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Bocchetti M, Ferraro MG, Melisi F, Grisolia P, Scrima M, Cossu AM, Yau TO. Overview of current detection methods and microRNA potential in Clostridioides difficile infection screening. World J Gastroenterol 2023; 29:3385-3399. [PMID: 37389232 PMCID: PMC10303512 DOI: 10.3748/wjg.v29.i22.3385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/23/2023] [Accepted: 05/04/2023] [Indexed: 06/06/2023] Open
Abstract
Clostridioides difficile (formerly called Clostridium difficile, C. difficile) infection (CDI) is listed as an urgent threat on the 2019 antibiotic resistance threats report in the United States by the Centers for Disease Control and Prevention. Early detection and appropriate disease management appear to be essential. Meanwhile, although the majority of cases are hospital-acquired CDI, community-acquired CDI cases are also on the rise, and this vulnerability is not limited to immunocompromised patients. Gastrointestinal treatments and/or gastrointestinal tract surgeries may be required for patients diagnosed with digestive diseases. Such treatments could suppress or interfere with the patient’s immune system and disrupt gut flora homeostasis, creating a suitable microecosystem for C. difficile overgrowth. Currently, stool-based non-invasive screening is the first-line approach to CDI diagnosis, but the accuracy is varied due to different clinical microbiology detection methods; therefore, improving reliability is clearly required. In this review, we briefly summarised the life cycle and toxicity of C. difficile, and we examined existing diagnostic approaches with an emphasis on novel biomarkers such as microRNAs. These biomarkers can be easily detected through non-invasive liquid biopsy and can yield crucial information about ongoing pathological phenomena, particularly in CDI.
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Affiliation(s)
- Marco Bocchetti
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli,” Naples 80138, Italy
- Department of Molecular Oncology, Precision Medicine Laboratory and COVID19 Laboratory, Biogem Scarl, Ariano Irpino 83031, Italy
| | - Maria Grazia Ferraro
- School of Infection and Immunity, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8QQ, United Kingdom
- Department of Pharmacy, School of Medicine and Surgery, University of Naples “Federico II,” Naples 80131, Italy
| | - Federica Melisi
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli,” Naples 80138, Italy
- Department of Molecular Oncology, Precision Medicine Laboratory and COVID19 Laboratory, Biogem Scarl, Ariano Irpino 83031, Italy
| | - Piera Grisolia
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli,” Naples 80138, Italy
- Department of Molecular Oncology, Precision Medicine Laboratory and COVID19 Laboratory, Biogem Scarl, Ariano Irpino 83031, Italy
| | - Marianna Scrima
- Department of Molecular Oncology, Precision Medicine Laboratory and COVID19 Laboratory, Biogem Scarl, Ariano Irpino 83031, Italy
| | - Alessia Maria Cossu
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli,” Naples 80138, Italy
- Department of Molecular Oncology, Precision Medicine Laboratory and COVID19 Laboratory, Biogem Scarl, Ariano Irpino 83031, Italy
| | - Tung On Yau
- School of Science and Technology, Nottingham Trent University, Nottingham NG11 8NS, United Kingdom
- Department of Rural Land Use, Scotland’s Rural College, Aberdeen AB21 9YA, Scotland, United Kingdom
- Department of Health Science, University of the People, Pasadena, CA 9110112, United States
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Qi H, Wang Y, Wu P, Ma Y, Wang J. Rapid and fully-automated detection of Clostridium difficile Toxin B via magnetic-particle-based chemiluminescent immunoassay. Am J Transl Res 2020; 12:4228-4236. [PMID: 32913500 PMCID: PMC7476116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/17/2020] [Indexed: 06/11/2023]
Abstract
Clostridium difficile colitis is caused by a cytotoxin produced by the anaerobic bacteria C. difficile on the epithelial cells of the large intestine, particularly C. difficile toxin B (Tcd B). Current C. difficile toxin assays have proven to be insensitive and have thus been ruled out from diagnostic purposes. Therefore, Tcd B detection via sandwich-type chemiluminescent immunoassay was proposed as a straightforward approach with potential diagnostic applicability. Here, two high-affinity anti-Tcd B monoclonal antibodies were successfully identified and implemented in a fully-automated magnetic-particle-based chemiluminescent immunoassay (CLEIA). In this test, toxin B was sandwiched between the anti-toxin B antibody-coated magnetic particles and alkaline phosphate-labeled anti-toxin B antibodies. Compared with traditional techniques, the proposed immunoassay demonstrated high sensitivity for toxin B identification and was further optimized to achieve a linear response ranging from 0.12 to 150 ng/mL with a limit of detection (LOD) of 0.47 ng/mL. Importantly, the entire process could be completed in less than 30 minutes. The proposed assay was used to detect toxin B in 104 randomly-selected human stool samples and delivered similar results to those of a commercial ELISA kit, highlighting its great potential for rapid and efficient toxin B determination in human stool specimens.
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Affiliation(s)
- Haonan Qi
- School of Biology and Biological Engineering, South China University of TechnologyGuangzhou 510006, China
| | - Yu Wang
- College of Food Sciences, South China University of TechnologyGuangzhou 510006, China
| | - Peidian Wu
- National & Local United Engineering Lab of Rapid Diagnostic Test, Guangzhou Wondfo Biotech Co., Ltd.Guangzhou 510663, China
| | - Yi Ma
- School of Biology and Biological Engineering, South China University of TechnologyGuangzhou 510006, China
| | - Jufang Wang
- School of Biology and Biological Engineering, South China University of TechnologyGuangzhou 510006, China
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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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Carroll KC, Mizusawa M. Laboratory Tests for the Diagnosis of Clostridium difficile. Clin Colon Rectal Surg 2020; 33:73-81. [PMID: 32104159 PMCID: PMC7042017 DOI: 10.1055/s-0039-3400476] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Clostridium (reclassified as " Clostridioides ") difficile is an anaerobic, gram-positive bacterium that causes significant disease through elaboration of two potent toxins in patients whose normal gut microbiota has been altered through antimicrobial or chemotherapeutic agents (dysbiosis). The optimum method of laboratory diagnosis is still somewhat controversial. Recent practice guidelines published by professional societies recommend a two-step approach beginning with a test for glutamate dehydrogenase (GDH), followed by a toxin test and/or a nucleic acid test. Alternatively, in institutions where established clinical algorithms guide testing, a nucleic acid test alone is acceptable. Nucleic acid tests are the methods of choice in approximately 50% of laboratories in the United States. These tests are considered as the most sensitive methods for detection of C. difficile in stool and are the least specific. Because of the lower specificity with nucleic acid tests, some clinicians believe that toxin enzyme immunoassays are better predictors of disease, despite their known poor performance in certain patient populations. This review will discuss the advantages and disadvantages of the currently available test methods for the diagnosis of C. difficile with a brief mention of some novel assays that are currently in clinical trials.
