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Medline ® Abstracts for References 4,51-57

of 'Clostridium difficile infection in adults: Clinical manifestations and diagnosis'

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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).
AU
Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, Pepin J, Wilcox MH, Society for Healthcare Epidemiology of America, Infectious Diseases Society of America
SO
Infect Control Hosp Epidemiol. 2010;31(5):431.
 
Since publication of the Society for Healthcare Epidemiology of America position paper on Clostridium difficile infection in 1995, significant changes have occurred in the epidemiology and treatment of this infection. C. difficile remains the most important cause of healthcare-associated diarrhea and is increasingly important as a community pathogen. A more virulent strain of C. difficile has 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.
AD
Department of Internal Medicine, Division of Infectious and Immunologic Diseases, University of California Davis Medical Center, Sacramento, California, USA.
PMID
51
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Clostridium difficile colitis: an efficient clinical approach to diagnosis.
AU
Manabe YC, Vinetz JM, Moore RD, Merz C, Charache P, Bartlett JG
SO
Ann Intern Med. 1995;123(11):835.
 
OBJECTIVE: To define clinical and laboratory variables that suggest the presence of Clostridium difficile colitis and to establish the number of stool specimens needed to reasonably exclude the diagnosis of C. difficile colitis.
DESIGN: Prospective study of consecutive inpatients whose stool specimens were sent to be evaluated for the presence of C. difficile toxin.
SETTING: University teaching hospital.
PATIENTS: 268 hospital inpatients in medical, surgical, and gynecology units.
MEASUREMENTS: Structured history and physical examination; detection of C. difficile toxin by cytotoxin tissue-culture assay with anti-C. difficile antiserum neutralization and by enzyme-linked immunoassay (EIA) for C. difficile toxins A and B; and detection of fecal leukocytes by microscopic examination and by latex agglutination lactoferrin assay.
RESULTS: 43 of 268 consecutive inpatients were positive for C. difficile toxin by EIA or tissue-culture assay. Although toxin was detected by EIA alone in 39 of the 43 patients, it was detected in an additional 4 patients (10%) by tissue-culture assay alone. Univariate and multivariate logistic regression analysis showed that the following clinical and laboratory features were associated with C. difficile toxin positivity: the onset of diarrhea 6 or more days after the administration of antibiotics (odds ratio, 1.38 [95% CI, 1.10 to 3.79]); hospital stay longer than 15 days (odds ratio, 1.33 [CI, 1.09 to 3.95]); the presence of fecal leukocytes determined by microscopy (odds ratio, 2.39 [CI, 1.05 to 5.42]) or lactoferrin assay (odds ratio, 3.74 [CI, 1.80 to 7.76]); the presence of semiformed (as opposed to watery) stools (odds ratio, 2.33 [CI, 1.10 to 4.90]); and cephalosporin use (odds ratio, 2.36 [CI, 1.10 to 5.09]). Toxin-positive patients were no more likely than controls to have had fever, abdominal pain or cramps, leukocytosis, green-colored diarrhea, or blood in the stool or to have received clindamycin or penicillin derivatives. Of the 43 patients with C. difficile toxin, 34 (79%) had positive results for the toxin on the first stool specimen, 5 (cumulative, 91%) had positive results on the second specimen, and 4 had positive results on the third specimen. Overall, the negative predictive value of the first stool specimen was 97%. All patients who had two or more clinical or laboratory predictors were diagnosed with C. difficile disease when either the first or the second stool specimen was positive for toxin.
CONCLUSIONS: Clinicians at the bedside can use readily available clinical and laboratory information to decide which patients are likely to have C. difficiledisease and when it is appropriate and useful to order specific diagnostic tests for C. difficile toxin. Such data are also useful in determining the number of stool samples that reasonably excludes the diagnosis of C. difficile colitis.
AD
Johns Hopkins School of Medicine, Division of Infectious Diseases, Baltimore, MD 21205, USA.
PMID
52
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Repeat stool testing to diagnose Clostridium difficile infection using enzyme immunoassay does not increase diagnostic yield.
AU
Deshpande A, Pasupuleti V, Patel P, Ajani G, Hall G, Hu B, Jain A, Rolston DD
SO
Clin Gastroenterol Hepatol. 2011;9(8):665.
 
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.
AD
Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Ohio, USA. deshpaa@ccf.org
PMID
53
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Evaluation of repeat Clostridium difficile enzyme immunoassay testing.
AU
Cardona DM, Rand KH
SO
J Clin Microbiol. 2008;46(11):3686. Epub 2008 Sep 24.
 
