A European survey of diagnostic methods and testing protocols for Clostridium difficile

Leiden University, Leyden, South Holland, Netherlands
Clinical Microbiology and Infection (Impact Factor: 5.77). 10/2003; 9(10):989 - 996. DOI: 10.1046/j.1469-0691.2003.00683.x
Source: PubMed


Objective To conduct a survey of the methods used in clinical microbiology laboratories in Europe to diagnose infection with Clostridium difficile.Methods A questionnaire was devised and sent to a co-ordinating member of the Study Group in each of eight European countries. This co-ordinator was in charge of forwarding the questionnaire to hospital laboratories arbitrarily selected. The number of laboratories in each country was determined on the basis of one laboratory for 10 000 beds of hospitalization. This questionnaire covered different aspects pertaining to Clostridium difficile associated to diarrhea (CDAD) diagnosis such as circumstances of request, criteria used for undertaking C. difficile investigations, methods used for the diagnosis, etc.Results A total of 212 questionnaires were completed and submitted for analysis: 87.7% of laboratories reported routinely performing C. difficile diagnostic tests. Methods used included toxin detection (93%), culture (55%), and glutamate dehydrogenase (GDH) detection (5.9%). Among the laboratories detecting toxins, different enzyme immunoassays (EIA) and cytotoxicity assays were used in 79% and 17.3% of cases, respectively. Among the different strategies reported, 4.8% were considered suboptimal for the diagnosis of C. difficile infections, but marked discrepancies could be observed between countries. The overall incidence (median) of CDAD was estimated at 1.1 for 1000 patient admissions.Conclusion The results of this study suggest marked discrepancies between laboratories and also between countries regarding the criteria by which C. difficile is investigated for, and the methods and the strategies that are used for the diagnosis of C. difficile. These discrepancies could be explained by the lack of clear guidelines for C. difficile diagnosis in each country, and by the importance that physicians attach to C. difficile. Precise guidelines for C. difficile diagnosis would be the first step to make possible accurate comparison of the incidence and the epidemiology of CDAD from one hospital to another or from one country to another.

