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Singh S, Newton-Foot M, Nel P, Pienaar C. Comparison of commercial assays and two-step approach to detect Clostridioides difficile in South Africa. Afr J Lab Med 2022; 11:1809. [PMID: 36263391 PMCID: PMC9575369 DOI: 10.4102/ajlm.v11i1.1809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 05/26/2022] [Indexed: 11/06/2022] Open
Abstract
Background Clostridioides difficile is the number one cause of hospital-acquired diarrhoea. Accurate diagnosis of C. difficile is of utmost importance as it guides patient management and infection control practices. Studies evaluating the performance of commercially available nucleic acid amplification tests (NAATs) versus algorithms are lacking in resource-limited settings. Objective This study assessed the performance of three commercially available tests and a two-step approach for the diagnosis of C. difficile infection using toxigenic culture (TC) as the gold standard. Methods Two hundred and twenty-three non-duplicate loose stool samples were submitted to the National Health Laboratory Service Microbiology Laboratory at Tygerberg Hospital, Cape Town, South Africa, from October 2017 to October 2018. The samples were tested in parallel using the C. DIFF QUIK CHEK COMPLETE enzyme immunoassay (EIA) and two NAATs (Xpert C. difficile and BD MAX Cdiff), and the results were compared to TC. The performance of a two-step approach consisting of the C. DIFF QUIK CHEK COMPLETE followed by the Xpert C. difficile was also determined. Results Of 223 faecal specimens tested, 37 (16.6%) were TC-positive. The sensitivity and specificity of the C. DIFF QUIK CHEK COMPLETE were 54.1% and 98.9%; Xpert C. difficile, 86.4% and 96.8%; BD MAX Cdiff, 89.2% and 96.8%; and two-step approach, 89.2% and 96.2%. Conclusion The C. DIFF QUIK CHEK COMPLETE, in a two-step approach with the Xpert C. difficile, performed similarly to the NAATs on their own and offer advantages in terms of cost and workflow in low-resource settings.
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Affiliation(s)
- Sarishna Singh
- National Health Laboratory Service Tygerberg Academic Laboratory, Division of Medical Microbiology, Tygerberg Hospital, Tygerberg, South Africa,Division of Medical Microbiology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Mae Newton-Foot
- National Health Laboratory Service Tygerberg Academic Laboratory, Division of Medical Microbiology, Tygerberg Hospital, Tygerberg, South Africa,Division of Medical Microbiology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Pieter Nel
- National Health Laboratory Service Tygerberg Academic Laboratory, Division of Medical Microbiology, Tygerberg Hospital, Tygerberg, South Africa,Division of Medical Microbiology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Colette Pienaar
- National Health Laboratory Service Tygerberg Academic Laboratory, Division of Medical Microbiology, Tygerberg Hospital, Tygerberg, South Africa,Division of Medical Microbiology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Abstract
Clostridium (reclassified as " Clostridioides ") difficile is an anaerobic, gram-positive bacterium that causes significant disease through elaboration of two potent toxins in patients whose normal gut microbiota has been altered through antimicrobial or chemotherapeutic agents (dysbiosis). The optimum method of laboratory diagnosis is still somewhat controversial. Recent practice guidelines published by professional societies recommend a two-step approach beginning with a test for glutamate dehydrogenase (GDH), followed by a toxin test and/or a nucleic acid test. Alternatively, in institutions where established clinical algorithms guide testing, a nucleic acid test alone is acceptable. Nucleic acid tests are the methods of choice in approximately 50% of laboratories in the United States. These tests are considered as the most sensitive methods for detection of C. difficile in stool and are the least specific. Because of the lower specificity with nucleic acid tests, some clinicians believe that toxin enzyme immunoassays are better predictors of disease, despite their known poor performance in certain patient populations. This review will discuss the advantages and disadvantages of the currently available test methods for the diagnosis of C. difficile with a brief mention of some novel assays that are currently in clinical trials.
