Utility of a Commercial PCR Assay and a Clinical Prediction Rule for Detection of Toxigenic Clostridium difficile in Asymptomatic Carriers

Donskey, Curtis J.; Sunkesula, Venkata; Jencson, Annette; Stone, Nimalie D.; Gould, Carolyn V.; McDonald, L. Clifford; Samore, Matthew H.; Mayer, Jeanmarie; Pacheco, Susan M.; Sambol, Susan P.; Petrella, Laurica A.; Terry, Deborah J.; Gerding, Dale N.

doi:10.1128/jcm.01852-13

Cited by 23 publications

(21 citation statements)

References 14 publications

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“…Additionally, the number of previous hospital stays within the past 6 months raised the probability of a positive CD-PCR by factor 1.6 each (95% CI: 1.1–2.2). This corresponds to previous studies which also determined previous episodes of CDI and treatment with antibiotics as the highest risk factors for a toxigenic CD colonization [34, 35]. …”

Section: Discussionsupporting

confidence: 89%

“…Using PCR from stool samples, as in our study, achieves a timely detection of C.difficile carriers. It has already been shown that rectal swabs taken at admission and tested using PCR following a selective broth preamplification can be used for even faster diagnostic [34, 40]. A disadvantage of the PCR screening test, however, is its relatively high price.…”

Section: Discussionmentioning

confidence: 99%

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Asymptomatic and yet C. difficile-toxin positive? Prevalence and risk factors of carriers of toxigenic Clostridium difficile among geriatric in-patients

2016

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Background Clostridium difficile infections (CDI) are the most frequent cause of diarrhoea in hospitals. Geriatric patients are more often affected by the condition, by a relapse and complications. Therefore, a crucial question is how often colonization with toxigenic Clostridium difficile strains occurs in elderly patients without diarrhoea and whether there is a “risk pattern” of colonized patients that can be defined by geriatric assessment. Furthermore, the probability for those asymptomatic carriers to develop a symptomatic infection over time has not been sufficiently explored.MethodsWe performed a cohort study design to assess the association of clinical variables with Clostridium difficile colonization. The first stool sample of 262 consecutive asymptomatic patients admitted to a geriatric unit was tested for toxigenic Clostridium difficile using PCR (GeneXpert, Cepheid). A comprehensive geriatric assessment (CGA) including Barthel Index, Mini Mental State Examination (MMSE) and hand grip-strength was performed. In addition, Charlson Comorbidity Index, body mass index, number and length of previous hospital stays, previous treatment with antibiotics, institutionalization, primary diagnoses and medication were recorded and evaluated as possible risk factors of colonization by means of binary logistic regression. Secondly, we explored the association of C. difficile colonization with subsequent development of CDI during hospital stay.ResultsAt admission, 43 (16.4%) patients tested positive for toxin B by PCR. Seven (16.3%) of these colonized patients developed clinical CDI during hospital stay, compared to one out of 219 patients with negative or invalid PCR testing (Odds ratio 12,3; Fisher’s exact test: p = 0.000). Overall, 7 out of 8 (87.5%) CDI patients had been colonized at admission. Risk factors of colonization with C. difficile were a history of CDI, previous antibiotic treatment and hospital stays. The parameters of the CGA were not significantly associated with colonization.ConclusionColonization with toxigenic Clostridium difficile strains occurs frequently in asymptomatic patients admitted to a geriatric unit. Previous CDI, antibiotic exposure and hospital stay, but not clinical variables such as CGA, are the main factors associated with asymptomatic Clostridium difficile carriage. Colonization is a crucial risk factor for subsequent development of symptomatic CDI.