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Affiliation(s)
- Karen C. Carroll
- Division of Medical Microbiology, Department of Pathology, the Johns Hopkins University School of Medicine, Baltimore, Maryland
- Address for correspondence Karen C. Carroll, MD Division of Medical Microbiology, Department of Pathology, the Johns Hopkins University School of MedicineMeyer B1-193, 600 North Wolfe Street, Baltimore MD 21287
| | - Masako Mizusawa
- Section of Infectious Diseases, Department of Internal Medicine, University of Missouri, Kansas City, Missouri
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Abreu Y Abreu AT, Velarde-Ruiz Velasco JA, Zavala-Solares MR, Remes-Troche JM, Carmona-Sánchez RI, Aldana-Ledesma JM, Camacho-Ortiz A, Contreras-Omaña R, Díaz-Seoane R, Elizondo-Vázquez CT, Garza-González E, Grajales-Figueroa G, Gómez-Escudero O, Jacobo-Karam JS, Morales-Arámbula M, Olivares-Guzmán LO, Sifuentes-Osornio J, Siu-Moguel AG, Soto-Solís R, Valdovinos-García LR, Valdovinos-Díaz MA, Vázquez-Elizondo G, Lazo-de la Vega Jasso SA. Consensus on the prevention, diagnosis, and treatment of Clostridium difficile infection. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2019; 84:204-219. [PMID: 30987771 DOI: 10.1016/j.rgmx.2018.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/26/2018] [Accepted: 12/10/2018] [Indexed: 02/07/2023]
Abstract
In recent decades, Clostridium difficile infection (CDI) has become a worldwide health problem. Mexico is no exception, and therefore the Asociación Mexicana de Gastroenterología brought together a multidisciplinary group (gastroenterologists, endoscopists, internists, infectious disease specialists, and microbiologists) to carry out the "Consensus on the prevention, diagnosis, and treatment of Clostridium difficile infection", establishing useful recommendations (in relation to the adult population) for the medical community. Said recommendations are presented herein. Among them, it was recognized that CDI should be suspected in subjects with diarrhea that have a history of antibiotic and/or immunosuppressant use, but that it can also be a community-acquired infection. A 2-step diagnostic algorithm was proposed, in which a highly sensitive test, such as glutamate dehydrogenase (GDH), is first utilized, and if positive, confirmed by the detection of toxins through immunoassay or nucleic acid detection tests. Another recommendation was that CDI based on clinical evaluation be categorized as mild-moderate, severe, and complicated severe, given that such a classification enables better therapeutic decisions to be made. In mild-moderate CDI, oral vancomycin is the medication of choice, and metronidazole is recommended as an alternative treatment. In addition, fecal microbiota transplantation was recognized as an efficacious option in patients with recurrence or in the more severe cases of infection, and surgery should be reserved for patients with severe colitis (toxic megacolon), in whom all medical treatment has failed.
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Affiliation(s)
| | - J A Velarde-Ruiz Velasco
- Servicio de Gastroenterología, Hospital Civil de Guadalajara «Fray Antonio Alcalde», Guadalajara, Jalisco, México.
| | - M R Zavala-Solares
- Servicio de Gastroenterología, Hospital General de México, Ciudad de México, México
| | - J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - R I Carmona-Sánchez
- Unidad de Medicina Ambulatoria Christus Muguerza, San Luis Potosí, S.L.P., México
| | - J M Aldana-Ledesma
- Servicio de Gastroenterología, Hospital Civil de Guadalajara «Fray Antonio Alcalde», Guadalajara, Jalisco, México
| | - A Camacho-Ortiz
- Servicio de Infectología, Hospital Universitario «Dr. José Eleuterio González», Monterrey, Nuevo León, México
| | - R Contreras-Omaña
- Centro de Investigación en Enfermedades Hepáticas y Gastroenterología, Pachuca, Hidalgo, México
| | | | | | - E Garza-González
- Servicio de Gastroenterología, Hospital Universitario «Dr. José Eleuterio González», Monterrey, Nuevo León, México
| | - G Grajales-Figueroa
- Departamento de Endoscopia, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | - O Gómez-Escudero
- Clínica de Gastroenterología, Endoscopía Digestiva y Motilidad Gastrointestinal, Hospital Ángeles, Puebla, Puebla, México
| | - J S Jacobo-Karam
- Hospital General 450, Secretaría de Salud, Durango, Durango, México
| | | | | | - J Sifuentes-Osornio
- Departamento de Infectología, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | | | - R Soto-Solís
- Departamento de Endoscopia, Centro Médico Nacional 20 de Noviembre, ISSSTE, Ciudad de México, México
| | - L R Valdovinos-García
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | - M A Valdovinos-Díaz
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | - G Vázquez-Elizondo
- Escuela Nacional de Medicina, Tecnológico de Monterrey, Monterrey, Nuevo León, México
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6
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Consensus on the prevention, diagnosis, and treatment of Clostridium difficile infection. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2019. [DOI: 10.1016/j.rgmxen.2018.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Solbach P, Chhatwal P, Woltemate S, Tacconelli E, Buhl M, Gerhard M, Thoeringer CK, Vehreschild MJGT, Jazmati N, Rupp J, Manns MP, Bachmann O, Suerbaum S. BaiCD gene cluster abundance is negatively correlated with Clostridium difficile infection. PLoS One 2018; 13:e0196977. [PMID: 29738579 PMCID: PMC5940204 DOI: 10.1371/journal.pone.0196977] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 04/24/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a major cause of hospital-acquired diarrhea. Secondary bile acids were shown to confer resistance to colonization by C. difficile. 7α-dehydroxylation is a key step in transformation of primary to secondary bile acids and required genes have been located in a single bile acid-inducible (bai) operon in C. scindens as well as in C. hiranonis, two Clostridium sp. recently reported to protect against C. difficile colonization. AIM To analyze baiCD gene abundance in C. difficile positive and negative fecal samples. MATERIAL & METHODS A species-specific qPCR for detecting baiCD genes was established. Fecal samples of patients with CDI, asymptomatic toxigenic C. difficile colonization (TCD), non-toxigenic C. difficile colonization (NTCD), of C. difficile negative (NC) patients, and of two patients before and after fecal microbiota transplantation (FMT) for recurrent CDI (rCDI) were tested for the presence of the baiCD genes. RESULTS The prevalence of the baiCD gene cluster was significantly higher in C. difficile negative fecal samples than in samples of patients diagnosed with CDI (72.5% (100/138) vs. 35.9% (23/64; p<0.0001). No differences in baiCD gene cluster prevalence were seen between NC and NTCD or NC and TCD samples. Both rCDI patients were baiCD-negative at baseline, but one of the two patients turned positive after successful FMT from a baiCD-positive donor. CONCLUSION Fecal samples of CDI patients are less frequently baiCD-positive than samples from asymptomatic carriers or C. difficile-negative individuals. Furthermore, we present a case of baiCD positivity observed after successful FMT for rCDI.
