A Diagnostic Algorithm for the Detection of Clostridium difficile-Associated Diarrhea

Background:Clostridium difficile is a common cause of hospital-acquired diarrhea, which is usually associ-ated with previous antibiotic use. The clinical manifesta-tions of C. difficile infection (CDI) may range from mild diarrhea to fulminant colitis. Clostridium difficile should be considered in diarrhea cases with a history of antibi-otic use within the last 8 weeks (community-associated CDI) or with a hospital stay of at least 3 days, regardless of the duration of antibiotic use (hospital-acquired CDI). Aims: This study investigated the frequency of CDI in diarrheic patients and evaluated the efficacy of the triple diagnostic algorithm that is proposed here for C. difficile detection. Study Design: Cross-sectional study. Methods: In this study, we compared three methods currently employed for C. difficile detection using 95 patient stool samples: an enzyme immunoassay (EIA) for toxin A/B (C. diff Toxin A+B; Diagnostic Auto-mation Inc.; Calabasas, CA, USA), an EIA for gluta-mate dehydrogenase (GDH) (C. DIFF CHEK-60TM, TechLab Inc.; Blacksburg, VA, USA), and a poly-merase chain reaction (PCR)-based assay (GeneXpert®C. difficile; Cepheid, Sunnyvale, CA, USA) that detects C. difficile toxin genes and conventional methods as well. In this study, 50.5% of the patients were male, 50 patients were outpatients, 32 were from inpatient clin-ics and 13 patients were from the intensive care unit. Results: Of the 95 stool samples tested for GDH, 28 were positive. Six samples were positive by PCR, while nine samples were positive for toxin A/B. The hyper-virulent strain NAP-1 and binary toxin was not detect-ed. The rate of occurrence of toxigenic C. difficile was 5.1% in the samples. Cefaclor, ampicillin-sulbactam, ertapenem, and piperacillin-tazobactam were the most commonly used antibiotics by patients preceding the onset of diarrhea. Among the patients who were hospi-talized in an intensive care unit for more than 7 days, 83.3% were positive for CDI by PCR screening. If the PCR test is accepted as the reference: C. difficile Toxin A/B ELISA sensitivity and specificity were 67% and 94%, respectively, and GDH sensitivity and specificity were 100% and 75%, respectively.Conclusion: Tests targeting C. difficile toxins are fre-quently applied for the purpose of diagnosing CDI in a clinical setting. However, changes in the temperature and reductant composition of the feces may affect toxin stability, potentially yielding false-negative test results. Therefore, employment of a GDH EIA, which has high sensitivity, as a screening test for the detection of toxi-genic strains, may prevent false-negative results, and its adoption as part of a multistep diagnostic algorithm may increase accuracy in the diagnosis of CDIs

