effective method with broad applicability to panel-based approaches, potentially simplifying workflow.
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Affiliation(s)
- Gerald A Denys
- Department of Pathology and Laboratory Medicine, Division of Clinical Microbiology, Indiana University School of Medicine, 350 West 11th Street, Room 6027B, Indianapolis, IN, USA
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Comparison of Simplexa universal direct PCR with cytotoxicity assay for diagnosis of Clostridium difficile infection: performance, cost, and correlation with disease. J Clin Microbiol 2013; 52:275-80. [PMID: 24226924 DOI: 10.1128/jcm.02545-13] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Simplexa Clostridium difficile universal direct PCR, a real-time PCR assay for the detection of the C. difficile toxin B (tcdB) gene using the 3M integrated cycler, was compared with a two-step algorithm which includes the C. Diff Chek-60 glutamate dehydrogenase (GDH) antigen assay followed by cytotoxin neutralization. Three hundred forty-two liquid or semisolid stools submitted for diagnostic C. difficile testing, 171 GDH antigen positive and 171 GDH antigen negative, were selected for the study. All samples were tested by the C. Diff Chek-60 GDH antigen assay, cytotoxin neutralization, and Simplexa direct PCR. Of 171 GDH-positive samples, 4 were excluded (from patients on therapy or from whom duplicate samples were obtained) and 88 were determined to be true positives for toxigenic C. difficile. Of the 88, 67 (76.1%) were positive by the two-step method and 86 (97.7%) were positive by PCR. Seventy-nine were positive by the GDH antigen assay only. Of 171 GDH antigen-negative samples, none were positive by PCR. One antigen-negative sample positive by the cytotoxin assay only was deemed a false positive based on chart review. Simplexa C. difficile universal direct PCR was significantly more sensitive for detecting toxigenic C. difficile bacteria than cytotoxin neutralization (P = 0.0002). However, most PCR-positive/cytotoxin-negative patients did not have clear C. difficile disease. The estimated cost avoidance provided by a more rapid molecular diagnosis was outweighed by the cost of isolating and treating PCR-positive/cytotoxin-negative patients. The costs, clinical consequences, and impact on nosocomial transmission of treating and/or isolating patients positive for toxigenic C. difficile by PCR but negative for in vivo toxin production merit further study.
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Abstract
OBJECTIVE Clostridium difficile is the most commonly reported infectious diarrhoea in HIV-infected patients in the United States. We set out to determine the incidence, risk factors and clinical presentation of C. difficile infections (CDIs) in a cohort of HIV-infected individuals. DESIGN We performed a nested, case-control analysis with four non-CDI controls randomly selected for each case. METHODS We assessed the incidence of CDI in the Johns Hopkins HIV Clinical Cohort between 1 July 2003 and 31 December 2010. Incident cases were defined as first positive C. difficile cytotoxin assay or PCR for toxin B gene. We used conditional logistic regression models to assess risk factors for CDI. We abstracted data on the clinical presentation and outcomes from case chart review. RESULTS We identified 154 incident CDI cases for an incidence of 8.3 cases per 1000 patient years. No unique clinical features of HIV-associated CDI were identified. In multivariate analysis, risk of CDI was independently increased for CD4 cell count of 50 cells/μl or less [adjusted odds ratio (AOR) 20.7, 95% confidence interval (CI) 2.8-151.4], hospital onset CDI (AOR 26.7, 95% CI 3.1-231.2) and use of clindamycin (AOR 27.6, 95% CI 2.2-339.4), fluoroquinolones (AOR 4.5, 95% CI 1.2-17.5), macrolides (AOR 6.3, 95% CI 1.8-22.1), gastric acid suppressants (AOR 3.1, 95% CI 1.4-6.9) or immunosuppressive agents (AOR 6.8, 95% CI 1.2-39.6). CONCLUSION The incidence of CDI in HIV-infected patients was twice that previously reported. Our data show that compromised cellular immunity, as defined by CD4 cell count of 50 cells/μl or less, is a risk factor for CDI. Clinicians should be aware of the increased CDI risk, particularly in those with severe CD4 cell count suppression.
