Hostname: page-component-78c5997874-mlc7c Total loading time: 0 Render date: 2024-11-04T21:47:24.909Z Has data issue: false hasContentIssue false
  • English
  • Français

Real-Time Polymerase Chain Reaction Detection of Asymptomatic Clostridium difficile Colonization and Rising C. difficile–Associated Disease Rates1

Published online by Cambridge University Press:  10 May 2016

Hoonmo L. Koo ,
John N. Van ,
Meina Zhao ,
Xunyan Ye ,
Paula A. Revell ,
Zhi-Dong Jiang ,
Carolyn Z. Grimes ,
Diana C. Koo ,
Todd Lasco  and
Claudia A. Kozinetz
...Show all authors
Hoonmo L. Koo
Affiliation:
Baylor College of Medicine, Houston, Texas University of Texas School of Public Health, Houston, Texas St. Luke’s Hospital, Houston, Texas
John N. Van
Affiliation:
Baylor College of Medicine, Houston, Texas
Meina Zhao
Affiliation:
Baylor College of Medicine, Houston, Texas
Xunyan Ye
Affiliation:
Baylor College of Medicine, Houston, Texas
Paula A. Revell
Affiliation:
Texas Children’s Hospital, Houston, Texas
Zhi-Dong Jiang
Affiliation:
University of Texas School of Public Health, Houston, Texas
Carolyn Z. Grimes
Affiliation:
University of Texas School of Public Health, Houston, Texas
Diana C. Koo
Affiliation:
University of Texas School of Public Health, Houston, Texas
Todd Lasco
Affiliation:
St. Luke’s Hospital, Houston, Texas
Claudia A. Kozinetz
Affiliation:
Baylor College of Medicine, Houston, Texas
Kevin W. Garey
Affiliation:
University of Texas School of Public Health, Houston, Texas St. Luke’s Hospital, Houston, Texas University of Houston College of Pharmacy, Houston, Texas
Herbert L. DuPont
Affiliation:
Baylor College of Medicine, Houston, Texas University of Texas School of Public Health, Houston, Texas St. Luke’s Hospital, Houston, Texas University of Texas Medical School at Houston, Houston, Texas
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective.

To evaluate the accuracy of real-time polymerase chain reaction (PCR) for Clostridium difficile–associated disease (CDAD) detection, after hospital CDAD rates significantly increased following real-time PCR initiation for CDAD diagnosis.

Design.

Hospital-wide surveillance study following examination of CDAD incidence density rates by interrupted time series design.

Setting.

Large university-based hospital.

Participants.

Hospitalized adult patients.

Methods.

CDAD rates were compared before and after real-time PCR implementation in a university hospital and in the absence of physician and infection control practice changes. After real-time PCR introduction, all hospitalized adult patients were screened for C. difficile by testing a fecal specimen by real-time PCR, toxin enzyme-linked immunosorbent assay, and toxigenic culture.

Results.

CDAD hospital rates significantly increased after changing from cell culture cytotoxicity assay to a real-time PCR assay. One hundred ninety-nine hospitalized subjects were enrolled, and 101 fecal specimens were collected. C. difficile was detected in 18 subjects (18%), including 5 subjects (28%) with either definite or probable CDAD and 13 patients (72%) with asymptomatic C. difficile colonization.

Conclusions.

The majority of healthcare-associated diarrhea is not attributable to CDAD, and the prevalence of asymptomatic C. difficile colonization exceeds CDAD rates in healthcare facilities. PCR detection of asymptomatic C. difficile colonization among patients with non-CDAD diarrhea may be contributing to rising CDAD rates and a significant number of CDAD false positives. PCR may be useful for CDAD screening, but further study is needed to guide interpretation of PCR detection of C. difficile and the value of confirmatory tests. A gold standard CDAD diagnostic assay is needed.

Infect Control Hosp Epidemiol 2014;35(6):667–673

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 35 , Issue 6 , 01 June 2014 , pp. 667 - 673
Copyright
© 2014 by The Society for Healthcare Epidemiology of America. All rights reserved.

