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168 Hanes House—Trent Drive DUMC 102359 Durham, NC 27710 [email protected] Diagnosis of C. difficile Infection (CDI) at Duke Health What test method does Duke use to diagnose CDI? Duke uses a PCR test that identifies the presence of toxigenic C. difficile What are potential pitfalls of PCR testing for CDI? A positive PCR test does not differentiate between patients who have CDI versus those who are colonized with C. difficile and have diarrhea for other reasons How common is asymptomatic colonization with C. difficile? Various studies have estimated that 7-18% of all patients admitted to acute care hospitals are colonized with C. difficile at the time of hospital admission. 1-6 Asymptomatic colonization with C. difficile is 5 to 10 times more common than symptomatic CDI in hospitalized patients. 7 Do patients with asymptomatic colonization with C. difficile require treatment? No, patients with asymptomatic colonization with C. difficile do not require treatment. Paradoxically, many of the drugs prescribed to treat C. difficile actually perturb the GI tract flora and can make individuals at increased risk for diarrhea or symptomatic CDI in the future. In addition, CDI treatments can be expensive and have toxicities. How can we improve the specificity of C. difficile diagnosis, to increase the likelihood that positive PCR tests indicate symptomatic infection requiring treatment? Verify the presence of clinically significant diarrhea, defined as 3 or more unformed stools within 24 hours Use clinical judgment -- consider whether your patient has received laxative medications, recent initiation of tube feeds, or oral contrast AND whether there are features concerning for CDI (fever, leukocytosis, abdominal tenderness) Apply the following algorithm to help determine when it is appropriate to order C. difficile PCR testing for your patient References 1. Donskey CJ, Kundrapu S, Deshpande A. Colonization versus carriage of Clostridium difficile. Infectious disease clinics of North America. 2015;29(1):13-28. 2. Clabots CR, Johnson S, Olson MM, Peterson LR, Gerding DN. Acquisition of Clostridium difficile by Hospitalized Patients: Evidence for Colonized New Admissions as a Source of Infection. Journal of Infectious Diseases. 1992;166(3):561-567. 3. Samore MH, DeGirolami PC, Tlucko A, Lichtenberg DA, Melvin ZA, Karchmer AW. Clostridium difficile Colonization and Diarrhea at a Tertiary Care Hospital. Clinical Infectious Diseases. 1994;18(2):181-187. 4. Kyne L, Warny M, Qamar A, Kelly CP. Asymptomatic Carriage of Clostridium difficile and Serum Levels of IgG Antibody against Toxin A. New England Journal of Medicine. 2000;342(6):390-397. 5. Loo VG, Bourgault A-M, Poirier L, et al. Host and Pathogen Factors for Clostridium difficile Infection and Colonization. New England Journal of Medicine. 2011;365(18):1693-1703. 6. Dubberke ER, Reske KA, Seiler S, Hink T, Kwon JH, Burnham CA. Risk Factors for Acquisition and Loss of Clostridium difficile Colonization in Hospitalized Patients. Antimicrobial agents and chemotherapy. 2015;59(8):4533-4543. 7. Polage CR, Gyorke CE, Kennedy MA, et al. Overdiagnosis of Clostridium difficile Infection in the Molecular Test Era. JAMA internal medicine. 2015;175(11):1792-1801.
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