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Differences in outcome according to Clostridium difficile testing method: a prospective multicentre diagnostic validation study of C difficile infection. THE LANCET. INFECTIOUS DISEASES 2013; 13:936-45. [PMID: 24007915 PMCID: PMC3822406 DOI: 10.1016/s1473-3099(13)70200-7] [Citation(s) in RCA: 325] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Diagnosis of Clostridium difficile infection is controversial because of many laboratory methods, compounded by two reference methods. Cytotoxigenic culture detects toxigenic C difficile and gives a positive result more frequently (eg, because of colonisation, which means that individuals can have the bacterium but no free toxin) than does the cytotoxin assay, which detects preformed toxin in faeces. We aimed to validate the reference methods according to clinical outcomes and to derive an optimum laboratory diagnostic algorithm for C difficile infection. Methods In this prospective, multicentre study, we did cytotoxigenic culture and cytotoxin assays on 12 420 faecal samples in four UK laboratories. We also performed tests that represent the three main targets for C difficile detection: bacterium (glutamate dehydrogenase), toxins, or toxin genes. We used routine blood test results, length of hospital stay, and 30-day mortality to clinically validate the reference methods. Data were categorised by reference method result: group 1, cytotoxin assay positive; group 2, cytotoxigenic culture positive and cytotoxin assay negative; and group 3, both reference methods negative. Findings Clinical and reference assay data were available for 6522 inpatient episodes. On univariate analysis, mortality was significantly higher in group 1 than in group 2 (72/435 [16·6%] vs 20/207 [9·7%], p=0·044) and in group 3 (503/5880 [8·6%], p<0·001), but not in group 2 compared with group 3 (p=0·4). A multivariate analysis accounting for potential confounders confirmed the mortality differences between groups 1 and 3 (OR 1·61, 95% CI 1·12–2·31). Multistage algorithms performed better than did standalone assays. Interpretation We noted no increase in mortality when toxigenic C difficile alone was present. Toxin (cytotoxin assay) positivity correlated with clinical outcome, and so this reference method best defines true cases of C difficile infection. A new diagnostic category of potential C difficile excretor (cytotoxigenic culture positive but cytotoxin assay negative) could be used to characterise patients with diarrhoea that is probably not due to C difficile infection, but who can cause cross-infection. Funding Department of Health and Health Protection Agency, UK.
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Correlation between Clostridium difficile bacterial load, commercial real-time PCR cycle thresholds, and results of diagnostic tests based on enzyme immunoassay and cell culture cytotoxicity assay. J Clin Microbiol 2013; 51:3624-30. [PMID: 23966497 DOI: 10.1128/jcm.01444-13] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The impact of Clostridium difficile fecal loads on diagnostic test results is poorly understood, but it may have clinical importance. In this study, we investigated the relationship between C. difficile fecal load and the results of four assays: a glutamate dehydrogenase (GDH) enzyme immunoassay (EIA), a toxin A/B antigen EIA (ToxAB), a cell culture cytotoxicity assay (CCA), and PCR targeting the tcdB gene. We also compared the PCR cycle threshold (CT) with the results of quantitative culture using Spearman's rank correlation coefficient. Finally, we sequenced the genomes of 24 strains with different detection profiles. A total of 203 clinical samples harboring toxigenic C. difficile were analyzed and sorted into one of four groups: 17 PCR(+) (group 1), 37 PCR(+) GDH(+) (group 2), 24 PCR(+) GDH(+) CCA(+) (group 3), and 125 PCR(+) GDH(+) ToxAB(+) (group 4). The overall median fecal load in log10 CFU/g was 6.67 (interquartile range [IQR], 5.57 to 7.54). The median fecal bacterial load of groups 1, 2, 3, and 4 were 4.15 (IQR, 3.00 to 4.98), 5.74 (IQR, 4.75 to 6.16), 6.20 (IQR, 5.23 to 6.80), and 7.08 (IQR, 6.35 to 7.83), respectively. Group 1 samples had lower fecal loads than those from each of the other groups (P < 0.001). Group 2 samples had lower fecal loads than those from groups 3 and 4 (P < 0.001). There was a significant correlation between PCR CT and fecal loads (ρ = -0.697; P < 0.001). NAP1 strains were associated with the detection of toxins by EIA or CCA (P = 0.041). This study demonstrates an association between C. difficile fecal load and the results of routinely used diagnostic tests.