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Footnotes

Presented in part: IDWeek 2013 Meeting; San Francisco, California; October 5, 2013.

References

1. McDonald, LC, Owings, M, Jernigan, DB. Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996–2003. Emerg Infect Dis 2006;12:409–415.Google Scholar
2. Redelings, MD, Sorvillo, F, Mascola, L. Increase in Clostridium difficile–related mortality rates, United States, 1999–2004. Emerg Infect Dis 2007;13:1417–1419.Google Scholar
3. Musher, DM, Aslam, S, Logan, N, et al. Relatively poor outcome after treatment of Clostridium difficile colitis with metronidazole. Clin Infect Dis 2005;40:1586–1590.CrossRefGoogle ScholarPubMed
4. O’Horo, JC, Jones, A, Sternke, M, Harper, C, Safdar, N. Molecular techniques for diagnosis of Clostridium difficile infection: systematic review and meta-analysis. Mayo Clin Proc 2012;87:643–651.Google Scholar
5. Schutze, GE, Willoughby, RE. Clostridium difficile infection in infants and children. Pediatrics 2013;131:196–200.Google Scholar
6. American Society for Microbiology (ASM). A Practical Guidance Document for the Laboratory Detection of Toxigenic Clostridium difficile. Washington, DC: ASM, September 21, 2010. http://www.asm.org/images/pdf/Clinical/clostridiumdifficile9-21.pdf. Accessed September 19, 2013.Google Scholar
7. Centers for Disease Control and Prevention. Vital signs: preventing Clostridium difficile infections. MMWR Morb Mortal Wkly Rep 2012;61:157–162.Google Scholar
8. Catanzaro, M, Cirone, J. Real-time polymerase chain reaction testing for Clostridium difficile reduces isolation time and improves patient management in a small community hospital. Am J Infect Control 2012;40:663–666.Google Scholar
9. Luna, RA, Boyanton, BL Jr, Mehta, S, et al. Rapid stool-based diagnosis of Clostridium difficile infection by real-time PCR in a children’s hospital. J Clin Microbiol 2011;49:851–857.Google Scholar
10. Fong, KS, Fatica, C, Hall, G, et al. Impact of PCR testing for Clostridium difficile on incident rates and potential on public reporting: is the playing field level? Infect Control Hosp Epidemiol 2011;32(9):932–933.CrossRefGoogle ScholarPubMed
11. Longtin, Y, Trottier, S, Brochu, G, et al. Impact of the type of diagnostic assay on Clostridium difficile infection and complication rates in a mandatory reporting program. Clin Infect Dis 2013;56:67–73.CrossRefGoogle Scholar
12. Gould, CV, Edwards, JR, Cohen, J, et al. Effect of nucleic acid amplification testing on population-based incidence rates of Clostridium difficile infection. Clin Infect Dis 2013;57:1304–1307.Google Scholar
13. Kvach, EJ, Ferguson, D, Riska, PF, Landry, ML. Comparison of BD GeneOhm Cdiff real-time PCR assay with a two-step algorithm and a toxin A/B enzyme-linked immunosorbent assay for diagnosis of toxigenic Clostridium difficile infection. J Clin Microbiol 2010;48:109–114.CrossRefGoogle Scholar
14. Borriello, SP, Honour, P. Simplified procedure for the routine isolation of Clostridium difficile from faeces. J Clin Pathol 1981;34:1124–1127.Google Scholar
15. Rosner, B. Fundamentals of Biostatistics. 5th ed. Boston: Brooks/Cole, 2000.Google Scholar
16. Box, GEP, Tiao, GC. Intervention analysis with applications to economic and environmental problems. J Am Stat Assoc 1975;70:70–79.CrossRefGoogle Scholar