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Affiliation(s)
- Karen C. Carroll
- Division of Medical Microbiology, Department of Pathology, the Johns Hopkins University School of Medicine, Baltimore, Maryland
- Address for correspondence Karen C. Carroll, MD Division of Medical Microbiology, Department of Pathology, the Johns Hopkins University School of MedicineMeyer B1-193, 600 North Wolfe Street, Baltimore MD 21287
| | - Masako Mizusawa
- Section of Infectious Diseases, Department of Internal Medicine, University of Missouri, Kansas City, Missouri
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Putsathit P, Maneerattanaporn M, Piewngam P, Kiratisin P, Riley TV. Prevalence and molecular epidemiology of Clostridium difficile infection in Thailand. New Microbes New Infect 2016; 15:27-32. [PMID: 28119780 PMCID: PMC5237757 DOI: 10.1016/j.nmni.2016.10.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 10/04/2016] [Accepted: 10/14/2016] [Indexed: 12/18/2022] Open
Abstract
Little is known about Clostridium difficile infection (CDI) in Asia generally, and specifically in Thailand. Given the high prevalence of inappropriate antibiotic usage in this region, CDI is likely to be common. This study investigated the prevalence and molecular epidemiology of CDI in Thailand. Stool specimens collected from inpatients with diarrhoea at Siriraj hospital in Bangkok (n = 422) were cultured on ChromID Cdiff agar and any presumptive C. difficile colonies were identified, PCR ribotyped and toxin profiled. As part of the routine C. difficile testing at Siriraj Hospital, 370 specimens also underwent testing with the BD MAX Cdiff assay to detect the presence of tcdB. With direct culture, 105 different isolates of C. difficile were recovered from 23.7% (100/422) of the stool specimens. The prevalence of toxigenic and nontoxigenic isolates was 9.2% (39/422) and 15.6% (66/422), respectively. Of the toxigenic isolates, 69.2% (27/39) and 30.8% (12/39) were tcdA and tcdB positive (A+B+), and A−B+, respectively; none contained binary toxin genes. The five most prevalent ribotypes (RTs) were 014/020 group (17/105), 010 (12/105), 017 (12/105), 039 (9/105) and 009 (6/105). Using toxigenic culture as the reference standard, the sensitivity, specificity, positive predictive value and negative predictive value of the BD MAX Cdiff assay were 68.6, 95.1, 63.2 and 96.1%, respectively. The high proportion of A−B+, RT 017 strains emphasises the need for diagnostic tests that detect either both toxins or just tcdB. Continued surveillance that involves stool culturing will allow molecular tracking and assist in elucidating the epidemiology of CDI in Thailand.
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Affiliation(s)
- P Putsathit
- Microbiology and Immunology, School of Pathology and Laboratory Medicine, The University of Western Australia, Crawley, Western Australia, Australia
| | - M Maneerattanaporn
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - P Piewngam
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - P Kiratisin
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - T V Riley
- Microbiology and Immunology, School of Pathology and Laboratory Medicine, The University of Western Australia, Crawley, Western Australia, Australia; Department of Microbiology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Nedlands, Western Australia, Australia
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Abstract
INTRODUCTION Clostridium difficile infection (CDI) is the leading cause of hospital-acquired diarrhea and is associated with a considerable health and cost burden. However, there is still not a clear consensus on the best laboratory diagnosis approach and a wide variation of testing methods and strategies can be encountered. AREAS COVERED We aim to review the most practical aspects of CDI diagnosis providing our own view on how to optimize CDI diagnosis. Expert commentary: Laboratory diagnosis in search of C. difficile toxins should be applied to all fecal diarrheic samples reaching the microbiology laboratory in patients > 2 years old, with or without classic risk factors for CDI. Detection of toxins either directly in the fecal sample or in the bacteria isolated in culture confirm CDI in the proper clinical setting. Nuclear Acid Assay techniques (NAAT) allow to speed up the process with epidemiological and therapeutic consequences.