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Affiliation(s)
- Philipp Solbach
- Hannover Medical School, Institute of Medical Microbiology and Hospital Epidemiology, Hannover, Germany
- Hannover Medical School, Department of Gastroenterology, Hepatology and Endocrinology, Hannover, Germany
- German Center for Infection Research (DZIF), partner site Hannover-Braunschweig, Hannover-Braunschweig, Germany
| | - Patrick Chhatwal
- Hannover Medical School, Institute of Medical Microbiology and Hospital Epidemiology, Hannover, Germany
- German Center for Infection Research (DZIF), partner site Hannover-Braunschweig, Hannover-Braunschweig, Germany
| | - Sabrina Woltemate
- Hannover Medical School, Institute of Medical Microbiology and Hospital Epidemiology, Hannover, Germany
- German Center for Infection Research (DZIF), partner site Hannover-Braunschweig, Hannover-Braunschweig, Germany
| | - Evelina Tacconelli
- Tübingen University Hospital, Division of Infectious Diseases, Department of Internal Medicine 1, Tübingen, Germany
- German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany
| | - Michael Buhl
- German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany
- Tübingen University Hospital, Institute of Medical Microbiology and Hygiene, Tübingen, Germany
| | - Markus Gerhard
- Technische Universität München, Institute for Medical Microbiology, Immunology and Hygiene, Munich, Germany
- German Center for Infection Research (DZIF), partner site Munich, Munich, Germany
| | - Christoph K. Thoeringer
- German Center for Infection Research (DZIF), partner site Munich, Munich, Germany
- Technische Universität München, Department of Internal Medicine II, Klinikum rechts der Isar, Munich, Germany
| | - Maria J. G. T. Vehreschild
- University Hospital of Cologne, 1st Department of Internal Medicine, Cologne, Germany
- German Center for Infection Research (DZIF), partner site Bonn-Cologne, Bonn-Cologne, Germany
| | - Nathalie Jazmati
- German Center for Infection Research (DZIF), partner site Bonn-Cologne, Bonn-Cologne, Germany
- University of Cologne, Institute for Medical Microbiology, Immunology and Hygiene, Cologne, Germany
| | - Jan Rupp
- University Hospital Schleswig-Holstein, Department of Infectious Diseases and Microbiology, Lübeck, Germany
- German Center for Infection Research (DZIF), partner site Hamburg-Borstel-Lübeck, Hamburg-Borstel-Lübeck, Germany
| | - Michael P. Manns
- Hannover Medical School, Department of Gastroenterology, Hepatology and Endocrinology, Hannover, Germany
| | - Oliver Bachmann
- Hannover Medical School, Department of Gastroenterology, Hepatology and Endocrinology, Hannover, Germany
- German Center for Infection Research (DZIF), partner site Hannover-Braunschweig, Hannover-Braunschweig, Germany
- * E-mail: (SS); (OB)
| | - Sebastian Suerbaum
- Hannover Medical School, Institute of Medical Microbiology and Hospital Epidemiology, Hannover, Germany
- German Center for Infection Research (DZIF), partner site Hannover-Braunschweig, Hannover-Braunschweig, Germany
- German Center for Infection Research (DZIF), partner site Munich, Munich, Germany
- LMU Munich, Max von Pettenkofer Institute, München, Germany
- * E-mail: (SS); (OB)
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Ohnishi K, Ainoda Y, Imamura A, Iwabuchi S, Okuda M, Nakano T. JAID/JSC Guidelines for Infection Treatment 2015-Intestinal infections. J Infect Chemother 2017; 24:1-17. [PMID: 28986191 DOI: 10.1016/j.jiac.2017.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 09/04/2017] [Accepted: 09/05/2017] [Indexed: 01/10/2023]
Affiliation(s)
| | | | | | - Kenji Ohnishi
- Tokyo Metropolitan Health and Medical Corporation Ebara Hospital, Tokyo, Japan
| | - Yusuke Ainoda
- Tokyo Metropolitan Health and Medical Corporation Ebara Hospital, Tokyo, Japan; Department of Infectious Diseases, Tokyo Women's Medical University, Japan
| | - Akifumi Imamura
- Department of Infectious Diseases, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Sentaro Iwabuchi
- Department of Infectious Diseases, Tokyo Metropolitan Bokutoh General Hospital, Tokyo, Japan
| | - Masumi Okuda
- Department of Pediatrics, Sasayama Medical Center, Hyogo College of Medicine, Sasayama, Hyogo, Japan
| | - Takashi Nakano
- Department of Pediatrics, Kawasaki Medical School, Okayama, Japan
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Abstract
Clostridium difficile infections (CDIs) have emerged as one of the principal threats to the health of hospitalized and immunocompromised patients. The importance of C difficile colonization is increasingly recognized not only as a source for false-positive clinical testing but also as a source of new infections within hospitals and other health care environments. In the last five years, several new treatment strategies that capitalize on the increasing understanding of the altered microbiome and host defenses in patients with CDI have completed clinical trials, including fecal microbiota transplantation. This article highlights the changing epidemiology, laboratory diagnostics, pathogenesis, and treatment of CDI.
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Makristathis A, Zeller I, Mitteregger D, Kundi M, Hirschl AM. Comprehensive evaluation of chemiluminescent immunoassays for the laboratory diagnosis of Clostridium difficile infection. Eur J Clin Microbiol Infect Dis 2017; 36:1253-1259. [PMID: 28181032 PMCID: PMC5495843 DOI: 10.1007/s10096-017-2916-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 01/24/2017] [Indexed: 01/05/2023]
Abstract
For the microbiological diagnosis of a Clostridium (C.) difficile infection (CDI), a two-test algorithm consisting of a C. difficile glutamate dehydrogenase (GDH)-immunoassay followed by a toxin-immunoassay in positive cases is widely used. In this study, two chemiluminescent immunoassays (CLIAs), one for GDH and the other for the toxins A and B, have been evaluated systematically using appropriate reference methods. Three-hundred diarrhoeal stool specimens submitted for CDI diagnosis were analysed by the LIAISON CLIAs (DiaSorin). Toxigenic culture (TC) and cell cytotoxicity assay (CCTA) were used as "gold standard" reference methods. In addition, GDH and toxin A and B enzyme immunoassays (EIAs), C. diff Chek-60 and toxin A/B II (TechLab), and the Cepheid Xpert C. difficile polymerase chain reaction (PCR) were performed. C. difficile was grown in 42 (14%), TC was positive in 35 (11.7%) and CCTA in 25 (8.3%) cases. CLIAs were more sensitive but less specific than the respective EIAs. Using culture as reference, the sensitivity of the GDH CLIA was 100%. In comparison to CCTA sensitivity, specificity, positive predictive value and negative predictive value of the two-test algorithm were 88, 99.3, 91.7 and 98.9% by CLIAs and 72, 99.6, 94.7 and 97.5% by EIAs. Discrepant results by CLIAs were more frequent than that by EIAs (9% vs. 6.3%); in those cases, PCR allowed for the accurate detection of toxigenic strains. Due to performance characteristics and testing comfort, CLIAs in combination with PCR represent a favourable option for the rapid laboratory C. difficile diagnostics.
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Affiliation(s)
- A Makristathis
- Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University Vienna, Vienna, Austria.
| | - I Zeller
- Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University Vienna, Vienna, Austria
| | - D Mitteregger
- Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University Vienna, Vienna, Austria
| | - M Kundi
- Department of Environmental Hygiene, Medical University Vienna, Vienna, Austria
| | - A M Hirschl
- Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University Vienna, Vienna, Austria
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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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Bouza E, Alcalá L, Reigadas E. Optimizing the diagnostic testing of Clostridium difficile infection. Expert Rev Anti Infect Ther 2016; 14:801-8. [PMID: 27462827 DOI: 10.1080/14787210.2016.1216313] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Clostridium difficile infection (CDI) is the leading cause of hospital-acquired diarrhea and is associated with a considerable health and cost burden. However, there is still not a clear consensus on the best laboratory diagnosis approach and a wide variation of testing methods and strategies can be encountered. AREAS COVERED We aim to review the most practical aspects of CDI diagnosis providing our own view on how to optimize CDI diagnosis. Expert commentary: Laboratory diagnosis in search of C. difficile toxins should be applied to all fecal diarrheic samples reaching the microbiology laboratory in patients > 2 years old, with or without classic risk factors for CDI. Detection of toxins either directly in the fecal sample or in the bacteria isolated in culture confirm CDI in the proper clinical setting. Nuclear Acid Assay techniques (NAAT) allow to speed up the process with epidemiological and therapeutic consequences.
