title: Clostridium difficile testing in the clinical laboratory by use of multiple testing algorithms.
abstract: The incidence of Clostridium difficile infection (CDI) has risen almost 3-fold in the United States over the past decade, emphasizing the need for rapid and accurate tests for CDI. The Cepheid Xpert C. difficile assay is an integrated, closed, nucleic acid amplification system that automates sample preparation and real-time PCR detection of the toxin B gene (tcdB). A total of 432 stool specimens from symptomatic patients were tested by a glutamate dehydrogenase (GDH) assay, a toxin A and B enzyme immunoassay (EIA), the Xpert C. difficile assay, and a cell culture cytotoxicity neutralization assay (CCCN). The results of these methods, used individually and in combination, were compared to those of toxigenic culture. Results for the Xpert C. difficile assay alone showed a sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of 94.4, 96.3, 84.0, and 98.8%, while the EIA alone gave corresponding values of 58.3, 94.7, 68.9, and 91.9%, respectively. An algorithm using the GDH assay and the EIA (plus the CCCN if the EIA was negative) showed corresponding values of 83.1, 96.7, 83.1, and 96.1%. The Xpert C. difficile assay was statistically superior to the EIA (P, <0.001 by Fisher's exact test) and to the GDH-EIA-CCCN algorithm (P, 0.0363). Combining the GDH and Xpert C. difficile assays lowered both the sensitivity and the NPV of the Xpert assay. The GDH-EIA-CCCN procedure required, on average, 2 days to complete testing on GDH-positive results, while testing by the Xpert C. difficile assay was completed, on average, in less than 1 h. Xpert C. difficile testing yielded the highest sensitivity and NPV, in the least amount of time, of the individual- and multiple-test algorithms evaluated in this study.
authors.affiliation: Southern California Permanente Medical Group, North Hollywood, California 91605, USA. Susan.M.Novak@kp.org
authors.forename: Susan M
authors.initials: SM
authors.lastname: Novak-Weekley
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Marlowe
authors.forename: John M
authors.initials: JM
authors.lastname: Miller
authors.forename: Joven
authors.initials: J
authors.lastname: Cumpio
authors.forename: Jim H
authors.initials: JH
authors.lastname: Nomura
authors.forename: Paula H
authors.initials: PH
authors.lastname: Vance
authors.forename: Alice
authors.initials: A
authors.lastname: Weissfeld
mesh_terms: D000465:Algorithms; D000818:Animals; D001426:Bacterial Proteins / Q000032:analysis / Q000235:genetics / Q000633:toxicity; D001427:Bacterial Toxins / Q000032:analysis / Q000235:genetics / Q000633:toxicity; D001431:Bacteriological Techniques / Q000379:methods*; D018929:Cell Culture Techniques; D002522:Chlorocebus aethiops; D016360:Clostridioides difficile / Q000235:genetics / Q000302:isolation & purification*; D003015:Clostridium Infections / Q000175:diagnosis* / Q000382:microbiology*; D004768:Enterotoxins / Q000032:analysis / Q000235:genetics / Q000633:toxicity; D005243:Feces / Q000382:microbiology; D005969:Glutamate Dehydrogenase / Q000032:analysis; D006801:Humans; D007124:Immunoenzyme Techniques / Q000379:methods; D009500:Neutralization Tests; D016133:Polymerase Chain Reaction / Q000379:methods; D011237:Predictive Value of Tests; D012680:Sensitivity and Specificity; D014709:Vero Cells
chemical_list: D001426:Bacterial Proteins; D001427:Bacterial Toxins; D004768:Enterotoxins; C041348:tcdA protein, Clostridium difficile; C031815:toxB protein, Clostridium difficile; D005969:Glutamate Dehydrogenase