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Section: Discussionsupporting

confidence: 89%

Section: Discussionmentioning

confidence: 99%

Asymptomatic and yet C. difficile-toxin positive? Prevalence and risk factors of carriers of toxigenic Clostridium difficile among geriatric in-patients

2016

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“…9 Not only do antibiotic-induced disruptions lead to a loss of colonization resistance to MDROs, but once colonization does occur, further disruptions can lead to dominance (defined as a single MDRO constituting ≥30% of the microbiota), which is associated with the occurrence of invasive infection and increased transmission risk through skin and environmental contamination. 10,11 MDROs, such as Clostridium difficile, vancomycin-resistant enterococci (VRE), and carbapenem-resistant Enterobacteriaceae (CRE), are major public health concerns in healthcare settings, where they are transmitted between patients and can colonize the lower intestine in more individuals than they infect. 12,13 …”

Section: Introductionmentioning

confidence: 99%

Intestinal microbiome disruption in patients in a long-term acute care hospital: A case for development of microbiome disruption indices to improve infection prevention

Halpin

Man

Kraft

et al. 2016

American Journal of Infection Control

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Antibiotic exposure correlated with diversity; however, other environmental and host factors not easily obtainable in a clinical setting are also known to impact the microbiota. Therefore, direct measurement of microbiome disruption by sequencing, rather than reliance on surrogate markers, might be most predictive of adverse outcomes. If and when microbiome characterization becomes a standard diagnostic test, improving our understanding of microbiome dynamics will allow for interpretation of results to improve patient outcomes.

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“…16 Recent advances in diagnostic testing for C. difficile have encouraged the evaluation of the feasibility of screening patients at admission for C. difficile and subsequent application of isolation precautions. [17][18][19] An outcome model identified C. difficile screening, coupled with isolation precautions, as a cost-effective intervention when the proportion of admitted patients with C. difficile colonization was greater than approximately 10%. 20 For healthcare-associated infections, computational models of pathogen transmission have become valuable tools to evaluate healthcare interventions, especially in the absence of controlled intervention studies.…”

mentioning

confidence: 99%

Effectiveness of Screening Hospital Admissions to Detect Asymptomatic Carriers of Clostridium difficile: A Modeling Evaluation

Lanzas

Dubberke

2014

Infect. Control Hosp. Epidemiol.

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ObjectiveBoth asymptomatic and symptomatic Clostridium difficile carriers contribute to new colonizations and infections within a hospital, but current control strategies focus only on preventing transmission from symptomatic carriers. Our objective was to evaluate the potential effectiveness of methods targeting asymptomatic carriers to control C. difficile colonization and infection (CDI) rates in a hospital ward: screening patients at admission to detect asymptomatic C. difficile carriers and placing positive patients into contact precautions.MethodsWe developed an agent-based transmission model for C. difficile that incorporates screening and contact precautions for asymptomatic carriers in a hospital ward. We simulated scenarios that vary according to screening test characteristics, colonization prevalence, and type of strain present at admission.ResultsIn our baseline scenario, on average, 42% of CDI cases were community-onset cases. Within the hospital-onset (HO) cases, approximately half were patients admitted as asymptomatic carriers who became symptomatic in the ward. On average, testing for asymptomatic carriers reduced the number of new colonizations and HO-CDI cases by 40%–50% and 10%–25%, respectively, compared with the baseline scenario. Test sensitivity, turnaround time, colonization prevalence at admission, and strain type had significant effects on testing efficacy.ConclusionsTesting for asymptomatic carriers at admission may reduce both the number of new colonizations and HO-CDI cases. Additional reductions could be achieved by preventing disease in patients who are admitted as asymptomatic carriers and developed CDI during the hospital stay.

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Utility of a Commercial PCR Assay and a Clinical Prediction Rule for Detection of Toxigenic Clostridium difficile in Asymptomatic Carriers

Cited by 23 publications

References 14 publications

Asymptomatic and yet C. difficile-toxin positive? Prevalence and risk factors of carriers of toxigenic Clostridium difficile among geriatric in-patients

Asymptomatic and yet C. difficile-toxin positive? Prevalence and risk factors of carriers of toxigenic Clostridium difficile among geriatric in-patients

Intestinal microbiome disruption in patients in a long-term acute care hospital: A case for development of microbiome disruption indices to improve infection prevention

Effectiveness of Screening Hospital Admissions to Detect Asymptomatic Carriers of Clostridium difficile: A Modeling Evaluation

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