Medline ® Abstracts for References 2,40-43
of 'Clostridium difficile infection in adults: Clinical manifestations and diagnosis'
Diagnosis and treatment of Clostridium difficile in adults: a systematic review.
Bagdasarian N, Rao K, Malani PN
JAMA. 2015 Jan;313(4):398-408.
IMPORTANCE: Since 2000, the incidence and severity of Clostridium difficile infection (CDI) have increased.
OBJECTIVE: To review current evidence regarding best practices for the diagnosis and treatment of CDI in adults (age≥18 years).
EVIDENCE REVIEW: Ovid MEDLINE and Cochrane databases were searched using keywords relevant to the diagnosis and treatment of CDI in adults. Articles published between January 1978 and October 31, 2014, were selected for inclusion based on targeted keyword searches, manual review of bibliographies, and whether the article was a guideline, systematic review, or meta-analysis published within the past 10 years. Of 4682 articles initially identified, 196 were selected for full review. Of these, the most pertinent 116 articles were included. Clinical trials, large observational studies, and more recently published articles were prioritized in the selection process.
FINDINGS: Laboratory testing cannot distinguish between asymptomatic colonization and symptomatic infection with C difficile. Diagnostic approaches are complex due to the availability of multiple testing strategies. Multistep algorithms using polymerase chain reaction (PCR) for the toxin gene(s) or single-step PCR on liquid stool samples have the best test performance characteristics (for multistep: sensitivity was 0.68-1.00 and specificity was 0.92-1.00; and for single step: sensitivity was 0.86-0.92 and specificity was 0.94-0.97). Vancomycin and metronidazole are first-line therapies for most patients, although treatment failures have been associated with metronidazole in severe or complicated cases of CDI. Recent data demonstrate clinical success rates of 66.3% for metronidazole vs 78.5% for vancomycin for severe CDI. Newer therapies show promising results, including fidaxomicin (similar clinical cure rates to vancomycin, with lower recurrence rates for fidaxomicin, 15.4% vs vancomycin, 25.3%; P = .005) and fecal microbiota transplantation (response rates of 83%-94% for recurrent CDI).
CONCLUSIONS AND RELEVANCE: Diagnostic testing for CDI should be performed only in symptomatic patients. Treatment strategies should be based on disease severity, history of prior CDI, and the individual patient's risk of recurrence. Vancomycin is the treatment of choice for severe or complicated CDI, with or without adjunctive therapies. Metronidazole is appropriate for mild disease. Fidaxomicin is a therapeutic option for patients with recurrent CDI or a high risk of recurrence. Fecal microbiota transplantation is associated with symptom resolution of recurrent CDI but its role in primary and severe CDI is not established.
Division of Infectious Disease, Department of Infection Control, St John Hospital and Medical Center, Detroit, Michigan2Department of Internal Medicine, Wayne State University, Detroit, Michigan.
Clostridium difficile colitis.
Kelly CP, Pothoulakis C, LaMont JT
N Engl J Med. 1994;330(4):257.
Evans Memorial Department of Clinical Research, Boston University Medical Center, MA 02118.
Strategies to prevent clostridium difficile infections in acute care hospitals.
Dubberke ER, Gerding DN, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Coffin SE, Fraser V, Griffin FA, Gross P, Kaye KS, Klompas M, Lo E, Marschall J, Mermel LA, Nicolle L, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS
Infect Control Hosp Epidemiol. 2008;29 Suppl 1:S81.
Washington University School of Medicine, St. Louis, Missouri, USA.
European Society of Clinical Microbiology and Infectious Diseases (ESCMID): data review and recommendations for diagnosing Clostridium difficile-infection (CDI).
Crobach MJ, Dekkers OM, Wilcox MH, Kuijper EJ
Clin Microbiol Infect. 2009;15(12):1053.
The aim of the present systematic review was to evaluate the available evidence on laboratory diagnosis of CDI and to formulate recommendations to optimize CDI testing. In comparison with cell culture cytotoxicity assay (CCA) and toxigenic culture (TC) of stools, we analyzed the test characteristics of 13 commercial available enzyme immunoasssays (EIA) detecting toxins A and/or B, 4 EIAs detecting Clostridium difficile glutamate dehydrogenase (GDH), and a real-time PCR for C. difficile toxin B gene. In comparison with CCA and TCA and assuming a prevalence of CDI of 5%, PPV and NPV varied between 0.28-0.77, 0.12-0.65 and 0.98-1.00, 0.97-1.00, respectively. Only if the tests were performed in a population with a CDI prevalence of 50 percent, would PPVs be acceptable (ranging from 0.71 to 1.00).To overcome the problem of a low PPV, we propose a two step approach, with a second test or a reference method in case of a positive first test. Further reducing the number of false negative results would require either retesting of all subjects with a negative first test, or re-testing all subjects with a negative second test, after an initially positive test. This approach resulted in non-significant improvements, and emphasizes the need for better diagnostic tests. Further studies to validate the applicability of two-step testing, including assessment of clinical features, are required.
Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands.
Department of Health. Health Protection Agency. Clostridium difficile infection: How to deal with the problem. Department of Health London 2008. Available at: www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1204186173530?p=1263812760663 (Accessed on April 01, 2010).
no abstract available