European Society of Clinical Microbiology and Infectious Diseases (ESCMID): Data review and recommendations for diagnosing Clostridium difficile-infection (CDI)

Clostridium diffi cile infection (CDI) is a leading cause of hospital-associated gastrointestinal illness and places a high burden on our health-care system. Patients with CDI typically have extended lengths-of-stay in hospitals, and CDI is a frequent cause of large hospital outbreaks of disease. This guideline provides recommendations for the diagnosis and management of patients with CDI as well as for the prevention and control of outbreaks while supplementing previously published guidelines. New molecular diagnostic stool tests will likely replace current enzyme immunoassay tests. We suggest treatment of patients be stratifi ed depending on whether they have mild-to-moderate, severe, or complicated disease. Therapy with metronidazole remains the choice for mildto-moderate disease but may not be adequate for patients with severe or complicated disease. We propose a classifi cation of disease severity to guide therapy that is useful for clinicians. We review current treatment options for patients with recurrent CDI and recommendations for the control and prevention of outbreaks of CDI. Am J Gastroenterol 2013; 108:478-498; doi: 10.1038/ajg.2013 12. In patients in whom oral antibiotics cannot reach a segment of the colon, such as with Hartman's pouch, ileostomy, or colon diversion, vancomycin therapy delivered via enema should be added to treatments above until the patient improves. (Conditional recommendation, low-quality evidence)13. The use of anti-peristaltic agents to control diarrhea from confi rmed or suspected CDI should be limited or avoided, as they may obscure symptoms and precipitate complicated disease. Use of anti-peristaltic agents in the setting of CDI must always be accompanied by medical therapy for CDI. (Strong recommendation, low-quality evidence) Management of severe and complicated CDI14. Supportive care should be delivered to all patients and includes intravenous fl uid resuscitation, electrolyte replacement, and pharmacological venous thromboembolism prophylaxis. Furthermore, in the absence of ileus or signifi cant abdominal distention, oral or enteral feeding should be continued. 17. Vancomycin delivered orally (500 mg four times per day) and per rectum (500 mg in a volume of 500 ml four times a day) plus intravenous metronidazole (500 mg three times a day) is the treatment of choice for patients with complicated CDI with ileus or toxic colon and / or signifi cant abdominal distention. (Strong recommendation, low-quality evidence)18. Surgical consult should be obtained in all patients with complicated CDI. Surgical therapy should be considered in patients with any one of the following attributed to CDI: hypotension requiring vasopressor therapy; clinical signs of sepsis and organ dysfunction (renal and pulmonary); mental status changes; white blood cell count ≥ 50,000 cells / μ l, lactate ≥ 5 mmol / l; or failure to improve on medical therapy after 5 days. (Strong recommendation, moderate-quality evidence) Management of recurrent CDI (RCDI)19. The fi rst recurrence of CDI can be treated ...

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“…Clinical practice guidelines have evolved over the past 3 years to suggest the following diagnostic approaches ( 11,28 …”

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confidence: 99%

Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections

Surawicz

Brandt

Binion

et al. 2013

American Journal of Gastroenterology

1,468

1,408

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“…The recent comprehensive study of C. difficile detection methods, 2 which reported the sensitivity of a commonly used GDH assay as 87.6% when compared with toxigenic culture, is consistent with concerns of falsely GDH-negative samples raised by the report of Larson et al 48 NovakWeekley et al 34 reported that initial GDH screening failed to identify approximately 15% of samples containing toxigenic C. difficile isolates. In addition, the mean sensitivity of membrane-type GDH assays in the ESCMID survey was only 60% when compared with toxigenic culture, 3 suggesting that GDH screening may not be as highly sensitive as previously assumed. 13 A recent meta-analysis of GDH tests by Shetty and colleagues 45 reported that, when compared with the results of toxigenic culture, the sensitivity of GDH assays ranged from a low of 79.2% to 98% and varied with the prevalence of CDI.…”

Section: Gdh Assaysmentioning

confidence: 77%

“…Nevertheless, because of its high sensitivity, culture, together with the identification of toxin production from pure cultures of organisms (referred to as toxigenic culture), has replaced the CCCN assay as the reference method for CDI diagnosis in most studies. 1,3 However, some investigators 3,6 still hold that the identification of toxin in stool, and not the detection of the organism or the gene that encodes the critical toxin, should be considered the reference method for diagnostic studies.…”

