Screening for Clostridium difficile colonization on admission to a hematopoietic stem cell transplant unit may reduce hospital-acquired C difficile infection

Cho, Janice; Seville, Maria Teresa; Khanna, Sahil; Pardi, Darrell S.; Sampathkumar, Priya; Kashyap, Purna C.

doi:10.1016/j.ajic.2017.10.009

Cited by 18 publications

(15 citation statements)

References 6 publications

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“…In addition, since gastrointestinal colonization with C difficile precedes CDI and may contribute to hospital spread of the organism, determining the rates of colonization in AHSCT patients is also of interest. However, colonization studies to date have combined patients receiving AHSCT with those undergoing allogeneic transplantation, two groups that may not be similar in incidence. In this study, we review a large single‐institutional series of patients receiving a first AHSCT and include a study of C difficile colonization in a subgroup of these patients.…”

Section: Introductionmentioning

confidence: 99%

Clostridioides difficile colonization and infection in patients admitted for a first autologous transplantation: Incidence, risk factors, and patient outcomes

Ford

Lopansri

Coombs

et al. 2019

Clinical Transplantation

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Background More data are needed regarding the incidence, risk factors, and outcomes for Clostridioides difficile infection (CDI) and colonization in patients undergoing an autologous hematopoietic stem cell transplantation (AHSCT). Methods We studied 472 consecutive patients admitted for a first AHSCT and conducted a prospective C difficile stool surveillance and ribotyping analysis in a subset of 94 patients. Results Clostridioides difficile infection was diagnosed in 7% of patients for an incidence of 3.4 CDI/1000 inpatient days, recurrent/reinfection CDI was rare. CDI was increased in patients who were colonized on admission, had required a recent pre‐admission inpatient stay for fever and/or serious infection, or received empiric therapy with a carbapenem or extended‐spectrum penicillin. CDI was associated with a longer length of stay and higher hospital costs. Twelve of 94 patients (13%) were found to have colonization on admission; CDI was diagnosed in 27% of these vs 1% in those with initial negative stools. Colonization in the hospital for those negative on admission was infrequent. C difficile ribotyping showed a predominance of 014/020. Conclusions Clostridioides difficile infection is a significant infection in patients receiving a first AHSCT. The risk factors identified may be useful in designing preventive interventions.

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Section: Introductionmentioning

confidence: 99%

Clostridioides difficile colonization and infection in patients admitted for a first autologous transplantation: Incidence, risk factors, and patient outcomes

Ford

Lopansri

Coombs

et al. 2019

Clinical Transplantation

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“…In one study of a hematopoietic stem cell transplant unit, placing individuals who screened positive for CD on contact isolation and minimizing their antibiotic exposure where possible led to a decrease in the unit's annual CDI rates. 10 Mathematical modeling studies also suggest that, by reducing CD transmission through patient isolation, universal CD screening of all newly admitted patients has significant potential to reduce CDI rates. 11 The role of isolation precautions for asymptomatic CD carriers in reducing CDI rates has also been demonstrated in single-center reports.…”

Section: Introductionmentioning

confidence: 99%

“…Universal CD screening to identify patients colonized with CD at time of admission has been shown to have potential for reducing CDI rates at institutions. In one study of a hematopoietic stem cell transplant unit, placing individuals who screened positive for CD on contact isolation and minimizing their antibiotic exposure where possible led to a decrease in the unit's annual CDI rates 10 . Mathematical modeling studies also suggest that, by reducing CD transmission through patient isolation, universal CD screening of all newly admitted patients has significant potential to reduce CDI rates 11 .…”

Section: Introductionmentioning

confidence: 99%

Universal molecular Clostridioides difficile screening and overtreatment in solid organ transplant recipients