17. Hall, AJ, Curns, AT, McDonald, LC, Parashar, UD, Lopman, BA. The roles of Clostridium difficile and norovirus among gastroenteritis-associated deaths in the United States, 1999–2007. Clin Infect Dis 2012;55:216–223.Google Scholar
18. Bartlett, JG. Clinical practice: antibiotic-associated diarrhea. N Engl J Med 2002;346:334–339.CrossRefGoogle ScholarPubMed
19. Kyne, L, Warny, M, Qamar, A, Kelly, CP. Asymptomatic carriage of Clostridium difficile and serum levels of IgG antibody against toxin A. N Engl J Med 2000;342:390–397.CrossRefGoogle ScholarPubMed
20. McFarland, LV, Mulligan, ME, Kwok, RY, Stamm, WE. Nosocomial acquisition of Clostridium difficile infection. N Engl J Med 1989;320:204–210.Google Scholar
21. Samore, MH, DeGirolami, PC, Tlucko, A, Lichtenberg, DA, Melvin, ZA, Karchmer, AW. Clostridium difficile colonization and diarrhea at a tertiary care hospital. Clin Infect Dis 1994;18:181–187.CrossRefGoogle ScholarPubMed
22. Riggs, MM, Sethi, AK, Zabarsky, TF, Eckstein, EC, Jump, RL, Donskey, CJ. Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents. Clin Infect Dis 2007;45:992–998.Google Scholar
23. Tenover, FC, Novak-Weekley, S, Woods, CW, et al. Impact of strain type on detection of toxigenic Clostridium difficile: comparison of molecular diagnostic and enzyme immunoassay approaches. J Clin Microbiol 2010;48:3719–3724.Google Scholar
24. Planche, TD, Davies, KA, Coen, PG, et al. Differences in outcome according to Clostridium difficile testing method: a prospective multicentre diagnostic validation study of C difficile infection. Lancet Infect Dis 2013;13:936–945.Google Scholar
25. Berg, AM, Kelly, CP, Farraye, FA. Clostridium difficile infection in the inflammatory bowel disease patient. Inflamm Bowel Dis 2013;19:194–204.Google Scholar
26. Koo, HL, Ajami, NJ, Jiang, ZD, et al. A nosocomial outbreak of norovirus infection masquerading as Clostridium difficile infection. Clin Infect Dis 2009;48:e75–e77.Google Scholar
27. Crobach, MJ, Dekkers, OM, Wilcox, MH, Kuijper, EJ. European Society of Clinical Microbiology and Infectious Diseases (ESCMID): data review and recommendations for diagnosing Clostridium difficile-infection (CDI). Clin Microbiol Infect 2009;15:1053–1066.Google Scholar
28. Deshpande, A, Pasupuleti, V, Rolston, DD, et al. Diagnostic accuracy of real-time polymerase chain reaction in detection of Clostridium difficile in the stool samples of patients with suspected Clostridium difficile infection: a meta-analysis. Clin Infect Dis 2013;53:e81–e90.Google Scholar
29. Wilcox, MH. Overcoming barriers to effective recognition and diagnosis of Clostridium difficile infection. Clin Microbiol Infect 2012;18(suppl 6):13–20.Google Scholar
30. Brecher, SM, Novak-Weekley, SM, Nagy, E. Laboratory diagnosis of Clostridium difficile infections: there is light at the end of the colon. Clin Infect Dis 2013;57:1175–1181.Google Scholar
31. Cohen, SH, Gerding, DN, Johnson, S, et al. 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). Infect Control Hosp Epidemiol 2010;31:431–455.Google Scholar
32. Louie, TJ, Emery, J, Krulicki, W, Byrne, B, Mah, M. OPT-80 eliminates Clostridium difficile and is sparing of bacteroides species during treatment of C. difficile infection. Antimicrob Agents Chemother 2009;53:261–263.CrossRefGoogle ScholarPubMed
33. Garey, KW, Graham, G, Gerard, L, et al. Prevalence of diarrhea at a university hospital and association with modifiable risk factors. Ann Pharmacother 2006;40:1030–1034.Google Scholar