Section: Culture On Agar Mediamentioning

confidence: 99%

“…1 The most widely used tests in clinical microbiology laboratories for detection of CDI [ie, enzyme immunoassays (EIAs) for toxins A and B] are no longer considered to have adequate sensitivity to be used as stand-alone tests for CDI. 1,2 A comprehensive survey of the literature, conducted by Crobach and colleagues 3 for the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), showed that the mean sensitivity of well-type EIAs for toxins A and B was 66%, whereas the mean sensitivity for membranetype EIAs for toxins A and B was only 52%, when compared with toxigenic culture as the reference method. Nucleic acid amplification tests (NAATs), which typically show both high sensitivity and specificity for detection of CDI, may ultimately be the best tests, according to recent commentaries and practice guidelines from the American Society for Microbiology (ASM, http://www.asm.org/images/ pdf/Clinical/clostridiumdifficile9-21.pdf, last accessed April 25, 2011) 4 -6 ; however, at publication of the SHEA-IDSA guidelines, there was insufficient data in the literature on which to base a recommendation for their use.…”

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confidence: 99%

“…The mean sensitivity of PCR in the ESCMID survey was 86%, whereas the mean specificity was 97%. 3 In lieu of using EIA tests or PCR assays as stand-alone tests, the SHEA-IDSA guidelines recommended a two-step algorithm using glutamate dehydrogenase (GDH) as a screening test, followed by either a cell culture cytotoxin neutralization (CCCN) assay or bacterial culture coupled with a toxin assay on the purified organism (ie, toxigenic culture) for confirmation. 1 The recommendations did not support the use of an EIA test for confirmation of GDH-positive samples because of a lack of sensitivity of the EIA tests.…”

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confidence: 99%

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Laboratory Diagnosis of Clostridium difficile Infection

Tenover¹,

Baron²,

Peterson

et al. 2011

The Journal of Molecular Diagnostics

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The laboratory diagnosis of Clostridium difficile infection (CDI) continues to be challenging. Recent guidelines from professional societies in the United States note that enzyme immunoassays for toxins A and B do not have adequate sensitivity to be used alone for detecting CDI, yet the optimal method for diagnosing this infection remains unclear. Nucleic acid amplification tests (NAATs) that target chromosomal toxin genes (usually the toxin B gene, tcdB) show high sensitivity and specificity, provide rapid results, and are amenable to both batch and on-demand testing, but these tests were not universally recommended for routine use in the recent guidelines. Rather, two-step algorithms that use glutamate dehydrogenase (GDH) assays to screen for C. difficile in stool specimens, followed by either direct cytotoxin testing or culture to identify toxin-producing C. difficile isolates, were recommended in one guideline and either GDH algorithms or NAATs were recommended in another guideline. Unfortunately, neither culture nor direct cytotoxin testing is widely available. In addition, this two-step approach requires 48 to 92 hours to complete, which may delay the initiation of therapy and critical infection control measures. Recent studies also show the sensitivity of several GDH assays to be <90%. This review considers the role of NAATs for diagnosing CDI and explores their potential advantages over two-step algorithms, including shorter time to results, while providing comparable, if not superior, accuracy.

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Diagnosis and Treatment ofClostridium difficilein Adults

Bagdasarian

Rao

Malani

2015

JAMA

415

328

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Diagnostic testing for CDI should be performed only in symptomatic patients. Treatment strategies should be based on disease severity, history of prior CDI, and the individual patient's risk of recurrence. Vancomycin is the treatment of choice for severe or complicated CDI, with or without adjunctive therapies. Metronidazole is appropriate for mild disease. Fidaxomicin is a therapeutic option for patients with recurrent CDI or a high risk of recurrence. Fecal microbiota transplantation is associated with symptom resolution of recurrent CDI but its role in primary and severe CDI is not established.

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European Society of Clinical Microbiology and Infectious Diseases (ESCMID): Data review and recommendations for diagnosing Clostridium difficile-infection (CDI)

Cited by 366 publications

References 61 publications

Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections

Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections

Laboratory Diagnosis of Clostridium difficile Infection

Diagnosis and Treatment ofClostridium difficilein Adults

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