McCort

Oehler

Enriquez

et al. 2020

Transplant Infectious Dis

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Background: Screening for Clostridioides difficile (CD) colonization can be performed using molecular testing to identify the presence of microbial DNA of the toxin gene. Colonization rates for hospitalized patients are as high as 20% and may be considerably higher in solid organ transplant (SOT) recipients. Treatment for CD should be based on clinical disease and not colonization, yet clinicians may misinterpret a positive CD screen resulting in overtreatment. Objectives: The objective of this analysis is to determine how often positive CD screens resulted in inappropriate treatment with oral vancomycin. Methods: Clostridioides difficile screens were performed using the Xpert C difficile assay (Cepheid), a nucleic acid amplification testing method utilizing polymerase chain reaction (PCR), on peri-rectal swabs for newly admitted patients. This was a single-center cohort study of adult patients with CD screens hospitalized between July 2015 and November 2018. The primary outcome was the rate of inappropriate oral vancomycin treatment in all patients and in SOT recipients, defined as therapy in the absence of diarrhea. Results: Of the 47 076 total CD screens reviewed, 1,921 were positive. In the SOT cohort, 58 of 329 screens were positive (4.1% vs 17.9%, P < .01). Of all patients with a positive CD screen, 20.1% (386/1921) were treated with oral vancomycin within 48 hours of swab collection. In the SOT cohort, 39.6% (23/58) with positive CD screens were treated with oral vancomycin within 48 hours. Of the SOT patients who received oral vancomycin, 39% (9/23) did not have true CD infection. Conclusion: Solid organ transplant recipients were more likely to have CD colonization detected by peri-rectal screening than the general inpatient population. SOT and non-SOT patients were treated with oral vancomycin at similar rates in response to the positive screen. Nearly half of the oral vancomycin use in SOT recipients was likely overtreatment, but this finding is limited by the low number of patients in this cohort.

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“…Current guidelines 2 suggest testing for C difficile when a patient has diarrhea in the absence of a more likely alternative cause. This recommendation seems inadequate for HSCT recipients who have numerous causes for diarrhea 3‐5 and in whom asymptomatic gastrointestinal colonization with toxigenic C difficile is not uncommon 6‐8 . These factors might significantly lower the specificity of the current guidelines in HSCT recipients, resulting in an excessive number of false‐positive clinical diagnoses and unnecessary and potentially harmful treatment.…”

Section: Introductionmentioning

confidence: 99%

“…This recommendation seems inadequate for HSCT recipients who have numerous causes for diarrhea [3][4][5] and in whom asymptomatic gastrointestinal colonization with toxigenic C difficile is not uncommon. [6][7][8] These factors might significantly lower the specificity of the current guidelines in HSCT recipients, resulting in an excessive number of false-positive clinical diagnoses and unnecessary and potentially harmful treatment. Although the possibility of CDI overdiagnosis has been suggested previously, 9 it has not been further investigated.…”

Section: Introductionmentioning

confidence: 99%

Are Clostridioides difficile infections being overdiagnosed in hematopoietic stem cell transplant recipients?

Ford

Lopansri

Coombs

et al. 2020

Transplant Infectious Dis

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Background Because both diarrhea due to other causes and gastrointestinal colonization with toxigenic Clostridioides difficile are common in HSCT, there is a possibility of false‐positive diagnoses of C difficile infections (CDI). Methods We estimated the probability of a patient being colonized by toxigenic C difficile by testing non‐diarrheal surveillance stools from 223 HSCT recipients and the probability that a specimen submitted for C difficile testing was not CDI by determining the number of clinical tests that returned negative from this cohort. The number of expected false‐positive CDI was estimated using these probabilities and compared with observed clinical test results. Results The expected false‐positive and the observed numbers of positive clinical results were similar. The 20 patients diagnosed with CDI were also similar to 142 patients with diarrhea and C difficile‐negative stools in number of stools on day of testing, associated symptoms, and the recorded number of days to formed stools. C difficile colonization was most commonly detected during the first week and CDI during the second. Retrospective analysis of 837 patients showed that 18 stools were submitted for each diagnosis of CDI. Ribotyping of the surveillance samples showed 17 ribotypes. Conclusions Although several assumptions could impact the accuracy of our false‐positive CDI estimates, it appears that many HSCT recipients diagnosed with CDI may actually represent colonized status and an alternative cause of diarrhea. Diagnostic stewardship, including limiting CDI diagnoses to patients with positive toxin and restricting stool submissions to patients with more severe symptoms, may decrease the number of false‐positive diagnoses.

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Screening for Clostridium difficile colonization on admission to a hematopoietic stem cell transplant unit may reduce hospital-acquired C difficile infection

Cited by 18 publications

References 6 publications

Clostridioides difficile colonization and infection in patients admitted for a first autologous transplantation: Incidence, risk factors, and patient outcomes

Clostridioides difficile colonization and infection in patients admitted for a first autologous transplantation: Incidence, risk factors, and patient outcomes

Universal molecular Clostridioides difficile screening and overtreatment in solid organ transplant recipients

Are Clostridioides difficile infections being overdiagnosed in hematopoietic stem cell transplant recipients?

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