Hayden T Schwenk1, Laura L Bio2, Jenna F Kruger3, Niaz Banaei4,5,6. 1. Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, California. 2. Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California. 3. Center for Quality and Clinical Effectiveness, Lucile Packard Children's Hospital Stanford, Palo Alto, California. 4. Department of Pathology, Stanford University School of Medicine, Stanford, California. 5. Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California. 6. Clinical Microbiology Laboratory, Stanford University Medical Center, Palo Alto, California.
Abstract
BACKGROUND: Reliance on tests that detect only the presence of toxigenic Clostridium difficile can result in overdiagnosis and overtreatment of C difficile infection (CDI). The C difficile polymerase chain reaction (PCR) cycle threshold (CT) can sensitively predict the presence of free C difficile toxins; however, the clinical application for this testing strategy remains unexplored. We evaluated the impact of dual PCR and toxin result reporting, as predicted by the CT, on CDI management and outcomes in children. METHODS: Before the intervention, results for C difficile testing at Lucile Packard Children's Hospital Stanford were reported as PCR positive (PCR+) or negative (PCR-) according to the GeneXpert C diff Epi tcdB PCR assay (Cepheid, Sunnyvale, California). Beginning October 5, 2016, the presence of free toxins, as predicted by the CT, was reported also. The CDI treatment rates 1 year before and 18 months after implementation of toxin reporting were compared. Demographic and treatment-related data were collected, and patient outcomes were followed up 8 weeks later. RESULTS: CDI treatment decreased 22% after the intervention (96% [preintervention] vs 74% [postintervention]; P < .001). During the postintervention period, there were 152 PCR+C difficile results, and 94 (62%) of them were toxin positive (toxin+) according to the CT. Of the 58 PCR+/toxin-negative (toxin-) results, 38 (66%) did not result in CDI treatment. Seven (18%) of the untreated PCR+/toxin- patients underwent repeat testing within 8 weeks, and 5 (13%) of them were subsequently PCR+/toxin+ and treated. No CDI-related complications were identified. CONCLUSIONS: Addition of the CT-predicted C difficile toxin result to PCR reporting reduces the proportion of PCR+ children treated for CDI.
BACKGROUND: Reliance on tests that detect only the presence of toxigenic Clostridium difficile can result in overdiagnosis and overtreatment of C difficile infection (CDI). The C difficile polymerase chain reaction (PCR) cycle threshold (CT) can sensitively predict the presence of free C difficile toxins; however, the clinical application for this testing strategy remains unexplored. We evaluated the impact of dual PCR and toxin result reporting, as predicted by the CT, on CDI management and outcomes in children. METHODS: Before the intervention, results for C difficile testing at Lucile Packard Children's Hospital Stanford were reported as PCR positive (PCR+) or negative (PCR-) according to the GeneXpert C diff Epi tcdB PCR assay (Cepheid, Sunnyvale, California). Beginning October 5, 2016, the presence of free toxins, as predicted by the CT, was reported also. The CDI treatment rates 1 year before and 18 months after implementation of toxin reporting were compared. Demographic and treatment-related data were collected, and patient outcomes were followed up 8 weeks later. RESULTS:CDI treatment decreased 22% after the intervention (96% [preintervention] vs 74% [postintervention]; P < .001). During the postintervention period, there were 152 PCR+C difficile results, and 94 (62%) of them were toxin positive (toxin+) according to the CT. Of the 58 PCR+/toxin-negative (toxin-) results, 38 (66%) did not result in CDI treatment. Seven (18%) of the untreated PCR+/toxin- patients underwent repeat testing within 8 weeks, and 5 (13%) of them were subsequently PCR+/toxin+ and treated. No CDI-related complications were identified. CONCLUSIONS: Addition of the CT-predicted C difficile toxin result to PCR reporting reduces the proportion of PCR+ children treated for CDI.
Authors: Glen Hansen; Stephen Young; Alan H B Wu; Emily Herding; Vickie Nordberg; Ray Mills; Christen Griego-Fullbright; Aaron Wagner; Chui Mei Ong; Shawna Lewis; Joseph Yoon; Joel Estis; Johanna Sandlund; Emily Friedland; Karen C Carroll Journal: J Clin Microbiol Date: 2019-10-23 Impact factor: 5.948
Authors: E Bouza; J M Aguado; L Alcalá; B Almirante; P Alonso-Fernández; M Borges; J Cobo; J Guardiola; J P Horcajada; E Maseda; J Mensa; N Merchante; P Muñoz; J L Pérez Sáenz; M Pujol; E Reigadas; M Salavert; J Barberán Journal: Rev Esp Quimioter Date: 2020-02-20 Impact factor: 1.553