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Available from: Ian R Poxton, Jun 17, 2014
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    • "In the clinical laboratories, the high cost and the need for anaerobic facilities and expert technicians make the C. difficile culturing so demanding which is not routinely performed. As a result, it is recommended to culture the bacterium in the case of consultation with infectious disease and/or gastroenterology specialists [33, 35]. Cycloserine-cefoxitin-fructose agar (CCFA), as a selective and differential agar medium, is the first choice of isolation media for the recovery of C. difficile from fecal specimens. "
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    ABSTRACT: The incidence and mortality rate of Clostridium difficile infection have increased remarkably in both hospital and community settings during the last two decades. The growth of infection may be caused by multiple factors including inappropriate antibiotic usage, poor standards of environmental cleanliness, changes in infection control practices, large outbreaks of C. difficile infection in hospitals, alteration of circulating strains of C. difficile, and spread of hypervirulent strains. Detection of high-risk populations could be helpful for prompt diagnosis and consequent treatment of patients suffering from C. difficile infection. Metronidazole and oral vancomycin are recommended antibiotics for the treatment of initial infection. Current treatments for C. difficile infection consist of supportive care, discontinuing the unnecessary antibiotic, and specific antimicrobial therapy. Moreover, novel approaches include fidaxomicin therapy, monoclonal antibodies, and fecal microbiota transplantation mediated therapy. Fecal microbiota transplantation has shown relevant efficacy to overcome C. difficile infection and reduce its recurrence.
    Full-text · Article · Jun 2014
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    • "Both methods are not suitable for routine diagnosis since results are delayed (at least to more than 24 h), they are labor-intensive, and fresh cell cultures are needed. To overcome these problems, numerous enzyme immunoassays (EIAs) have been developed which are now used widely in clinical laboratories [2]. However, the described performance of EIAs varies widely, with sensitivity and specificity ranging from 23 to 99% and 70 to 100%, respectively [3–9]. "
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    ABSTRACT: Many laboratories use enzyme immunoassays (EIAs) for the diagnosis of Clostridium difficile infection (CDI). More recently, polymerase chain reaction (PCR)-based diagnosis has been described as a sensitive test. Real-time PCR for the detection of C. difficile toxin A and B genes was evaluated. A prospective evaluation was performed on stool samples from 150 hospitalized adult patients and 141 healthy volunteers. PCR was compared to toxigenic culture (TC), direct cytotoxicity test (CTT), ImmunoCard® Toxin A and B (Meridian Bioscience), and enzyme-linked immunosorbent assay (ELISA) (Vidas). The results were correlated with clinical data using a standardized questionnaire. The diagnostic yield of the PCR was further evaluated after implementation. Using toxigenic culture as the gold standard, the sensitivity and specificity of PCR were 100 and 99.2%, respectively. Patients were categorized as follows: TC/PCR-positive (n = 17) and negative TC (n = 133). The differences in these groups were more frequent use of antibiotics and leukocytosis (p < 0.05). The diagnostic yield of PCR was evaluated during a period of 6 months and showed an increase of positive patients by 50%. PCR for the detection of toxigenic C. difficile has a high sensitivity and can rule out CDI, but cannot differentiate CDI from asymptomatic carriage. Clinicians should be aware of this in order to prevent inappropriate treatment and delay of other diagnostics.
    Preview · Article · Feb 2012 · European Journal of Clinical Microbiology
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    • "It appears likely that, at some point, there must have been a clinical sign of a C. difficile variant. However, we may have missed this because we did not possess adequate data regarding the nationwide prevalence of C. difficile variants prior to 2005, because culturing, C. difficile is a strenuous procedure in the majority of laboratories, and EIAs for TcdA only have been widely utilized for the diagnosis of C. difficile infection in Korea, as has been reported in other European countries (Barbut et al., 2003). These commercial toxin A EIAs are not capable of detecting tcdA 2 tcdB + variants, as variant strains of C. difficile that harbour deletions of 1.7–1.8 "
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    ABSTRACT: The prevalence of toxigenic Clostridium difficile in Korea has been reported to be approximately 60-80 %. Although the prevalence of the tcdA -tcdB+ C. difficile strain was less then 5 % prior to the year 2000, it has become an emerging nosocomial pathogen in Korea. Therefore, we have attempted to determine the multicentre nationwide prevalence of tcdA +tcdB+ and tcdA-tcdB+ C. difficile for epidemiological purposes. C. difficile strains (n=724, 30 from 2000, 80 from 2001, 74 from 2002, 76 from 2003, 179 from 2004, 285 from 2005) were obtained retrospectively from January 2000 to December 2005 from in-patients at 6 hospitals, all of whom were suspected of having C. difficile-associated disease (CDAD), colitis or pseudomembranous colitis. The numbers of participating hospitals varied yearly (1 in 2000, 2 in 2001-2003, 3 in 2004, 5 in 2005). The hospitals were located in Seoul (n=4), Kyunggi Province (n=1) and Busan (n=1), Korea. PCR assays for tcdA and tcdB genes were conducted using 724 unduplicated C. difficile isolates. The mean prevalence of tcdA+ tcdB+ and tcdA-tcdB+ C. difficile strains over the 6 years was 51.8 % (38.4-59.3%) and 25.8 %(10-56.0 %), respectively. The mean prevalence of tcdA-tcdB+ C. difficile strains was less than 7 % until 2002, but began to increase in 2003 (13.2 %) and achieved a peak in 2004 (50.3 %). In 2005, the mean prevalence of tcdA+tcdB+ and tcdA-tcdB+ C. difficile strains was 47.7 % (30.9-60.3 %) and 27.0 % (17.6-54.8 %), respectively. This nationwide epidemiological study showed that tcdA-tcdB+ C. difficile strains have already spread extensively throughout Korea, and our results provide basic data regarding the controversies currently surrounding the toxigenicity of tcdA -tcdB+ C. difficile. The use of enzyme immunoassays capable of detecting both TcdA and TcdB is strongly recommended for the diagnosis of CDAD in microbiology laboratories, in order to control the spread of the tcdA-tcdB+ strains of C. difficile.
    Full-text · Article · Jul 2008 · Journal of Medical Microbiology
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