Clinical application of polymerase chain reaction to diagnose Clostridium difficile in hospitalized patients with diarrhea.
OBJECTIVE
Clostridium difficile is a common cause of diarrhea in hospitalized patients and is associated with significant morbidity and cost. The current diagnostic standard, enzyme immunoassay (EIA), has low sensitivity, leading to duplicate testing and empiric treatment. We sought to show the usefulness and potential cost effectiveness of polymerase chain reaction (PCR) amplification of toxin B gene for diagnosis of C. difficile-induced diarrhea.


METHODS
A total of 148 stool samples from academic and community-based hospitals were sent for EIA testing and were evaluated prospectively for the presence of toxin B gene by PCR. Results were compared with EIA regarding sensitivity, specificity, and predictive values. Medical charts were reviewed to determine the following: (1) number of EIAs sent per admission, (2) number sent within a 24-hour time period, and (3) how caregivers practiced based on EIA results.


RESULTS
The mean age of 130 patients was 55 years. EIA and PCR were positive in 6.8% and 13.6% of patients, respectively. EIA sensitivity was 40%, specificity was 98%, and positive and negative predictive values were 80% and 91%, respectively. The cost of the PCR was $22/sample. Empiric treatment for C. difficile was given unnecessarily in 42% of EIA-negative results. Thirty percent of patients had 3 or more EIAs sent during their hospital admission. Of patients with multiple samples sent, 57% had more than 1 sample sent in a 24-hour period.


CONCLUSIONS
Many physicians do not conform to practice guidelines regarding recommended diagnosis and empiric treatment of C. difficile. Toxin B gene PCR represents a more sensitive and potentially cost-effective method to diagnose C. difficile-induced diarrhea than EIA and should be considered for use as an alternative diagnostic standard.
Division of Digestive Diseases, University of Cincinnati, Ohio, USA. ammorelli@msn.com
Michael S
MS
Morelli
Susan D
SD
Rouster
Ralph A
RA
Giannella
Kenneth E
KE
Sherman
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001426:Bacterial Proteins / Q000032:analysis / Q000276:immunology; D001427:Bacterial Toxins / Q000032:analysis / Q000276:immunology; D016360:Clostridioides difficile / Q000302:isolation & purification*; D003362:Cost-Benefit Analysis; D003938:Diagnostic Techniques, Digestive System / Q000191:economics; D003967:Diarrhea / Q000382:microbiology*; D004761:Enterocolitis, Pseudomembranous / Q000150:complications / Q000175:diagnosis* / Q000382:microbiology*; D005243:Feces / Q000382:microbiology; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007124:Immunoenzyme Techniques / Q000379:methods; D008297:Male; D008875:Middle Aged; D016133:Polymerase Chain Reaction / Q000191:economics / Q000379:methods*; D011237:Predictive Value of Tests; D011446:Prospective Studies
D001426:Bacterial Proteins; D001427:Bacterial Toxins; C031815:toxB protein, Clostridium difficile