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Affiliation(s)
- Emilio Bouza
- a Department of Clinical Microbiology and Infectious Diseases , Hospital General Universitario Gregorio Marañón , Madrid , Spain.,b Facultad de Medicina , Universidad Complutense de Madrid (UCM) , Madrid , Spain.,c Instituto de Investigación Sanitaria Gregorio Marañón , Madrid , Spain.,d CIBER de Enfermedades Respiratorias (CIBERES CD06/06/0058) , Madrid , Spain
| | - Luis Alcalá
- a Department of Clinical Microbiology and Infectious Diseases , Hospital General Universitario Gregorio Marañón , Madrid , Spain.,d CIBER de Enfermedades Respiratorias (CIBERES CD06/06/0058) , Madrid , Spain
| | - Elena Reigadas
- a Department of Clinical Microbiology and Infectious Diseases , Hospital General Universitario Gregorio Marañón , Madrid , Spain.,c Instituto de Investigación Sanitaria Gregorio Marañón , Madrid , Spain
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Erb S, Frei R, Strandén AM, Dangel M, Tschudin-Sutter S, Widmer AF. Low sensitivity of fecal toxin A/B enzyme immunoassay for diagnosis of Clostridium difficile infection in immunocompromised patients. Clin Microbiol Infect 2015; 21:998.e9-998.e15. [PMID: 26232535 DOI: 10.1016/j.cmi.2015.07.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 07/14/2015] [Accepted: 07/14/2015] [Indexed: 12/17/2022]
Abstract
The optimal approach in laboratory diagnosis of Clostridium difficile infection (CDI) is still not well defined. Toxigenic culture (TC) or alternatively fecal toxin assay by cell cytotoxicity neutralization assay are considered to be the reference standard, but these methods are time-consuming and labor intensive. In many medical centers, diagnosis of CDI is therefore still based on fecal toxin A/B enzyme immunoassay (EIA) directly from stool alone, balancing cost and speed against limited diagnostic sensitivity. The aim of the study was to assess in which patient population the additional workload of TC is justified. All consecutive stool specimens submitted for diagnosis of suspected CDI between 2004 and 2011 at a tertiary-care center were examined by toxin EIA and TC. Clinical data of patients with established diagnosis of CDI were collected in a standardized case-report form. From 12,481 stool specimens submitted to the microbiologic laboratory, 480 (3.8%) fulfilled CDI criteria; 274 (57.1%) were diagnosed by toxin EIA; and an additional 206 (42.9%) were diagnosed by TC when toxin EIA was negative. Independent predictors for negative toxin EIA but positive TC were high-dose corticosteroids (odds ratio (OR) 2.97, 95% confidence interval (CI) 1.50-5.90, p 0.002), leukocytopenia <1000/μL (OR 2.52, 95% CI 1.22-5.23, p 0.013) and nonsevere CDI (OR 2.21, 95% CI 1.39-3.50, p 0.001). There was no difference in outcomes such as in-hospital mortality and recurrence between both groups. In conclusion, negative toxin EIA does not rule out CDI in immunocompromised patients in the setting of relevant clinical symptoms. Methods with improved sensitivity such as TC or PCR should be used, particularly in this patient population.
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Affiliation(s)
- S Erb
- Division of Infectious Diseases and Hospital Epidemiology, Switzerland
| | - R Frei
- Division of Clinical Microbiology, University Hospital Basel, Basel, Switzerland
| | - A M Strandén
- Division of Infectious Diseases and Hospital Epidemiology, Switzerland
| | - M Dangel
- Division of Infectious Diseases and Hospital Epidemiology, Switzerland
| | - S Tschudin-Sutter
- Division of Infectious Diseases and Hospital Epidemiology, Switzerland
| | - A F Widmer
- Division of Infectious Diseases and Hospital Epidemiology, Switzerland.
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Stahlmann J, Schönberg M, Herrmann M, von Müller L. Detection of nosocomial Clostridium difficile infections with toxigenic strains despite negative toxin A and B testing on stool samples. Clin Microbiol Infect 2014; 20:O590-2. [PMID: 24450741 DOI: 10.1111/1469-0691.12558] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 12/15/2013] [Accepted: 12/16/2013] [Indexed: 01/05/2023]
Abstract
A two-step diagnostic algorithm is recommended to detect Clostridium difficile infections; however, samples are regularly found that are glutamate dehydrogenase (GDH) positive but stool toxin negative. In the present single-centre prospective study we focused on these 'difficult-to-interpret' samples and characterized them by anaerobic culture, toxigenic culture, slpA sequence typing and multiplex PCR (GenoType CDiff). The majority of stool toxin A and B-negative samples have been caused by toxigenic strains including ribotype 027. The multiplex PCR was faster and more sensitive compared with culture and allowed preliminary identification of hypervirulent strains in stool samples on the same day.
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Affiliation(s)
- J Stahlmann
- Institute of Medical Microbiology and Hygiene, National Advisory Laboratory for Clostridium Difficile, University of Saarland Medical Center, Homburg, Saar, Germany
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