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Affiliation(s)
- Emilio Bouza
- a Department of Clinical Microbiology and Infectious Diseases , Hospital General Universitario Gregorio Marañón , Madrid , Spain.,b Facultad de Medicina , Universidad Complutense de Madrid (UCM) , Madrid , Spain.,c Instituto de Investigación Sanitaria Gregorio Marañón , Madrid , Spain.,d CIBER de Enfermedades Respiratorias (CIBERES CD06/06/0058) , Madrid , Spain
| | - Luis Alcalá
- a Department of Clinical Microbiology and Infectious Diseases , Hospital General Universitario Gregorio Marañón , Madrid , Spain.,d CIBER de Enfermedades Respiratorias (CIBERES CD06/06/0058) , Madrid , Spain
| | - Elena Reigadas
- a Department of Clinical Microbiology and Infectious Diseases , Hospital General Universitario Gregorio Marañón , Madrid , Spain.,c Instituto de Investigación Sanitaria Gregorio Marañón , Madrid , Spain
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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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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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Clostridium difficile Infections in Children: Impact of the Diagnostic Method on Infection Rates. Infect Control Hosp Epidemiol 2016; 37:1087-93. [DOI: 10.1017/ice.2016.123] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUNDPolymerase chain reaction (PCR) assays based on the detection of the toxin B gene are replacing enzyme-linked immunosorbent assay (ELISA)–based toxin production detection or cell cytotoxicity assay in most laboratories.OBJECTIVETo determine the proportion of pediatric patients diagnosed withClostridium difficile infection by PCR who would have also been diagnosed by ELISA and to compare the clinical characteristics of PCR+/ELISA+ vs PCR+/ELISA− patients.METHODSUsing the microbiology laboratory information system, stool samples positive for C. difficile by PCR between October 2010 and July 2014 were identified. Using frozen stool specimens, an ELISA for toxin A and B was performed. A retrospective medical chart review was conducted to obtain demographic and clinical data. Duplicate samples were excluded.RESULTSA total of 136 PCR-positive samples underwent ELISA testing: 54 (40%) were positive for toxin A or B. The mean (SD) age of the entire cohort was 8.5 (6.2) years. There was no difference in age, gender, clinical manifestation, previous medical problems, and management between patients positive or negative by ELISA. However, patients positive by ELISA were more likely to have had a recent exposure to antibiotics (67.9% vs 50%; crude odds ratio, 2.1 [95% CI, 1.03–4.28]).CONCLUSIONIn our pediatric population, 60% of patients with C. difficile diagnosed by PCR had no toxin detectable by ELISA. ELISA-negative patients were less likely to have received an antibiotic recently compared with ELISA-positive patients. These results highlight the need to standardize laboratory criteria for the diagnosis of C. difficile infections in children.Infect Control Hosp Epidemiol 2016;37:1087–1093
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Nagpal R, Ogata K, Tsuji H, Matsuda K, Takahashi T, Nomoto K, Suzuki Y, Kawashima K, Nagata S, Yamashiro Y. Sensitive quantification of Clostridium perfringens in human feces by quantitative real-time PCR targeting alpha-toxin and enterotoxin genes. BMC Microbiol 2015; 15:219. [PMID: 26482797 PMCID: PMC4615878 DOI: 10.1186/s12866-015-0561-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 10/08/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clostridium perfringens is a widespread pathogen, but the precise quantification of this subdominant gut microbe remains difficult due to its low fecal count (particularly in asymptomatic subjects) and also due to the presence of abundant polymerase-inhibitory substances in human feces. Also, information on the intestinal carriage of toxigenic C. perfringens strains in healthy subjects is sparse. Therefore, we developed a sensitive quantitative real-time PCR assays for quantification of C. perfringens in human feces by targeting its α-toxin and enterotoxin genes. To validate the assays, we finally observed the occurrence of α-toxigenic and enterotoxigenic C. perfringens in the fecal microbiota of healthy Japanese infants and young adults. METHODS The plc-specific qPCR assay was newly validated, while primers for 16S rRNA and cpe genes were retrieved from literature. The assays were validated for specificity and sensitivity in pre-inoculated fecal samples, and were finally applied to quantify C. perfringens in stool samples from apparently healthy infants (n 124) and young adults (n 221). RESULTS The qPCR assays were highly specific and sensitive, with a minimum detection limit of 10(3) bacterial cells/g feces. Alpha-toxigenic C. perfringens was detected in 36% infants and 33% adults, with counts ranging widely (10(3)-10(7) bacterial cells/g). Intriguingly, the mean count of α-toxigenic C. perfringens was significantly higher in infants (6.0±1.5 log10 bacterial cells/g), as compared to that in adults (4.8±1.2). Moreover, the prevalence of enterotoxigenic C. perfringens was also found to be significantly higher in infants, as compared to that in adults. The mean enterotoxigenic C. perfringens count was 5.9±1.9 and 4.8±0.8 log10 bacterial cells/g in infants and adults, respectively. CONCLUSIONS These data indicate that some healthy infants and young adults carry α-toxigenic and enterotoxigenic C. perfringens at significant levels, and may be predisposed to related diseases. Thus, high fecal carriage of toxigenic C. perfringens in healthy children warrants further investigation on its potential sources and clinical significance in these subjects. In summary, we present a novel qPCR assay for sensitive and accurate quantification of α-toxigenic and enterotoxigenic C. perfringens in human feces, which should facilitate prospective studies of the gut microbiota.
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Affiliation(s)
- Ravinder Nagpal
- Probiotics Research Laboratory, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | | | | | - Kazunori Matsuda
- Yakult Honsha European Research Center for Microbiology, Ghent-Zwijnaarde, Belgium.
| | | | | | - Yoshio Suzuki
- Department of Sports Science, Juntendo University School of Health and Sports Sciences, Chiba, Japan.
| | | | - Satoru Nagata
- Department of Pediatrics, School of Medicine, Tokyo Women's Medical University, Tokyo, Japan.
| | - Yuichiro Yamashiro
- Probiotics Research Laboratory, Juntendo University Graduate School of Medicine, Tokyo, Japan.
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Evaluation of the BD Max Cdiff assay for the detection of toxigenic Clostridium difficile in human stool specimens. Pathology 2015; 47:165-8. [PMID: 25551308 DOI: 10.1097/pat.0000000000000214] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The Becton Dickinson (BD) PCR-based GeneOhm Cdiff assay has demonstrated a high sensitivity and specificity for detecting Clostridium difficile. Recently, the BD Max platform, using the same principles as BD GeneOhm, has become available in Australia. This study aimed to investigate the sensitivity and specificity of BD Max Cdiff assay for the detection of toxigenic C. difficile in an Australian setting. Between December 2013 and January 2014, 406 stool specimens from 349 patients were analysed with the BD Max Cdiff assay. Direct and enrichment toxigenic culture were performed on bioMérieux ChromID C. difficile agar as a reference method. isolates from specimens with discrepant results were further analysed with an in-house PCR to detect the presence of toxin genes. The overall prevalence of toxigenic C. difficile was 7.2%. Concordance between the BD Max assay and enrichment culture was 98.5%. The sensitivity, specificity, positive predictive value and negative predictive value for the BD Max Cdiff assay were 95.5%, 99.0%, 87.5% and 99.7%, respectively, when compared to direct culture, and 91.7%, 99.0%, 88.0% and 99.4%, respectively, when compared to enrichment culture. The new BD Max Cdiff assay appeared to be an excellent platform for rapid and accurate detection of toxigenic C. difficile.
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Planche T, Wilcox MH. Diagnostic Pitfalls in Clostridium difficile Infection. Infect Dis Clin North Am 2015; 29:63-82. [DOI: 10.1016/j.idc.2014.11.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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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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Neemann K, Minhas V, Loberiza FR, Freifield A. Transplant related outcomes in patients with hematopoietic stem cell transplant withClostridium difficileassociated diarrhea. Leuk Lymphoma 2014; 56:260-2. [DOI: 10.3109/10428194.2014.917637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Combination of culture, antigen and toxin detection, and cytotoxin neutralization assay for optimal Clostridium difficile diagnostic testing. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2014; 24:89-92. [PMID: 24421808 DOI: 10.1155/2013/934945] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND There has been a growing interest in developing an appropriate laboratory diagnostic algorithm for Clostridium difficile, mainly as a result of increases in both the number and severity of cases of C difficile infection in the past decade. A C difficile diagnostic algorithm is necessary because diagnostic kits, mostly for the detection of toxins A and B or glutamate dehydrogenase (GDH) antigen, are not sufficient as stand-alone assays for optimal diagnosis of C difficile infection. In addition, conventional reference methods for C difficile detection (eg, toxigenic culture and cytotoxin neutralization [CTN] assays) are not routinely practiced in diagnostic laboratory settings. OBJECTIVE To review the four-step algorithm used at Diagnostic Services of Manitoba sites for the laboratory diagnosis of toxigenic C difficile. RESULT One year of retrospective C difficile data using the proposed algorithm was reported. Of 5695 stool samples tested, 9.1% (n=517) had toxigenic C difficile. Sixty per cent (310 of 517) of toxigenic C difficile stools were detected following the first two steps of the algorithm. CTN confirmation of GDH-positive, toxin A- and B-negative assays resulted in detection of an additional 37.7% (198 of 517) of toxigenic C difficile. Culture of the third specimen, from patients who had two previous negative specimens, detected an additional 2.32% (12 of 517) of toxigenic C difficile samples. DISCUSSION Using GDH antigen as the screening and toxin A and B as confirmatory test for C difficile, 85% of specimens were reported negative or positive within 4 h. Without CTN confirmation for GDH antigen and toxin A and B discordant results, 37% (195 of 517) of toxigenic C difficile stools would have been missed. Following the algorithm, culture was needed for only 2.72% of all specimens submitted for C difficile testing. CONCLUSION The overview of the data illustrated the significance of each stage of this four-step C difficile algorithm and emphasized the value of using CTN assay and culture as parts of an algorithm that ensures accurate diagnosis of toxigenic C difficile.
