title: [New methodological advances: algorithm proposal for management of Clostridium difficile infection].
abstract: BACKGROUND
  Clostridium difficile infection (CDI) is considered the most common cause of health care-associated diarrhea and also is an etiologic agent of community diarrhea. The aim of this study was to assess the potential benefit of a test that detects glutamate dehydrogenase (GDH) antigen and C. difficile toxin A/B, simultaneously, followed by detection of C. difficile toxin B (tcdB) gene by PCR as confirmatory assay on discrepant samples, and to propose an algorithm more efficient.
  
  
  METHODS
  From June 2012 to January 2013 at Hospital Infantil Universitario Niño Jesús, Madrid, the stool samples were studied for the simultaneous detection of GDH and toxin A/B, and also for detection of toxin A/B alone. When results between GDH and toxin A/B were discordant, a single sample for patient was selected for detection of C. difficile toxin B (tcdB) gene.
  
  
  RESULTS
  A total of 116 samples (52 patients) were tested. Four were positive and 75 negative for toxigenic C. difficile (Toxin A/B, alone or combined with GDH). C. difficile was detected in the remaining 37 samples but not toxin A/B, regardless of the method used, except one. Twenty of the 37 specimens were further tested for C. difficile toxin B (tcdB) gene and 7 were positive.
  
  
  CONCLUSIONS
  The simultaneous detection of GDH and toxin A/B combined with PCR recovered undiagnosed cases of CDI. In accordance with our data, we propose a two-step algorithm: detection of GDH and PCR (in samples GDH positive). This algorithm could provide a superior cost-benefit ratio in our population.
authors.affiliation: María José González-Abad, Hospital Infantil Universitario Niño Jesús Avda. Menéndez Pelayo, 65, 28009 Madrid, Spain. mjglezabad@yahoo.es m.
authors.forename: María José
authors.initials: MJ
authors.lastname: González-Abad
authors.forename: Mercedes
authors.initials: M
authors.lastname: Alonso-Sanz
mesh_terms: D000293:Adolescent; D000465:Algorithms; D000942:Antigens, Bacterial / Q000032:analysis; D001426:Bacterial Proteins / Q000032:analysis; D001427:Bacterial Toxins / Q000032:analysis; D002648:Child; D002675:Child, Preschool; D016360:Clostridioides difficile / Q000276:immunology / Q000302:isolation & purification*; D003362:Cost-Benefit Analysis; D042241:Early Diagnosis; D004761:Enterocolitis, Pseudomembranous / Q000175:diagnosis* / Q000382:microbiology; D004768:Enterotoxins / Q000032:analysis; D005243:Feces / Q000382:microbiology; D005260:Female; D005969:Glutamate Dehydrogenase / Q000032:analysis; D006801:Humans; D007124:Immunoenzyme Techniques / Q000191:economics; D007223:Infant; D008297:Male; D016133:Polymerase Chain Reaction / Q000191:economics
chemical_list: D000942:Antigens, Bacterial; D001426:Bacterial Proteins; D001427:Bacterial Toxins; D004768:Enterotoxins; C041348:tcdA protein, Clostridium difficile; C031815:toxB protein, Clostridium difficile; D005969:Glutamate Dehydrogenase