Easily Modified Factors Contribute to Delays in Diagnosis of Clostridium difficile Infection: a Cohort Study and Intervention

Abstract

cAlthough rapid laboratory tests are available for diagnosis of Clostridium difficile infection (CDI), delays in completion of CDI testing are common in clinical practice. We conducted a cohort study of 242 inpatients tested for CDI to determine the timing of different steps involved in diagnostic testing and to identify modifiable factors contributing to delays in diagnosis. The average time from test order to test result was 1.8 days (range, 0.2 to 10.6), with time from order to stool collection accounting for most of the delay (mean, 1.0 day; range, 0 to 10). Several modifiable factors contributed to delays, including not providing stool collection supplies to patients in a timely fashion, rejection of specimens due to incorrect labeling or leaking from the container, and holding samples in the laboratory for batch processing. Delays in testing contributed to delays in initiation of treatment for patients diagnosed with CDI and to frequent prescription of empirical CDI therapy for patients with mild to moderate symptoms whose testing was ultimately negative. An intervention that addressed several easily modified factors contributing to delays resulted in a significant decrease in the time required to complete CDI testing. These findings suggest that health care facilities may benefit from a review of their processes for CDI testing to identify and address modifiable factors that contribute to delays in diagnosis and treatment of CDI.C lostridium difficile is the most important cause of health careassociated diarrhea in developed countries (1). During the past decade, the emergence of an epidemic C. difficile strain, termed North American pulsed-field gel electrophoresis type 1, has been associated with dramatic increases in the incidence and severity of C. difficile infection (CDI) in North America and Europe (1-3). In the context of these changes in the epidemiology of C. difficile, accurate and efficient strategies to diagnose CDI are crucial to guide management and prevent transmission. Enzyme immunoassays for glutamate dehydrogenase or for toxins A and B and real-time PCR assays for toxin genes can provide rapid CDI test results in the laboratory (4-8); the enzyme immunoassays for toxins A and B are recommended only as part of multistep testing algorithms (4, 7). However, delays in completion of CDI diagnostic testing are common in clinical practice. Identification of easily modified factors that contribute to these delays could benefit infection control programs and clinicians who manage patients with CDI.Scheurer et al. (9) recently reported that the mean time from onset of symptoms to collection of samples for C. difficile testing was 2.2 days. Similarly, we reported that the mean time from onset of diarrhea to diagnosis of infection was 2 days in our hospital and 4 days in our long-term-care facility (10). In a hospital that tested for CDI using stool culture and external toxin analysis, Frenz and McIntyre (11) found that the mean time from onset of diarrhea to collection of samples for testing was ...

Accuracy of loop-mediated isothermal amplification for the diagnosis of Clostridium difficile infection: a systematic review

“…A rapid, accurate diagnosis followed by prompt treatment are critical in the management of CDI and prevention of transmission [38,39]. Barbut et al found that a change from toxigenic culture and CTA to a NAAT or a 2-step algorithm including GDH and NAAT resulted in a significant reduction in the time to reporting of test results and earlier initiation of treatment, reduced empiric therapy in patients without CDI, and a decrease in processing of multiple samples.…”

Point-of-Care Testing for Clostridium Difficile Infection: A Real-World Feasibility Study of a Rapid Molecular Test in Two Hospital Settings

“…The average time taken to test for CDI in one study was 1.8 days [ 3 ], although other centers performing testing three times per day report turnaround times of 8 h [ 4 ]. The authors have previously reported a median turnaround time of 17.3 h in their institution’s laboratory [ 1 ].…”

Skin and Environmental Contamination in Patients Diagnosed With Clostridium difficile Infection but Not Meeting Clinical Criteria for Testing

“…Thus, in the absence of toxin testing, our findings suggest that there is a need for efforts to reduce testing of patients not meeting clinical criteria for CDI testing. 3,9 In particular, reducing testing of patients with diarrhea but with no recent antibiotic exposure might be of benefit given our finding that patients with no recent antibiotic exposure were unlikely to shed spores. Finally, spores on skin and in the environment have been shown to be an important source for acquisition on hands of healthcare personnel 5,6,10 and therefore are likely to be an important source for transmission.…”

“…1 In practice, however, CDI tests are often ordered for patients without clinically significant diarrhea or with clear alternative explanations for diarrhea. 2,3 For example, Dubberke et al 2 reported that 36% of patients with orders for CDI testing did not meet criteria for diarrhea and 19% had received laxatives in the 2 days prior to stool collection. Such testing of patients not meeting clinical criteria for CDI testing may result in false-positive diagnoses of CDI due to detection of asymptomatic carriers of toxigenic C. difficile, particularly if sensitive nucleic acid amplification tests are used.…”