Association between <i>Clostridioides difficile</i> infection testing results and decision to treat

Evans, Martin E.; McCauley, Brian P; Simbartl, Loretta A.

doi:10.1017/ice.2021.333

Cited by 3 publications

(2 citation statements)

References 9 publications

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“… 7 A Veterans Affairs study reviewing patients with positive PCR and negative toxin EIA found 29.5% of discordant patients were treated. 8 Fewer than 10% of those categorized in our facility as CDI-negative and >80% of those categorized as CDI-positive were treated with antibiotics, suggesting relatively adherent stewardship practices consistent with the recommended algorithm.…”

Section: Discussionmentioning

confidence: 83%

A retrospective chart review assessing antibiotic treatment of hospitalized patients with discordant Clostridioides difficile assays in an urban hospitalized setting

Stoddart,

Kuo,

Spence

et al. 2024

ASHE

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Clostridioides difficile infection (CDI) threatens vulnerable populations in health care. Two-step testing improves specificity, avoiding over-treatment. This study analyzed inpatient records to estimate diagnostic outcomes and identify characteristics associated with treatment after discordant testing. Among discordant patients, those aged 65+ years were significantly more likely to be prescribed antibiotics (67% vs 39%).

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Section: Discussionmentioning

confidence: 83%

A retrospective chart review assessing antibiotic treatment of hospitalized patients with discordant Clostridioides difficile assays in an urban hospitalized setting

Stoddart,

Kuo,

Spence

et al. 2024

ASHE

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“…14 Thus, facilities using the 2-step algorithm would not report an NAAT positive (þ)/toxin negative (−) result (ie, NAATpositive result followed by a toxin EIA-negative result) to the NHSN, which has led to decreased CDI rates in some facilities. 15 However, recent studies indicate that some patients with an NAATþ/toxin− result are treated for CDI, [16][17][18][19][20][21][22][23] suggesting that a portion of unreported NAATþ/toxin− results are considered active infection. To explore this discrepancy, we conducted a multisite analysis of patients tested by this 2-step algorithm to determine whether NAATþ/toxin− patients had similar characteristics and were as likely to receive CDI treatment as NAATþ/ toxinþ patients.…”

mentioning

confidence: 99%

Potential underreporting of treated patients using a Clostridioides difficile testing algorithm that screens with a nucleic acid amplification test

Guh,

Fridkin,

Goodenough

et al. 2024

Infect. Control Hosp. Epidemiol.

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Objective: Patients tested for Clostridioides difficile infection (CDI) using a 2-step algorithm with a nucleic acid amplification test (NAAT) followed by toxin assay are not reported to the National Healthcare Safety Network as a laboratory-identified CDI event if they are NAAT positive (+)/toxin negative (−). We compared NAAT+/toxin− and NAAT+/toxin+ patients and identified factors associated with CDI treatment among NAAT+/toxin− patients. Design: Retrospective observational study. Setting: The study was conducted across 36 laboratories at 5 Emerging Infections Program sites. Patients: We defined a CDI case as a positive test detected by this 2-step algorithm during 2018–2020 in a patient aged ≥1 year with no positive test in the previous 8 weeks. Methods: We used multivariable logistic regression to compare CDI-related complications and recurrence between NAAT+/toxin− and NAAT+/toxin+ cases. We used a mixed-effects logistic model to identify factors associated with treatment in NAAT+/toxin− cases. Results: Of 1,801 cases, 1,252 were NAAT+/toxin−, and 549 were NAAT+/toxin+. CDI treatment was given to 866 (71.5%) of 1,212 NAAT+/toxin− cases versus 510 (95.9%) of 532 NAAT+/toxin+ cases (P < .0001). NAAT+/toxin− status was protective for recurrence (adjusted odds ratio [aOR], 0.65; 95% CI, 0.55–0.77) but not CDI-related complications (aOR, 1.05; 95% CI, 0.87–1.28). Among NAAT+/toxin− cases, white blood cell count ≥15,000/µL (aOR, 1.87; 95% CI, 1.28–2.74), ≥3 unformed stools for ≥1 day (aOR, 1.90; 95% CI, 1.40–2.59), and diagnosis by a laboratory that provided no or neutral interpretive comments (aOR, 3.23; 95% CI, 2.23–4.68) were predictors of CDI treatment. Conclusion: Use of this 2-step algorithm likely results in underreporting of some NAAT+/toxin− cases with clinically relevant CDI. Disease severity and laboratory interpretive comments influence treatment decisions for NAAT+/toxin− cases.

