title: Point-of-Care Testing for Clostridium Difficile Infection: A Real-World Feasibility Study of a Rapid Molecular Test in Two Hospital Settings.
abstract: BACKGROUND
  In the developed world, Clostridium difficile infection (CDI) is the most important cause of nosocomial infectious diarrhea. In addition to providing epidemiological data and helping to indicate that a local outbreak may be occurring, laboratory tests are used to augment clinical decisions on individual patients. Very rarely do diagnostic tests provide results at the point of decision making; in the intervening period between requesting investigations on a patient with suspected CDI and return of the laboratory result, decisions must be made regarding patient isolation and treatment.
  
  
  METHODS
  A 22-month, real-world feasibility study was conducted in patients with clinically significant diarrhea, in a London Hospital between March 2011 and January 2013, in three older persons' wards and two intensive care units (ICUs) to determine acceptability, ease of use, change in turnaround time and clinical utility of a rapid, polymerase chain reaction (PCR)-based point-of-care test (POCT) (Cepheid GeneXpert(®), Sunnyvale, California, USA) for diagnosis of Clostridium difficile. Nurses in the older persons' ward and laboratory technicians in the ICU were trained to perform the test. Residual samples were sent to the centralized laboratory for parallel testing using a two-step algorithm.
  
  
  RESULTS
  A total of 335 samples were tested using the POCT with a median turnaround time of 1.85 h compared with 18 h for the centralized laboratory test. Overall agreement with centralized laboratory testing was 98.1%. Discrepant samples were more frequent on elderly wards than ICU. Overall 20/335 (6%) processing errors were encountered and were highest in the first few months of the study. Significantly more processing errors occurred on the older persons' wards 13/102 (12.7%) than on ICU 7/271 (2.6%). Older persons' patients who had POCT were significantly less likely to have a test requested for bacterial stool culture (3.1% vs. 10.9% p = 0.044). This difference was not observed in the ICU patients. No other differences in ancillary test requesting, mortality or length of stay were observed.
  
  
  CONCLUSIONS
  The majority of users reported that the POCT was easy to perform and was an acceptable part of their job. POCT using this system is feasible and acceptable to nursing staff and technicians working within these two hospital-based settings.
authors.affiliation: Centre for Clinical Infection and Diagnostics Research, King's College London and Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, SE1 7EH, London, UK. Simon.goldenberg@gstt.nhs.uk.
authors.forename: Simon D
authors.initials: SD
authors.lastname: Goldenberg
authors.affiliation: Centre for Clinical Infection and Diagnostics Research, King's College London and Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, SE1 7EH, London, UK.
authors.forename: Karen N
authors.initials: KN
authors.lastname: Bisnauthsing
authors.affiliation: Centre for Clinical Infection and Diagnostics Research, King's College London and Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, SE1 7EH, London, UK.
authors.forename: Amita
authors.initials: A
authors.lastname: Patel
authors.affiliation: Cepheid Europe, Maurens-Scopont, France.
authors.forename: Anne
authors.initials: A
authors.lastname: Postulka
authors.affiliation: Department of Critical Care, Guys and St Thomas' NHS Foundation Trust, London, UK.
authors.forename: Duncan
authors.initials: D
authors.lastname: Wyncoll
authors.affiliation: Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK.
authors.forename: Rebekah
authors.initials: R
authors.lastname: Schiff
authors.affiliation: Centre for Clinical Infection and Diagnostics Research, King's College London and Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, SE1 7EH, London, UK.
authors.forename: Gary L
authors.initials: GL
authors.lastname: French
keywords: Clostridium difficile; Infection; Nosocomial infectious diarrhea; Point-of-care testing; Rapid diagnostics