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Diagnosis of Clostridium difficile infection: an ongoing conundrum for clinicians and for clinical laboratories. Clin Microbiol Rev 2014; 26:604-30. [PMID: 23824374 DOI: 10.1128/cmr.00016-13] [Citation(s) in RCA: 277] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Clostridium difficile is a formidable nosocomial and community-acquired pathogen, causing clinical presentations ranging from asymptomatic colonization to self-limiting diarrhea to toxic megacolon and fulminant colitis. Since the early 2000s, the incidence of C. difficile disease has increased dramatically, and this is thought to be due to the emergence of new strain types. For many years, the mainstay of C. difficile disease diagnosis was enzyme immunoassays for detection of the C. difficile toxin(s), although it is now generally accepted that these assays lack sensitivity. A number of molecular assays are commercially available for the detection of C. difficile. This review covers the history and biology of C. difficile and provides an in-depth discussion of the laboratory methods used for the diagnosis of C. difficile infection (CDI). In addition, strain typing methods for C. difficile and the evolving epidemiology of colonization and infection with this organism are discussed. Finally, considerations for diagnosing C. difficile disease in special patient populations, such as children, oncology patients, transplant patients, and patients with inflammatory bowel disease, are described. As detection of C. difficile in clinical specimens does not always equate with disease, the diagnosis of C. difficile infection continues to be a challenge for both laboratories and clinicians.
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Upton DA. Le Clostridium difficile dans les populations d’âge pédiatrique. Paediatr Child Health 2014. [DOI: 10.1093/pch/19.1.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Allen UD. Clostridium difficile in paediatric populations. Paediatr Child Health 2014; 19:43-54. [PMID: 24627655 PMCID: PMC3938221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
An increase in Clostridium difficile infection incidence has been observed among hospitalized children in the United States. The present statement, targeted at clinicians caring for infants and children in community and institutional settings, summarizes the relevant information relating to the role of C difficile in childhood diarrhea and provides recommendations for diagnosis, prevention and treatment. Significant differences between adult and paediatric risk factors and disease are discussed, along with emerging therapies. The relationship between age and disease severity in children with a newly emergent and more fluoroqinolone-resistant strain of C difficile (North American Pulse-field type-1 [NAP1]) remains unknown. The importance of antimicrobial stewardship as a preventive strategy is highlighted. This statement replaces a previous Canadian Paediatric Society position statement on C difficile published in 2000.
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Economic evaluation of laboratory testing strategies for hospital-associated Clostridium difficile infection. J Clin Microbiol 2013; 52:489-96. [PMID: 24478478 DOI: 10.1128/jcm.02777-13] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile infection (CDI) is the most common cause of infectious diarrhea in health care settings, and for patients presumed to have CDI, their isolation while awaiting laboratory results is costly. Newer rapid tests for CDI may reduce this burden, but the economic consequences of different testing algorithms remain unexplored. We used decision analysis from the hospital perspective to compare multiple CDI testing algorithms for adult inpatients with suspected CDI, assuming patient management according to laboratory results. CDI testing strategies included combinations of on-demand PCR (odPCR), batch PCR, lateral-flow diagnostics, plate-reader enzyme immunoassay, and direct tissue culture cytotoxicity. In the reference scenario, algorithms incorporating rapid testing were cost-effective relative to nonrapid algorithms. For every 10,000 symptomatic adults, relative to a strategy of treating nobody, lateral-flow glutamate dehydrogenase (GDH)/odPCR generated 831 true-positive results and cost $1,600 per additional true-positive case treated. Stand-alone odPCR was more effective and more expensive, identifying 174 additional true-positive cases at $6,900 per additional case treated. All other testing strategies were dominated by (i.e., more costly and less effective than) stand-alone odPCR or odPCR preceded by lateral-flow screening. A cost-benefit analysis (including estimated costs of missed cases) favored stand-alone odPCR in most settings but favored odPCR preceded by lateral-flow testing if a missed CDI case resulted in less than $5,000 of extended hospital stay costs and <2 transmissions, if lateral-flow GDH diagnostic sensitivity was >93%, or if the symptomatic carrier proportion among the toxigenic culture-positive cases was >80%. These results can aid guideline developers and laboratory directors who are considering rapid testing algorithms for diagnosing CDI.
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Is the prevalence of Clostridium difficile in animals underestimated? Vet J 2013; 197:694-8. [DOI: 10.1016/j.tvjl.2013.03.053] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 02/18/2013] [Accepted: 03/07/2013] [Indexed: 11/18/2022]
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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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Pant C, Deshpande A, Altaf MA, Minocha A, Sferra TJ. Clostridium difficile infection in children: a comprehensive review. Curr Med Res Opin 2013; 29:967-84. [PMID: 23659563 DOI: 10.1185/03007995.2013.803058] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To provide a comprehensive review of the literature relating to Clostridium difficile (C. difficile) infection (CDI) in the pediatric population. METHODS Two investigators conducted independent searches of PubMed, Web of Science, and Scopus until March 31st, 2013. All databases were searched using the terms 'Clostridium difficile infection', 'Clostridium difficile associated diarrhea' 'antibiotic associated diarrhea', 'C. difficile', in combination with 'pediatric' and 'paediatric'. Articles which discussed pediatric CDI were reviewed and relevant cross references also read and evaluated for inclusion. Selection bias could be a possible limitation of this approach. FINDINGS There is strong evidence for an increased incidence of pediatric CDI. Increasingly, the infection is being acquired from the community, often without a preceding history of antibiotic use. The severity of the disease has remained unchanged. Several medical conditions may be associated with the development of pediatric CDI. Infection prevention and control with antimicrobial stewardship are of paramount importance. It is important to consider the age of the child while testing for CDI. Traditional therapy with metronidazole or vancomycin remains the mainstay of treatment. Newer antibiotics such as fidaxomicin appear promising especially for the treatment of recurrent infection. Conservative surgical options may be a life-saving measure in severe or fulminant cases. CONCLUSIONS Pediatric providers should be cognizant of the increased incidence of CDI in children. Early and judicious testing coupled with the timely institution of therapy will help to secure better outcomes for this disease.
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Affiliation(s)
- Chaitanya Pant
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Faires MC, Pearl DL, Berke O, Reid-Smith RJ, Weese JS. The identification and epidemiology of meticillin-resistant Staphylococcus aureus and Clostridium difficile in patient rooms and the ward environment. BMC Infect Dis 2013; 13:342. [PMID: 23883171 PMCID: PMC3727943 DOI: 10.1186/1471-2334-13-342] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 07/18/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Research has indicated that the environment may play an important role in the transmission of meticillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile in healthcare facilities. Despite the significance of this finding, few data exist from longitudinal studies investigating MRSA and C. difficile contamination, concurrently, in both patient rooms and the general ward environment. The objectives of this study were to determine the prevalence of MRSA and C. difficile contamination in patient rooms and the ward environment and identify risk factors associated with a surface being contaminated with these pathogens. METHODS Environmental surfaces in patient rooms and the general environment in the medical and surgical wards of a community hospital were sampled six times over a 15 week period. Sterile electrostatic cloths were used for sampling and information pertaining to the surface sampled was recorded. MRSA isolates and C. difficile specimens were obtained from hospitalized patients.Enrichment culture was performed and spa typing or ribotyping was conducted for MRSA or C. difficile, respectively. Exact logistic regression models were constructed to examine risk factors associated with MRSA and C. difficile contamination. RESULTS Sixteen (41%) patient rooms had ≥ 1 surfaces contaminated with MRSA and/or C. difficile. For 218 surfaces investigated, 3.2% and 6.4% were contaminated with MRSA or C. difficile, respectively. Regression models indicated that surfaces in rooms exposed to a C. difficile patient had significantly increased odds of being contaminated with C. difficile, compared to surfaces in unexposed patient rooms. Additionally, compared to plastic surfaces, cork surfaces had significantly increased odds of being contaminated with C. difficile. For 236 samples collected from the ward environment, MRSA and C. difficile were recovered from 2.5% and 5.9% of samples, respectively. Overall, the majority of MRSA and C. difficile strains were molecularly identified as spa type 2/t002 (84.6%, n = 11) and ribotype 078 (50%, n = 14), respectively. CONCLUSIONS In patient rooms and the ward environment, specific materials and locations were identified as being contaminated with MRSA or C. difficile. These sites should be cleaned and disinfected with increased vigilance to help limit the transmission and dissemination of MRSA and C. difficile within the hospital.