PDF

___

Thielman NM, Wilson KH: Antibiotic-associated colitis. In Principles and Practice of Infectious Diseases. 7th press. Benett (ed) Mandell GL, JE Dolin R. (eds), Churchill Livingstone, New York 2010.
Bagdasarian N, Rao K, Malani PN. Diagnosis and treatment of Clostridium difficile in adults: a systematic review. JAMA 2015;313:398-408.
Rodriguez C, Korsak N, Taminiau B, Avesani V, Van Broeck J, Delmée M, et al. Clostridium difficile infection in elderly nurs- ing home residents. Anaerobe 2014;30:184-7.
Tunçcan OG, Ulutan F, Karakuş R. The frequency of Clostrid- ium difficile toxin in neutropenic and non-neutropenic patients with antibiotic-associated diarrhea and analysis of the risk fac- tors. Mikrobiyol Bul 2008;42:573-83.
Freeman J, Bauer MP, Baines SD, Corver J, Fawley WN, Goor- huis B, et al. The Changing Epidemiology of Clostridium dif- ficile Infections. Clin Microbiol Rev 2010;529-49.
Crobach MJ, Dekkers OM, Wilcox MH, Kuijper EJ. Europe- an Society of Clinical Microbiology and Infectious Diseases (ESCMID): data review and recommendations for diagnosing Clostridium difficile-infection (CDI). Clin Microbiol Infect 2009;15:1053-66.
Merz CS, Kramer C, Forman M, Gluck L, Mills K, Senft K, et al. Comparison of four commercially available rapid enzyme immunassays with cytotoxin assay for detection of Clostrid- ium difficile toxin(s) from stool specimens. J Clin Microbiol 1994;32:1142-7.
Alcalá L, Sánchez-Cambronero L, Catalán MP, Sánchez-So- molinos M, Peláez MT, Marín M, et al. Comparison of three commercial methods for rapid detection of Clostridium dif- ficile toxin A and B from fecal specimens. J Clin Microbiol 2008;46:3833-5.
Sloan LM, Duresko BJ, Gustafson DR, Rosenblatt JE. Compari- son of real time PCR for detection of the tcdC gene with four toxin immunassays and culture in diagnosis of Clostridium dif- ficile infection. J Clin Microbiol 2008;46:1996-2001.
Altindis M, Usluer S, Ciftçi H, Tunç N, Cetinkaya Z, Aktepe OC. Investigation of the presence of Clostridium difficile in an- tibiotic associated diarrhea patients by culture and toxin detec- tion methods. Mikrobiyol Bul 2007;41:29-37.
Oldfield EC. Clostridium difficile-associated diarrhea: risk fac- tors, diagnostic methods, and treatment. Rev Gastroenterol Dis- ord 2004;4:186-95.
Zheng L, Keller SF, Lyerly DM, Carman RJ, Genheimer CW, Gleaves CA, et al. Multicenter evaluation of a new screening test that detects Clostridium difficile in fecal specimens. J Clin Microbiol 2004;42:3837-40.
Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDon- ald LC, et al; Society for Healthcare Epidemiology of America; Infectious Diseases Society of America. Clinical Practice Guide- lines 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 2010;31:5.
LaSala PR, Svensson AM, Mohammad AA, Perrotta PL. Com- parison of Analytical and Clinical Performance of Three Meth- ods for Detection of Clostridium difficile. Arch Pathol Lab Med 2012;136:527-31.
Fenner L, Widmer AF, Goy G, Rudin S, Frei R. Rapid and reli- able diagnostic algorithm for detection of Clostridium difficile. J Clin Microbiol 2008;46:328-30.
Williamson DA, Basu I, Freeman J, Swager T, Roberts SA. Improved detection of toxigenic C. difficile using the Cepheid Xpert C. difficile assay and impact on C. difficile infection rates in tertiary hospital: A double edged sward. Am J Infect Control 2013;41:270-2.
Babady NE, Stiles J, Ruggiero P, Khosa P, Huang D, Shuptar S, et al. Evaluation of Cepheid Xpert C. difficile epi assay for diagnosis of C. difficile infection and typing of the NAP1 strain at a cancer hospital. J Clin Microbiol 2010;48:4519-24.
Lyerly DM, Ball DW, Toth J, Wilkins TD. Characterization of cross-reactive proteins detected by Culturette Brand Rapid La- tex Test for Clostridium difficile. J Clin Microbiol 1988;26:397- 400.
Goldenberg SD, French GL. Diagnostic testing for C. difficile: a comprehensive survey of laboratories in England. J Hosp Infect 2011;79:4-7.
Surawicz CM. Clostridium difficile infection: risk factors, di- agnosis and management. Curr Treat Options Gastroenterol 2015;13:121-9.
Korac M, Milosevic I, Markovic M, Popovic N, Ilic M, Mar- kovic A, et al. Clostridium difficile infection: a Serbian single- center experience. J Infect Dev Ctries 2015;19;9:136-40.
Kilic A. Clostridium difficile Infection: Epidemiology, Risk Factors, Pathogenesis, Clinical Features, Diagnosis and Thera- py. Mikrobiyol Bul 2013;47:556-66.
Khanna S, Pardi DS, Aronson SL, Kammer PP, Orenstein R, St Sauver JL, et al. The epidemiology of community-acquired Clostridium difficile infection: a population-based study. Am J Gastroenterol 2012;107:89-95.
Sloan LM, Duresko BJ, Gustafson DR, Rosenblatt JE. Compari- son of real-time PCR for detection of the tcdC gene with four toxin immunoassays and culture in diagnosis of Clostridium dif- ficile infection. J Clin Microbiol 2008;46:1996-2001.
Juneau C, Mendias EN, Wagal N, Loeffelholz M, Savidge T, Croisant S, et al. Community-Acquired Clostridium Difficile Infection: Awareness and Clinical Implications. J Nurse Pract 2013;9:1-6.
Zheng, L, Keller SF, Lyerly DM, Carman RJ, Genheimer CW, et al. Multicenter evaluation of a new screening test that de- tects Clostridium difficile in fecal specimens. J Clin Microbiol 2004;42:3837-40.
Debast SB, Bauer MP, Kuijper EJ; European Society of Clini- cal Microbiology and Infectious Diseases. European Society of Clinical Microbiology and Infectious Diseases: update of the treatment guidance document for Clostridium difficile infection. Clin Microbiol Infect 2014;20:1-26.
Krutova M, Matejkova J, Nyc OC. Difficile ribotype 027 or 176? Folia Microbiol (Praha) 2014;59:523-6.