title: Predicting Clostridium difficile stool cytotoxin results in hospitalized patients with diarrhea.
abstract: OBJECTIVE
  To validate a model for the prediction of Clostridium difficile cytotoxin assay results, and to identify a subgroup of patients with a very low likelihood of C. difficile-associated disease in whom the yield of routine cytotoxin testing is low.
  
  
  METHODS
  Prospective cohort study. Relevant clinical symptoms, signs, and antibiotic exposure were recorded before reporting of assay results. Each predictor was assigned a score based on regression coefficients, and patients were stratified according to their total score.
  
  
  METHODS
  Two urban, tertiary care, university hospitals.
  
  
  METHODS
  A total of 609 consecutive adult inpatients who received testing for C. difficile cytotoxin during a 3-month period in 1994.
  
  
  RESULTS
  The prevalence of positive cytotoxin assays was 8% in the validation set, compared with 14% in the derivation set. Defining patients without both prior antibiotic use and at least one symptom predictor (significant diarrhea or abdominal pain) as a low-risk subgroup, the misclassification rate was 2.8% (5/177) for assay results; of the five misclassified cases patients, only one was judged to have C. difficile-associated disease. Use of this rule to identify low-risk patients could have potentially averted 29% of all cytotoxin assays.
  
  
  CONCLUSIONS
  Patients without a history of antibiotic use and either significant diarrhea or abdominal pain are unlikely to have positive C. difficile cytotoxin assays and may not require cytotoxin testing.
authors.affiliation: Division of Clinical Decision Making, New England Medical Center and Tufts University School of Medicine, Boston, Mass, USA.
authors.forename: D A
authors.initials: DA
authors.lastname: Katz
authors.forename: D W
authors.initials: DW
authors.lastname: Bates
authors.forename: E
authors.initials: E
authors.lastname: Rittenberg
authors.forename: A
authors.initials: A
authors.lastname: Onderdonk
authors.forename: K
authors.initials: K
authors.lastname: Sands
authors.forename: L A
authors.initials: LA
authors.lastname: Barefoot
authors.forename: D
authors.initials: D
authors.lastname: Snydman
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000009:adverse effects / Q000627:therapeutic use; D002478:Cells, Cultured; D016360:Clostridioides difficile / Q000302:isolation & purification*; D003015:Clostridium Infections / Q000175:diagnosis*; D015331:Cohort Studies; D003603:Cytotoxins / Q000032:analysis*; D003967:Diarrhea / Q000209:etiology; D004761:Enterocolitis, Pseudomembranous / Q000175:diagnosis* / Q000209:etiology; D005243:Feces / Q000382:microbiology; D005260:Female; D006760:Hospitalization; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012372:ROC Curve
chemical_list: D000900:Anti-Bacterial Agents; D003603:Cytotoxins