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Affiliation(s)
- Meredith C Faires
- Department of Population Medicine, University of Guelph, Guelph, ON, Canada.
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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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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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Garimella PS, Agarwal R, Katz A. The utility of repeat enzyme immunoassay testing for the diagnosis of Clostridium difficile infection: a systematic review of the literature. J Postgrad Med 2013; 58:194-8. [PMID: 23023352 DOI: 10.4103/0022-3859.101392] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Over the last 20 years, the prevalence of healthcare-associated Clostridium difficile (C. diff) disease has increased. While multiple tests are available for the diagnosis of C. diff infection, enzyme immunoassay (EIA) testing for toxin is the most used. Repeat EIA testing, although of limited utility, is common in medical practice. To assess the utility of repeat EIA testing to diagnose C. diff infections. Systematic literature review. Eligible studies performed >1 EIA test for C. diff toxin and were published in English. Electronic searches of MEDLINE and EMBASE were performed and bibliographies of review articles and conference abstracts were hand searched. Of 805 citations identified, 32 were reviewed in detail and nine were included in the final review. All studies except one were retrospective chart reviews. Seven studies had data on number of participants (32,526), and the overall reporting of test setting and patient characteristics was poor. The prevalence of C. diff infection ranged from 9.1% to 18.5%. The yield of the first EIA test ranged from 8.4% to 16.6%, dropping to 1.5-4.7% with a second test. The utility of repeat testing was evident in outbreak settings, where the yield of repeat testing was 5%. Repeat C. diff testing for hospitalized patients has low clinical utility and may be considered in outbreak settings or when the pre-test probability of disease is high. Future studies should aim to identify patients with a likelihood of disease and determine the utility of repeat testing compared with empiric treatment.
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Affiliation(s)
- P S Garimella
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, 1900 W. Polk St, Chicago, IL 60607, USA
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Berg AM, Kelly CP, Farraye FA. Clostridium difficile infection in the inflammatory bowel disease patient. Inflamm Bowel Dis 2013; 19:194-204. [PMID: 22508484 DOI: 10.1002/ibd.22964] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Clostridium difficile infection (CDI) has been increasing in frequency and severity in patients with inflammatory bowel disease (IBD). Population based and single center studies have shown worse clinical outcomes in concomitant CDI and IBD, with several reporting longer length of hospital stay, higher colectomy rates and increased mortality. Clinically, CDI may be difficult to distinguish from an IBD flare and may range from an asymptomatic carrier state to severe life threatening colitis. The traditional risk factors for CDI have included hospitalization, antibiotic use, older age and severe co-morbid disease but IBD patients have several distinct characteristics including younger age, community acquisition, lack of antibiotic exposure, colonic IBD and steroid use. CDI can occur in the small bowel and specifically in ulcerative colitis patients who have had a colectomy and an ileal pouch anal anastomosis. PCR based assays and combination Elisa algorithms have improved the sensitivity and specificity of testing, though in IBD patients have raised clinical questions about how to best manage diarrhea in the setting of possible C. difficile colonization. Treatment modalities for CDI have not been examined in randomized clinical trials in the IBD population. Newer antibiotics, immunotherapy and fecal microbiota transplantation may alter current treatment strategies. This review will focus on the unique epidemiology of CDI in IBD patients, detail clinical disease states, and provide updated diagnostic strategies, prevention and treatment options.
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Affiliation(s)
- Adam M Berg
- Section of Gastroenterology, Boston Medical Center, Boston, Massachusetts 02118-2338, USA.
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Multicenter clinical evaluation of the portrait toxigenic C. difficile assay for detection of toxigenic Clostridium difficile strains in clinical stool specimens. J Clin Microbiol 2012; 50:3932-6. [PMID: 23015667 DOI: 10.1128/jcm.02083-12] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
We compared the Portrait Toxigenic C. difficile Assay, a new semiautomated sample-to-result molecular test, to a toxigenic bacterial culture/cell cytotoxin neutralization assay (TBC/CCNA) for the detection of toxigenic Clostridium difficile in 549 stool specimens. Stool specimens were also tested by one of three alternative FDA-cleared molecular tests for toxigenic C. difficile (Xpert C. difficile, Illumigene C. difficile, or GeneOhm Cdiff). The sensitivities and specificities of the molecular tests compared to TBC/CCNA were as follows: 98.2% and 92.8% for the Portrait assay, 100% and 91.7% for the Xpert assay, 93.3% and 95.1% for the Illumigene assay, and 97.4% and 98.5% for the GeneOhm assay, respectively. The majority of Portrait false-positive results (20/31; 64.5%) were also positive for C. difficile by an alternative molecular test, suggesting an increased sensitivity compared to the culture-based "gold standard" method. The Portrait test detected an assay input of 30 CFU in 100% of spiked samples and detected an input of 10 CFU in 96.7% of samples tested.
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Deshpande A, Pasupuleti V, Patel P, Pant C, Pagadala M, Hall G, Hu B, Jain A, Rolston DDK, Sferra TJ, Atreja A. Repeat stool testing for Clostridium difficile using enzyme immunoassay in patients with inflammatory bowel disease increases diagnostic yield. Curr Med Res Opin 2012; 28:1553-60. [PMID: 22852871 DOI: 10.1185/03007995.2012.717529] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The incidence and severity of Clostridium difficile infection (CDI) in patients with inflammatory bowel disease (IBD) is increasing. CDI is diagnosed by toxin enzyme immunoassay (EIA) or real-time polymerase chain reaction (PCR) performed on stool samples. An earlier study evaluating EIA in IBD patients with CDI suggested that more than one stool sample be tested to increase diagnostic yield. We investigated whether repeat stool testing improves diagnostic accuracy for CDI in hospitalized IBD patients compared to hospitalized patients with CDI and no IBD. METHODS We performed retrospective data analysis from January 2005-May 2011 on 63,086 hospitalized patients who were tested for CDI using EIA or PCR. Of these, 2579 patients had IBD. Transition probabilities were calculated based on results from repeated tests. RESULTS Inclusive of all inpatients tested for CDI, 56,583 were tested using toxin EIA and 6503 were tested using PCR. In patients with no IBD, the first stool sample tested was positive in 90% and 94% with EIA and PCR respectively. In IBD patients tested using EIA, 101 were diagnosed with CDI. The first stool sample tested was positive in 81% of patients. Successive second and third stool samples yielded additional 14% and 5% CDI positive IBD patients. CONCLUSIONS Approximately one in five IBD patients with CDI required repeat testing to yield a positive result with EIA. There are minimal diagnostic gains of repeat testing by EIA or PCR in patients without IBD. We recommend repeat stool testing for CDI when using EIA to increase diagnostic yield in IBD patients.
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Affiliation(s)
- Abhishek Deshpande
- Department of Neurological Surgery, Neurological Institute, Cleveland, OH 44106-4984, USA.