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Clinical significance of toxin EIA positivity in patients with suspected Clostridioides difficile infection: systematic review and meta-analysis

Tansarli,

Falagas,

Fang

2024

J Clin Microbiol

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The laboratory diagnosis of Clostridioides difficile infection (CDI) is controversial. Nucleic acid amplification tests (NAAT) and toxin enzyme immunoassays (EIA) are most widely used, often in combination. However, the interpretation of a positive NAAT and negative toxin immunoassay (NAAT+/EIA−) is uncertain. PubMed and EMBASE were searched for studies reporting clinical outcomes in NAAT+/EIA− versus NAAT+/EIA+ patients. Forty-six studies comprising 33,959 patients were included in this meta-analysis. All-cause mortality (RR 0.96, 95% CI 0.80–1.15), attributable mortality (RR 0.61, 95% CI 0.20–1.91), fulminant CDI (RR 0.83, 95% CI 0.57–1.20), radiographic evidence of CDI (RR 0.87, 95% CI 0.65–1.16), total CDI complications (RR 0.95, 95% CI 0.59–1.53), colectomies (RR 0.78, 95% CI 0.34–1.79), and ICU admission (RR 1.04, 95% CI 0.84–1.30) did not significantly differ between NAAT+/EIA− and NAAT+/EIA+ patients. However, rates of recurrent (RR 0.62, 95% CI 0.50–0.77) or severe (RR 0.74, 95% CI 0.63–0.88) CDI were significantly lower in NAAT+/EIA− patients than in NAAT+/EIA+ patients. The pooled prevalence of NAAT+/EIA− patients who were treated with antibiotics for CDI was 73.4% (pooled proportion 0.72, 95% CI 0.52–0.88). NAAT+/EIA− patients have lower rates of recurrence and are at reduced risk for severe CDI compared with NAAT+/EIA+ patients but have a risk of CDI-related complications and mortality comparable to that of NAAT+/EIA+ patients. Toxin results cannot rule in or rule out CDI, and the decision whether to treat symptomatic NAAT+/EIA− patients for CDI should be based on clinical presentation and not on the toxin result. IMPORTANCE Clostridioides difficile infection (CDI) is a common cause of healthcare-associated infections and the leading cause of antibiotic-associated diarrhea. However, the laboratory diagnosis of CDI, primarily done by nucleic acid amplification test (NAAT) and enzyme immunoassay (EIA), is controversial, especially in patients who test positive by NAAT but negative by EIA. In this systematic review, we compared the clinical outcomes of NAAT+/EIA− versus NAAT+/EIA+ patients and found that the two groups have similar risk of mortality and CDI-related complications. However, NAAT+/EIA− patients had significantly lower rates of recurrence and severe CDI than NAAT+/EIA+ patients, and most NAAT+/EIA− patients received CDI therapy. Toxin testing can help to predict the likelihood of CDI recurrence or severe infection, but the toxin result should not be a determining factor in the administration of CDI therapy. The decision on whether to treat NAAT+/EIA− patients should be based on clinical assessment.

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Association between Clostridioides difficile infection testing results and decision to treat

Cited by 3 publications

References 9 publications

A retrospective chart review assessing antibiotic treatment of hospitalized patients with discordant Clostridioides difficile assays in an urban hospitalized setting

A retrospective chart review assessing antibiotic treatment of hospitalized patients with discordant Clostridioides difficile assays in an urban hospitalized setting

Potential underreporting of treated patients using a Clostridioides difficile testing algorithm that screens with a nucleic acid amplification test

Clinical significance of toxin EIA positivity in patients with suspected Clostridioides difficile infection: systematic review and meta-analysis

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