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Miller S, Wiita A, Wright C, Reyes H, Liu C. Evaluation of Glutamate Dehydrogenase Immunoassay Screening with Toxin Confirmation for the Diagnosis ofClostridium difficileInfection. Lab Med 2013. [DOI: 10.1309/lm31zx1pfrztgjui] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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Baron EJ, Miller JM, Weinstein MP, Richter SS, Gilligan PH, Thomson RB, Bourbeau P, Carroll KC, Kehl SC, Dunne WM, Robinson-Dunn B, Schwartzman JD, Chapin KC, Snyder JW, Forbes BA, Patel R, Rosenblatt JE, Pritt BS. A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM)(a). Clin Infect Dis 2013; 57:e22-e121. [PMID: 23845951 PMCID: PMC3719886 DOI: 10.1093/cid/cit278] [Citation(s) in RCA: 306] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 04/22/2013] [Indexed: 12/18/2022] Open
Abstract
The critical role of the microbiology laboratory in infectious disease diagnosis calls for a close, positive working relationship between the physician and the microbiologists who provide enormous value to the health care team. This document, developed by both laboratory and clinical experts, provides information on which tests are valuable and in which contexts, and on tests that add little or no value for diagnostic decisions. Sections are divided into anatomic systems, including Bloodstream Infections and Infections of the Cardiovascular System, Central Nervous System Infections, Ocular Infections, Soft Tissue Infections of the Head and Neck, Upper Respiratory Infections, Lower Respiratory Tract infections, Infections of the Gastrointestinal Tract, Intraabdominal Infections, Bone and Joint Infections, Urinary Tract Infections, Genital Infections, and Skin and Soft Tissue Infections; or into etiologic agent groups, including Tickborne Infections, Viral Syndromes, and Blood and Tissue Parasite Infections. Each section contains introductory concepts, a summary of key points, and detailed tables that list suspected agents; the most reliable tests to order; the samples (and volumes) to collect in order of preference; specimen transport devices, procedures, times, and temperatures; and detailed notes on specific issues regarding the test methods, such as when tests are likely to require a specialized laboratory or have prolonged turnaround times. There is redundancy among the tables and sections, as many agents and assay choices overlap. The document is intended to serve as a reference to guide physicians in choosing tests that will aid them to diagnose infectious diseases in their patients.
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Affiliation(s)
- Ellen Jo Baron
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA.
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Hernández-Rocha C, Barra-Carrasco J, Álvarez-Lobos M, Paredes-Sabja D, Guzmán-Durán AM. Prospective comparison of a commercial multiplex real-time polymerase chain reaction and an enzyme immunoassay with toxigenic culture in the diagnosis of Clostridium difficile–associated infections. Diagn Microbiol Infect Dis 2013; 75:361-5. [DOI: 10.1016/j.diagmicrobio.2012.12.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 12/11/2012] [Accepted: 12/19/2012] [Indexed: 01/05/2023]
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Two-stage algorithm for Clostridium difficile: glutamate-dehydrogenase-positive toxin-negative enzyme immunoassay results may require further testing. J Hosp Infect 2013; 83:347-9. [DOI: 10.1016/j.jhin.2012.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Accepted: 12/31/2012] [Indexed: 01/05/2023]
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Evaluation of multiplex PCR with enhanced spore germination for detection of Clostridium difficile from stool samples of the hospitalized patients. BIOMED RESEARCH INTERNATIONAL 2013; 2013:875437. [PMID: 23586062 PMCID: PMC3613053 DOI: 10.1155/2013/875437] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Revised: 01/31/2013] [Accepted: 02/16/2013] [Indexed: 01/05/2023]
Abstract
Clostridium difficile poses as the most common etiologic agent of nosocomial diarrhea. Although there are many diagnostic methods to detect C. difficile directly from stool samples, the nucleic acid-based approach has been largely performed in several laboratories due to its high sensitivity and specificity as well as rapid turnaround time. In this study, a multiplex PCR was newly designed with recent accumulated nucleotide sequences. The PCR testing with various C. difficile ribotypes, other Clostridium spp., and non-Clostridium strains revealed 100% specificity with the ability to detect as low as ~22 genomic copy number per PCR reaction. Different combinations of sample processing were evaluated prior to multiplex PCR for the detection of C. difficile in fecal samples from hospitalized patients. The most optimal condition was the non-selective enrichment at 37°C for 1 h in brain heart infusion broth supplemented with taurocholate, followed by the multiplex PCR. The detection limit after sample processing was shown as being 5 spores per gram of fecal sample. Two hundred and thirty-eight fecal samples collected from the University affiliated hospital were analyzed by the enrichment multiplex PCR procedure. The results suggested that the combination of sample processing with the high-performance detection method would be applicable for routine diagnostic use in clinical setting.