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Nassour I, Carchman EH, Simmons RL, Zuckerbraun BS. Novel management strategies in the treatment of severe Clostridium difficile infection. Adv Surg 2012; 46:111-35. [PMID: 22873036 DOI: 10.1016/j.yasu.2012.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
CDI is increasing in incidence and severity. Clinicians must have a low threshold to consider the diagnosis and to treat patients with the clinical syndrome and risk factors before laboratory confirmation of the diagnosis. In patients who have signs of advanced disease, escalation of care with antimicrobial strategies and multidisciplinary care including surgical consultation is necessary. Furthermore, lowering the threshold for surgery compared with traditional approaches likely results in improved survival. Novel surgical approaches may obviate total abdominal colectomy and the associated immediate and long-term morbidity in this often fragile patient population, thus allowing clinicians to embrace surgical therapy earlier in the course of severe, complicated disease.
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Affiliation(s)
- Ibrahim Nassour
- Department of Surgery, University of Pittsburgh, 200 Lothrop Street, F1200 PUH, Pittsburgh, PA 15213, USA
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Badger VO, Ledeboer NA, Graham MB, Edmiston CE. Clostridium difficile: epidemiology, pathogenesis, management, and prevention of a recalcitrant healthcare-associated pathogen. JPEN J Parenter Enteral Nutr 2012; 36:645-62. [PMID: 22577120 DOI: 10.1177/0148607112446703] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Clostridium difficile is the leading cause of healthcare-associated infectious diarrhea. Although C difficile is part of normal flora in some healthy individuals, patients with selective risk factors are often vulnerable to the toxigenic potential of this virulent healthcare pathogen. The spectrum of C difficile infection (CDI) is highly variable, ranging from mild to severe illness, presenting with single to multiple disease recurrences. Current approaches to treatment are based on severity of illness, number of recurrences, and clinical presentation. Oral vancomycin and metronidazole have formed the foundation for treatment of CDI, but therapeutic failures are commonly reported, especially involving hypervirulent clones. Alternative therapies, including newer antimicrobials, probiotics, immunotherapy, and fecal transplantation, have all met with varying degrees of efficacy. Although toxigenic culture (TC) testing from anaerobic culture remains the gold standard, newer technologies, including enzyme immunoassay, common antigen (glutamate dehydrogenase) testing, and real-time polymerase chain reaction (PCR) are less time-consuming and rapid. However, TC and PCR have reported high specificity and sensitivity when compared with other laboratory tests. Because of the significant morbidity and mortality associated with CDI, a high index of suspicion is warranted. Prevention and eradication of CDI require a multidisciplinary approach, including early disease recognition through appropriate surveillance, implementation of effective contact isolation strategies, adherence to environmental controls, judicious hand hygiene, evidence-based treatment, and management that includes antibiotic stewardship, continuous education of healthcare workers, and administrative support.
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Affiliation(s)
- Victor O Badger
- Department of Internal Medicine, Division of Infection Diseases, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA
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Carroll KC, Bartlett JG. Biology of Clostridium difficile: implications for epidemiology and diagnosis. Annu Rev Microbiol 2012; 65:501-21. [PMID: 21682645 DOI: 10.1146/annurev-micro-090110-102824] [Citation(s) in RCA: 172] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Clostridium difficile is an anaerobic, spore-forming, gram-positive rod that causes a spectrum of antibiotic-associated colitis through the elaboration of two large clostridial toxins and other virulence factors. Since its discovery in 1978 as the agent responsible for pseudomembranous colitis, the organism has continued to evolve into an adaptable, aggressive, hypervirulent strain. Advances in molecular methods and improved animal models have facilitated an understanding of how this organism survives in the environment, adapts to the gastrointestinal tract of animals and humans, and accomplishes its unique pathogenesis. The advances in microbiology have been accompanied by some important clinical observations including increased rates of C. difficile infection, increased virulence, and multiple outbreaks. The major new risk is fluoroquinolone use; there is also an association with proton pump inhibitors and increased recognition of cases in outpatients, pediatric patients, and patients without recent antibiotic use. The combination of more aggressive strains with mobile genomes in a setting of an expanded pool of individuals at risk has refocused attention on and challenged assumptions regarding diagnostic gold standards. Future research is likely to build upon the advancements in phylogenetics to create novel strategies for diagnosis, treatment, and prevention.
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Affiliation(s)
- Karen C Carroll
- Division of Medical Microbiology, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21205, USA.
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Doing KM, Hintz MS. Prospective evaluation of the Meridian Illumigene™ loop-mediated amplification assay and the Gen Probe ProGastro™ Cd polymerase chain reaction assay for the direct detection of toxigenic Clostridium difficile from fecal samples. Diagn Microbiol Infect Dis 2012; 72:8-13. [DOI: 10.1016/j.diagmicrobio.2011.09.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Revised: 08/08/2011] [Accepted: 09/06/2011] [Indexed: 10/24/2022]
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Loop-mediated isothermal amplification compared to real-time PCR and enzyme immunoassay for toxigenic Clostridium difficile detection. J Clin Microbiol 2011; 50:640-5. [PMID: 22189114 DOI: 10.1128/jcm.01014-11] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile infection is the primary cause of health care-associated diarrhea. While most laboratories have been using rapid antigen tests for detecting C. difficile toxins, they have poor sensitivity; newer molecular methods offer rapid results with high test sensitivity and specificity. This study was designed to compare the performances of two molecular assays (Meridian illumigene and BD GeneOhm) and two antigen assays (Wampole Quik Chek Complete and TechLab Tox A/B II) to detect toxigenic C. difficile. Fecal specimens from hospitalized patients (n = 139) suspected of having C. difficile infection were tested by the four assays. Nine specimens were positive and 109 were negative by all four methods. After discrepant analysis by toxigenic culture (n = 21), the total numbers of stool specimens classified as positive and negative for toxigenic C. difficile were 21 (15%) and 118 (85%), respectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were as follows: GeneOhm (95.2%, 100%, 100%, and 99.2%), illumigene (95.2%, 96.6%, 83.3%, and 99.2%), Tox A/B II (52.4%, 97.5%, 78.6%, and 92.4%), and Quik Chek Complete (47.6%, 100%, 100%, and 91.9%). The illumigene assay performed comparably to the GeneOhm assay with a slight decrease in test specificity; the sensitivities of both far exceeded those of the antigen assays. The clinical characteristics of the concordant and discrepant study patients were similar, including stool consistency and frequency. In the era of rapid molecular-based tests for toxigenic C. difficile, toxin enzyme immunoassays (EIAs) should no longer be considered the standard of care.
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Carroll KC. Tests for the diagnosis of Clostridium difficile infection: The next generation. Anaerobe 2011; 17:170-4. [DOI: 10.1016/j.anaerobe.2011.01.002] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Revised: 01/19/2011] [Accepted: 01/21/2011] [Indexed: 11/26/2022]
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Repeat stool testing to diagnose Clostridium difficile infection using enzyme immunoassay does not increase diagnostic yield. Clin Gastroenterol Hepatol 2011; 9:665-669.e1. [PMID: 21635969 DOI: 10.1016/j.cgh.2011.04.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Revised: 04/21/2011] [Accepted: 04/28/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Clostridium difficile infection (CDI) is a hospital-acquired infection with increasing incidence and severity. The most frequently used test to diagnose CDI is an enzyme immunoassay (EIA) for toxins A and B in stool samples. It is common to test 2 or more stool samples, based on the assumption that this detects CDI with greater sensitivity than analysis of 1 sample. We investigated whether repeat stool testing significantly improves the diagnostic yield for CDI. METHODS We performed a retrospective analysis of hospitalized patients who were tested for CDI using EIA. From year 2005 to 2008, 39,402 stool samples from 17,971 patients with 29,373 diarrhea episodes were tested. Transition probabilities were calculated based on results from repeated tests. RESULTS A total of 2692 diarrheal episodes (9.17%) were diagnosed with CDI. Based on results of 3 consecutive tests, 2675 (99.36%) were diagnosed with CDI. The first stool sample tested produced positive results for 90.7% of cases. When samples were tested consecutively, for the second and third time, an additional 6.6% and 2% patients had positive test results, respectively. If the first test result was negative, the probability of the second test result being positive was 2.7%. If the first 2 test results were negative, the probability of the third test result being positive was 2.3%. CONCLUSIONS In patients who had multiple stool samples tested for CDI by EIA, almost 91% were accurately diagnosed based on the results of a single stool sample alone. Subsequent testing yielded a positive result in only 8.6% of patients. We therefore recommend that repeat testing not be done on a routine basis because it does not significantly improve diagnostic yield.