Clostridium difficile is the leading cause of antibiotic-associated diarrhea and pseudomembranous colitis, which have significant morbidity and mortality. Accurate and timely diagnosis is critical. Repeat enzyme immunoassay testing for C. difficile toxin has been recommended because of<100% sensitivity. All C. difficile tests between 1 January 2006 and 31 December 2006 were retrospectively analyzed for results and testing patterns. The Wampole C. difficile Tox A/B II enzyme immunoassay kit was used. There were a total of 8,256 tests from 3,112 patients; 49% of tests were repeated. Of the 3,749 initially negative patient tests, 96 were positive upon repeat testing within 10 days of the first test. Of repeat tests, 0.9% repeated on day 0 (same day as the first test), 1.8% on day 1, 3.8% on day 2, 2.6% on day 3, 5.4% on days 4 to 6, and 10.6% on days 7 to 10 were positive. Thirty-eight patients had a positive test within 48 h of an initial negative test, and based on chart review, 18 patients were treated empirically while 16 were treated following the new result. None had evidence of medical complications. Of initially positive patients, 91% were positive upon repeat testing on day 0, 75% on day 1, and 58% on day 2, to a low of 14% on days 7 to 10. Depending on the clinical setting, these data support not repeating C. difficile tests within 2 days of a negative resultand limiting repeat testing to>/=1 week of a positive result.
AD
Department of Pathology, Immunology, and Laboratory Medicine, P.O. Box 100275, University of Florida, College of Medicine, Gainesville, FL 32601-0275, USA.
PMID
54
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Lack of value of repeat stool testing for Clostridium difficile toxin.
AU
Mohan SS, McDermott BP, Parchuri S, Cunha BA
SO
Am J Med. 2006;119(4):356.e7.
 
Twenty years ago, Clostridium difficile was first established as a cause of pseudomembranous colitis and antibiotic-associated diarrhea.C. difficile diarrhea is a widely recognized problem in the inpatient setting, with potentially significant morbidity and mortality. Antibiotics, and some chemotherapy agents, can potentially cause C. difficile colitis/diarrhea. The most commonly implicated agents are ampicillin, clindamycin, and cephalosporins. Diarrhea during antibiotic therapy is common and may be caused by C. difficile. Testing for C. difficile differentiates diarrheas into C. difficile positive and C. difficile negative. C. difficile can be carried asymptomatically as normal gastrointestinal flora, and in adults who have received antibiotic therapy, carrier states can be as high as 46%. Hospitalized patients are often colonized with C. difficile. C. difficile produces 3 virulence factors: an enterotoxin (toxin A), a cytotoxin (toxin B), and a substance to inhibit bowel motility. Different tests can be used to detect these toxins. The most widely used test is the enzyme immunoassay (EIA) for toxin A, toxin B, or both. The EIA C. difficile toxin assay has sensitivity and specificity ranges of 50% to 90% and 70% to 95%, respectively. Diagnostically, C. difficile cell culture cytotoxin assay remains the gold standard with sensitivity and specificity of 93% and 89%, respectively. Because of lack of confidence of the EIA for C. difficile, some clinicians assume an initial negative result may represent a false-negative test, and repeat testing is often done. We evaluated the value of repeat stool testing for C. difficile toxin A and B by EIA in inpatients with nosocomial diarrhea on antibiotics.
AD
Infectious Disease Division, Winthrop-University Hospital, Mineola, New York 11501, USA.
PMID
55
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The lack of value of repeated Clostridium difficile cytotoxicity assays.
AU
Renshaw AA, Stelling JM, Doolittle MH
SO
Arch Pathol Lab Med. 1996;120(1):49.
 
OBJECTIVE: To determine the value of repeated Clostridium difficile cytotoxicity assays (CA).
DESIGN: All CAs performed during 1993 were retrospectively reviewed and correlated with clinical data. Assays were grouped into episodes, which were defined as one or more successive tests performed on a single patient within 7 days or less of each other.
SETTING: A 751-bed tertiary care facility.
PATIENTS: All patients with Clostridium difficile CAs submitted to the microbiology laboratory.
RESULTS: There were 947 episodes with two or more CAs. In 15 of these episodes, a negative CA result was followed by a positive result, and in 25 cases, a positive result was followed by a negative one. We reviewed the clinical data for these cases. Of the 947 episodes with two or more CAs, the repeated assays provided new information that was used in patient care in fewer than nine cases. Repeated testing within 7 days of aninitial CA accounted for 36% of all assays performed, but provided clinically useful information in only about 1% of cases.
CONCLUSIONS: Clostridium difficile CAs should not be repeated within a 7-day period.
AD
Department of Pathology, Brigham and Women's Hospital, Boston, Mass., USA.
PMID
56
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Nonutility of repeat laboratory testing for detection of Clostridium difficile by use of PCR or enzyme immunoassay.
AU
Aichinger E, Schleck CD, Harmsen WS, Nyre LM, Patel R
SO
J Clin Microbiol. 2008;46(11):3795. Epub 2008 Sep 10.
 
The diagnostic gains of repeat testing for Clostridium difficile by enzyme immunoassay and PCR (i.e., initial negative result followed by positive result) within a 7-day period were 1.9 and 1.7%, respectively. There is little value of repeat testing for C. difficile by enzyme immunoassay or PCR.
AD
Division of Clinical Microbiology, College of Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA.
PMID
57
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The utility of repeated stool toxin testing for diagnosing Clostridium difficile colitis.
AU
Gade R, Turett G
SO
South Med J. 2009;102(10):1007.
 
Clostridium difficile is diagnosed using the enzyme-linked immunoassay (EIA) with the specificity and sensitivity ranging from 50-90% and 70-95%, respectively. Due to the wide ranges, there is considerable confusion regarding the value of the EIA toxin test. We undertook this study to evaluate the benefit of repeat stool toxin testing.
AD
Department of Infectious Diseases, Saint Vincent's Catholic Medical Center, New York, NY 10011, USA. drrajgade@yahoo.com
PMID