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Becker SL, Vogt J, Knopp S, Panning M, Warhurst DC, Polman K, Marti H, von Müller L, Yansouni CP, Jacobs J, Bottieau E, Sacko M, Rijal S, Meyanti F, Miles MA, Boelaert M, Lutumba P, van Lieshout L, N'Goran EK, Chappuis F, Utzinger J. Persistent digestive disorders in the tropics: causative infectious pathogens and reference diagnostic tests. BMC Infect Dis 2013; 13:37. [PMID: 23347408 PMCID: PMC3579720 DOI: 10.1186/1471-2334-13-37] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Accepted: 01/14/2013] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Persistent digestive disorders account for considerable disease burden in the tropics. Despite advances in understanding acute gastrointestinal infections, important issues concerning epidemiology, diagnosis, treatment and control of most persistent digestive symptomatologies remain to be elucidated. Helminths and intestinal protozoa are considered to play major roles, but the full extent of the aetiologic spectrum is still unclear. We provide an overview of pathogens causing digestive disorders in the tropics and evaluate available reference tests. METHODS We searched the literature to identify pathogens that might give rise to persistent diarrhoea, chronic abdominal pain and/or blood in the stool. We reviewed existing laboratory diagnostic methods for each pathogen and stratified them by (i) microscopy; (ii) culture techniques; (iii) immunological tests; and (iv) molecular methods. Pathogen-specific reference tests providing highest diagnostic accuracy are described in greater detail. RESULTS Over 30 pathogens may cause persistent digestive disorders. Bacteria, viruses and parasites are important aetiologic agents of acute and long-lasting symptomatologies. An integrated approach, consisting of stool culture, microscopy and/or specific immunological techniques for toxin, antigen and antibody detection, is required for accurate diagnosis of bacteria and parasites. Molecular techniques are essential for sensitive diagnosis of many viruses, bacteria and intestinal protozoa, and are increasingly utilised as adjuncts for helminth identification. CONCLUSIONS Diagnosis of the broad spectrum of intestinal pathogens is often cumbersome. There is a need for rapid diagnostic tests that are simple and affordable for resource-constrained settings, so that the management of patients suffering from persistent digestive disorders can be improved.
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Affiliation(s)
- Sören L Becker
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
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Gyorke CE, Wang S, Leslie JL, Cohen SH, Solnick JV, Polage CR. Evaluation of Clostridium difficile fecal load and limit of detection during a prospective comparison of two molecular tests, the illumigene C. difficile and Xpert C. difficile/Epi tests. J Clin Microbiol 2013; 51:278-80. [PMID: 23052320 PMCID: PMC3536201 DOI: 10.1128/jcm.02120-12] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 10/05/2012] [Indexed: 12/18/2022] Open
Abstract
In a large prospective comparison, the illumigene test detected Clostridium difficile in 98% of toxin-positive and 58% of toxin-negative samples confirmed positive by other methods. The Xpert was uniformly sensitive. Most samples with discrepant results had C. difficile concentrations below the illumigene limit of detection. The significance of low-level C. difficile detection needs investigation.
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Affiliation(s)
| | - Susan Wang
- Department of Pathology and Laboratory Medicine
| | | | - Stuart H. Cohen
- Department of Internal Medicine, Division of Infectious Diseases
| | - Jay V. Solnick
- Department of Internal Medicine, Division of Infectious Diseases
- Department of Medical Microbiology and Immunology, University of California, Davis, School of Medicine, Davis, California, USA
| | - Christopher R. Polage
- Department of Pathology and Laboratory Medicine
- Department of Internal Medicine, Division of Infectious Diseases
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Polage CR, Chin DL, Leslie JL, Tang J, Cohen SH, Solnick JV. Outcomes in patients tested for Clostridium difficile toxins. Diagn Microbiol Infect Dis 2012; 74:369-73. [PMID: 23009731 PMCID: PMC3496840 DOI: 10.1016/j.diagmicrobio.2012.08.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 06/12/2012] [Accepted: 08/16/2012] [Indexed: 12/20/2022]
Abstract
Clostridium difficile testing is shifting from toxin detection to C. difficile detection. Yet, up to 60% of patients with C. difficile by culture test negative for toxins and it is unclear whether they are infected or carriers. We reviewed medical records for 7046 inpatients with a C. difficile toxin test from 2005 to 2009 to determine the duration of diarrhea and rate of complications and mortality among toxin-positive (toxin+) and toxin- patients. Overall, toxin- patients had less severe diarrhea, fewer diarrhea days, and lower mortality (P < 0.001, all comparisons) than toxin+ patients. One toxin- patient (n = 1/6121; 0.02%) was diagnosed with pseudomembranous colitis, but there were no complications such as megacolon or colectomy for fulminant CDI among toxin- patients. These data suggest that C. difficile-attributable complications are rare among patients testing negative for C. difficile toxins. More studies are needed to evaluate the clinical significance of C. difficile detection in toxin- patients.