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Qutub MO, AlBaz N, Hawken P, Anoos A. Comparison between the two-step and the three-step algorithms for the detection of toxigenic Clostridium difficile. Indian J Med Microbiol 2011; 29:293-6. [DOI: 10.4103/0255-0857.83916] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Brown NA, Lebar WD, Young CL, Hankerd RE, Newton DW. Diagnosis of Clostridium difficile infection: comparison of four methods on specimens collected in Cary-Blair transport medium and tcdB PCR on fresh versus frozen samples. Infect Dis Rep 2011; 3:e5. [PMID: 24470904 PMCID: PMC3892603 DOI: 10.4081/idr.2011.e5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Revised: 04/15/2011] [Accepted: 04/20/2011] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile infection (CDI) caused by toxigenic strains of C. difficile is primarily a nosocomial infection with increasing prevalence. Stool specimens are typically collected in Cary-Blair transport medium to maximize culture-based detection of common stool pathogens. The goal of this study was to establish an analytically accurate and efficient algorithm for the detection of CDI in our patient population using samples collected in Cary-Blair transport medium. In addition, we wished to determine whether the sensitivity and specificity of PCR was affected by freezing samples before testing. Using 357 specimens, we compared four methods: enzyme immunoassay for the antigen glutamate dehydrogenase (Wampole™ C. DIFF CHEK-60 Assay, GDH), toxin A and B enzyme immunoassay (Remel ProSpecT™ C. difficile Toxin A/B Microplate Assay, Toxin EIA), cell culture cytotoxicity neutralization assay (Bartels™ Cytotoxicity Assay, CT), and real-time PCR targeting the toxin B gene (BD GeneOhm™ Cdiff Assay, PCR). The analytic sensitivity and specificity of each as determined using a combined gold standard were as follows: GDH, 100% and 93.2%; Toxin EIA, 82.9% and 82.9%; CT, 100% and 100%; PCR (performed on frozen specimens) 74.3% and 96.6%; respectively. However, the sensitivity and specificity of PCR improved to 100% when performed on 50 fresh stool samples collected in Cary-Blair. While CT remains a sensitive method for the detection of CDI, GDH offers an excellent initial screening method to rule out CDI. While the performance of each assay did not appear to be affected by collection in Cary-Blair medium, PCR performed better using fresh specimens.
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Affiliation(s)
- Noah A Brown
- Department of Pathology, University of Michigan Health System, Ann Arbor, MI, USA
| | - William D Lebar
- Department of Pathology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Carol L Young
- Department of Pathology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Rosemary E Hankerd
- Department of Pathology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Duane W Newton
- Department of Pathology, University of Michigan Health System, Ann Arbor, MI, USA
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Deshpande A, Pasupuleti V, Pant C, Hall G, Jain A. Potential value of repeat stool testing for Clostridium difficile stool toxin using enzyme immunoassay? Curr Med Res Opin 2010; 26:2635-41. [PMID: 20923255 DOI: 10.1185/03007995.2010.522155] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aim of this brief review is to summarize the literature as it relates to the potential value of repeat stool testing for Clostridium difficile (C. difficile) toxin using an enzyme immunoassay (EIA) for toxin A&B and also propose a potential newer algorithm for diagnosing C. difficile. RESEARCH DESIGN AND METHODS Two investigators conducted independent literature searches using PubMed, Web of Science, and Scopus until May 1st, 2010. All databases were searched using the terms Clostridium difficile, CDAD, antibiotic associated diarrhea, C. difficile in combination with enzyme immunoassay, enzyme linked immunosorbent assay, Clostridium difficile toxin A, Clostridium difficile toxin B, Clostridium difficile toxin and repeat stool testing. Articles which discussed EIA in C. difficile infection (CDI) patients were reviewed and relevant cross references also read and evaluated for inclusion. Selection bias could be a possible limitation of the approach used in selecting or finding articles for this article. FINDINGS The evidence for repeat stool testing for C. difficile toxin detection using toxin EIA is becoming weaker. Most recent published practice guidelines recommend a two- or three-step testing algorithm for the detection of C. difficile. CONCLUSIONS EIA for C. difficile stool toxin has a limited sensitivity, but, it does not warrant repeat stool testing. The data for this are suggestive but not conclusive. More studies and better tests are needed to have clear guidelines which can specify the number of tests needed in a diagnostic workup of suspected C. difficile infection. A two-step or three-step method in the diagnosis of C. difficile-associated diarrhea offered a marked increase in sensitivity compared to that of toxin A&B EIA alone.
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Abstract
Clostridium difficile has re-emerged as a major hospital-acquired infection since 2001. Despite development of polymerase chain reaction-based testing, no single clinical diagnostic test has emerged with sufficient sensitivity, specificity, and turnaround time to be entirely reliable for disease diagnosis. The importance of C difficile acquired outside the hospital environment remains an unknown factor and awaits further epidemiologic investigation. This article discusses the changing epidemiology, clinical presentation, and pathogenesis of C difficile infection and highlights the ongoing challenges of laboratory diagnosis, treatment, and disease relapse.
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Medina-Torres C, Weese J, Staempfli H. Validation of a Commercial Enzyme Immunoassay for Detection of Clostridium difficile Toxins in Feces of Horses with Acute Diarrhea. J Vet Intern Med 2010; 24:628-32. [DOI: 10.1111/j.1939-1676.2010.00506.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Doing KM, Hintz MS, Keefe C, Horne S, LeVasseur S, Kulikowski ML. Reevaluation of the Premier Clostridium difficile toxin A and B immunoassay with comparison to glutamate dehydrogenase common antigen testing evaluating Bartels cytotoxin and Prodesse ProGastro™ Cd polymerase chain reaction as confirmatory procedures. Diagn Microbiol Infect Dis 2010; 66:129-34. [DOI: 10.1016/j.diagmicrobio.2009.09.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Revised: 09/01/2009] [Accepted: 09/02/2009] [Indexed: 11/17/2022]
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50
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Clostridium difficile testing in the clinical laboratory by use of multiple testing algorithms. J Clin Microbiol 2010; 48:889-93. [PMID: 20071552 DOI: 10.1128/jcm.01801-09] [Citation(s) in RCA: 167] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The incidence of Clostridium difficile infection (CDI) has risen almost 3-fold in the United States over the past decade, emphasizing the need for rapid and accurate tests for CDI. The Cepheid Xpert C. difficile assay is an integrated, closed, nucleic acid amplification system that automates sample preparation and real-time PCR detection of the toxin B gene (tcdB). A total of 432 stool specimens from symptomatic patients were tested by a glutamate dehydrogenase (GDH) assay, a toxin A and B enzyme immunoassay (EIA), the Xpert C. difficile assay, and a cell culture cytotoxicity neutralization assay (CCCN). The results of these methods, used individually and in combination, were compared to those of toxigenic culture. Results for the Xpert C. difficile assay alone showed a sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of 94.4, 96.3, 84.0, and 98.8%, while the EIA alone gave corresponding values of 58.3, 94.7, 68.9, and 91.9%, respectively. An algorithm using the GDH assay and the EIA (plus the CCCN if the EIA was negative) showed corresponding values of 83.1, 96.7, 83.1, and 96.1%. The Xpert C. difficile assay was statistically superior to the EIA (P, <0.001 by Fisher's exact test) and to the GDH-EIA-CCCN algorithm (P, 0.0363). Combining the GDH and Xpert C. difficile assays lowered both the sensitivity and the NPV of the Xpert assay. The GDH-EIA-CCCN procedure required, on average, 2 days to complete testing on GDH-positive results, while testing by the Xpert C. difficile assay was completed, on average, in less than 1 h. Xpert C. difficile testing yielded the highest sensitivity and NPV, in the least amount of time, of the individual- and multiple-test algorithms evaluated in this study.
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