Laxative Use Does Not Preclude Diagnosis or Reduce Disease Severity in Clostridiodes difficile Infection

Abstract

Background To optimize utility of laboratory testing for Clostridiodes difficile infection (CDI), the 2017 Infectious Diseases Society of America–Society for Healthcare Epidemiology of America (IDSA-SHEA) clinical practice guidelines recommend excluding patients from stool testing for C. difficile if they have received laxatives within the preceding 48 hours. Sparse data support this recommendation. Methods Patients with new-onset diarrhea (≥3 bowel movements in any 24-hour period in the 48 hours before stool collection) and a positive stool C. difficile nucleic acid amplification test were enrolled. Laxative use within 48 hours before stool testing, severity of illness (defined by 4 distinct scoring methods), and clinical outcomes were recorded. Results 209 patients with CDI were studied, 65 of whom had received laxatives. There were no significant differences in the proportion of patients meeting severe CDI criteria by 4 severity scoring methods in patients receiving versus not receiving laxatives (66.2% vs 56.3%, respectively; P = .224) by IDSA-SHEA, the primary scoring system. Similar rates of serious outcomes attributable to CDI, including death, intensive care unit admission, and colectomy, were observed in the laxative and no laxative groups. Conclusions Our study found similar rates of severe CDI and serious CDI-attributable clinical outcomes in CDI-diagnosed patients who did or did not receive laxatives. Precluding recent laxative users from CDI testing, as proposed by the IDSA-SHEA guideline, carries a potential for harm due to delayed diagnosis and treatment.

An Osmotic Laxative Renders Mice Susceptible to Prolonged Clostridioides difficile Colonization and Hinders Clearance

“…The rationale behind the recommendation is that patients taking laxatives may be asymptomatically colonized with C. difficile , resulting in unnecessary antibiotic treatment ( 56 – 58 ). Furthermore, some studies identified laxatives as a risk factor for developing CDIs or recurrent CDIs ( 59 – 61 ), and a recent study found that the proportions of severe CDIs were similar between patients taking and those not taking laxatives ( 62 ). However, there have also been some studies that suggest that laxatives are not a risk factor for developing CDIs ( 63 , 64 ).…”

An osmotic laxative renders mice susceptible to prolonged Clostridioides difficile colonization and hinders clearance

“…The rationale behind the recommendation is that patients taking laxatives may be asymptomatically colonized with C. difficile, resulting in unnecessary antibiotic treatment (55)(56)(57). Furthermore, some studies identified laxatives as a risk factor for developing CDIs or recurrent CDIs (58-60) and a recent study found the proportion of severe CDIs was similar between patients taking and not taking laxatives (61). However, there have also been some studies that suggest laxatives are not a risk factor for developing CDIs (62,63).…”

Improving Appropriate Diagnosis of Clostridioides difficile Infection Through an Enteric Pathogen Order Set With Computerized Clinical Decision Support: An Interrupted Time Series Analysis

“…An important consideration when implementing diagnostic stewardship interventions is assessing the potential for unintended adverse consequences by more restrictive testing approaches. A recent study found similar rates of serious outcomes among patients who tested positive for C difficile who did and did not receive laxatives and raises concern that exclusion of patients receiving recent laxatives from testing could lead to delayed or missed diagnoses of severe CDI [ 23 ]. As many institutions have incorporated CCDS tools that restrict testing in the setting of laxatives, the findings of the above study may have important implications.…”