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Affiliation(s)
- Christopher R Polage
- Department of Pathology and Laboratory Medicine, UC Davis Medical Center, Sacramento, CA 95817, USA.
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45
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Comparison of a frozen human foreskin fibroblast cell assay to an enzyme immunoassay and toxigenic culture for the detection of toxigenic Clostridium difficile. Diagn Microbiol Infect Dis 2012; 75:42-5. [PMID: 23107315 PMCID: PMC3525856 DOI: 10.1016/j.diagmicrobio.2012.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 09/12/2012] [Accepted: 09/20/2012] [Indexed: 12/14/2022]
Abstract
This study set out to validate the Hs27 ReadyCell assay (RCCNA) as an alternative CCNA method compared against a commonly used commercial enzyme immunoassay (EIA) method and toxigenic culture (TC) reference standard. A total of 860 samples were identified from those submitted to the Health Protection Agency microbiology laboratories over a 30-week period. RCCNA performed much better than EIA when using TC as a gold standard, with sensitivities of 90.8% versus 78.6% and positive predictive value of 87.3% to 81.9%, respectively. The Hs27 Human Foreskin Fibroblast ReadyCells are an easy-to-use and a sensitive CCNA method for the detection of toxigenic Clostridium difficile directly from stool. A turnaround time of up to 48 h for a negative result and possible need for repeat testing make it an unsuitable method to be used in most clinical laboratory setting.
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46
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LaSala PR, Svensson AM, Mohammad AA, Perrotta PL. Comparison of analytical and clinical performance of three methods for detection of Clostridium difficile. Arch Pathol Lab Med 2012; 136:527-31. [PMID: 22540301 DOI: 10.5858/arpa.2011-0305-oa] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Diagnostic laboratory testing for Clostridium difficile infection has undergone considerable and rapid evolution during the last decade. The ideal detection method(s), which should exhibit high analytical and clinical sensitivity and specificity, remains undefined. OBJECTIVE We sought to evaluate the analytical and clinical performance characteristics of three methods for the laboratory detection of C difficile. DESIGN This study used 114 consecutive stool samples to compare three methods of C difficile detection: an enzyme immunoassay (EIA) for toxins A/B, a lateral flow membrane immunoassay for glutamate dehydrogenase (GDH), and a qualitative real-time polymerase chain reaction (PCR) assay. Medical records of all patients having ≥1 positive test result were reviewed to estimate the clinical likelihood of C difficile infection. RESULTS Based upon laboratory result consensus values, analytical sensitivity was significantly higher for GDH (94%) and PCR (94%) assays than for toxin EIA (25%). Analytical specificity was significantly higher for PCR (100%) and EIA (100%) than for GDH assay (93%). In contrast, assay performance based upon clinical probability of C difficile infection suggested lower discriminatory power (ie, clinical specificity) of the more analytically sensitive methods. CONCLUSIONS Higher rates of C difficile detection will be realized upon implementation of GDH assay and/or real-time PCR-based testing algorithms than by testing with EIA alone. Further study is required to elucidate potential downstream costs for higher detection rates.
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Affiliation(s)
- P Rocco LaSala
- Clinical Laboratories, Department of Pathology, Robert C.Byrd Health Science Center, West Virginia University Hospitals, Morgantown, WV 26506, USA.
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Passaretti CL, Otter JA, Reich NG, Myers J, Shepard J, Ross T, Carroll KC, Lipsett P, Perl TM. An Evaluation of Environmental Decontamination With Hydrogen Peroxide Vapor for Reducing the Risk of Patient Acquisition of Multidrug-Resistant Organisms. Clin Infect Dis 2012; 56:27-35. [DOI: 10.1093/cid/cis839] [Citation(s) in RCA: 156] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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Ylisiurua P, Koskela M, Vainio O, Tuokko H. Comparison of antigen and two molecular methods for the detection of Clostridium difficile toxins. ACTA ACUST UNITED AC 2012; 45:19-25. [PMID: 22998479 DOI: 10.3109/00365548.2012.708780] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Clostridium difficile (CD) is considered an important cause of diarrhoea associated with the antimicrobial treatment of infections. The pathogenicity of CD is due to toxins A and B, produced by toxigenic CD strains. METHODS We evaluated 3 methods for detecting CD toxins: the RIDASCREEN® enzyme immunoassay (EIA) (R-Biopharm)--one detecting toxins directly in the stool specimens and another detecting toxins from isolated CD strains--and 2 molecular methods, the illumigene™ loop-mediated isothermal amplification (LAMP) assay (Meridian) and RIDA®GENE polymerase chain reaction (PCR) assay (R-Biopharm), as direct identification methods from stool specimens. Toxigenic culture (TC) was used as the reference method. RESULTS Altogether 884 stool samples were analyzed, of which 253 (29%) were positive by TC. Six hundred and seventy-two specimens were tested by RIDASCREEN EIA, 430 were tested with the illumigene LAMP assay, and 212 were tested with the RIDA GENE PCR assay. CD toxin A and B antigen tests by EIA were very insensitive, both directly from stool specimens (2 series; 57-61%) and in isolated CD strains (53%); consequently the negative predictive value remained low (84-93% and 91%, respectively). Specificity, however, was very good at 98-100%. The 2 molecular methods detected CD toxin genes excellently and equally, resulting in sensitivities, specificities, and positive and negative predictive values of 98%, 100%, 100%, and 98%, respectively. CONCLUSIONS Both molecular assays were easy to use, rapid, sensitive, and specific for the detection of toxigenic CD strains.
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Affiliation(s)
- Pirkko Ylisiurua
- Clinical Microbiology Laboratory, Oulu University Hospital, Oulu, Finland.
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Comparison of BD GeneOhm Cdiff and Seegene Seeplex ACE PCR assays using toxigenic Clostridium difficile culture for direct detection of tcdB from stool specimens. J Clin Microbiol 2012; 50:3765-7. [PMID: 22952270 DOI: 10.1128/jcm.01440-12] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
We evaluated the performances of 2 PCR assays (BD GeneOhm and Seegene ACE) for direct detection of tcdB from stool specimens. The concordance rate between BD and Seegene was 96.3%. The sensitivities, specificities, positive predictive values (PPVs), and negative predictive values (NPVs) of BD and Seegene were 95.7%, 96.5%, 91.8%, and 98.2% and 90.0%, 97.1%, 92.6%, and 96.0%, respectively.
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50
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The value of repeat Clostridium difficile toxin testing during and after an outbreak of C difficile-associated diarrhea. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2012; 22:e12-5. [PMID: 22654928 DOI: 10.1155/2011/591239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The recent increase in Clostridium difficile-associated diarrhea (CDAD) has led to questions about the reproducibility and sensitivity of C difficile toxin testing (CDTT). While there have been recommendations to repeat CDTT following a negative result, previous studies have failed to show a benefit. However, no studies were performed during an outbreak of CDAD. The value of repeat CDTT after an initial negative result in patients tested during and after an outbreak of CDAD is reported in the present study, as well as the reproducibility of CDTT when multiple samples are received and tested on the same day. METHODS The results of CDTT, performed using a cell cytotoxicity assay between April 1, 2001, and March 31, 2008, were retrieved and searched for patients who had repeat samples tested after an initial negative result. The result and the number of days after a negative result were determined using the date of the most recent negative test. The cumulative positivity rate was calculated by adding all of the repeat positive test results for the days in question and dividing by the total number of tests performed during that time. RESULTS A total of 8661 patients submitted 14,991 stool specimens for CDTT during the study period. There were 3095 samples that tested positive (20.6%) for the toxin. The results were divided into two time periods to reflect the CDAD outbreak, which began in April 2002: period 1 (outbreak) was from April 1, 2002, to March 31, 2006, and period 2 was from April 1, 2006, to March 31, 2008. The rate of positivity was 24.2% during period 1, and 11.6% during period 2 (P<0.001). Repeat CDTT was performed 619 times on samples received on the same day as the initial specimen, and only three (0.5%) were discordant. A total of 1630 samples were retested within one to seven days of a negative result, and 103 (6.3%) tested positive (7.8% period 1 and 2.9% period 2; P=0.002). The likelihood of a positive result on repeat testing in the first three days after a negative result was low (0.9%, 7% and 4%, respectively). The cumulative positivity for repeat testing performed in the first three days was 0.9%, 3.3% and 3.5%, respectively, and did not differ significantly at day 3 during the period of high CDTT positivity (P=0.110). CONCLUSIONS The value of repeat CDTT, performed using a cell cytotoxicity assay, was low in the first three days after an initial negative result and was unchanged during a CDAD outbreak.
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