title: False Negative Results in Clostridium difficile Testing.
abstract: Accurate diagnosis of Clostridium difficile infection (CDI) is paramount for patient management. The wrong diagnosis places patients at risk, delays treatment, and/ or contributes to transmission of infection in the healthcare setting. Although amplification of the toxin B gene by polymerase chain reaction (PCR) is a sensitive method for detecting toxigenic C. difficile, false negative results still occur and could impact the diagnosis and treatment of this infection.
  
  
  
  This study investigated 48 patients that tested negative for toxigenic C. difficile via GeneXpert C. difficile epi test, while simultaneously testing positive for toxigenic C. difficile via stool culture. Fifty discrepant samples were collected over a 15-month period and all C. difficile isolates were characterized by ribotype. Patient charts were reviewed to assess whether discrepant results impacted the treatment course or clinical outcome of affected patients.
  
  
  
  Fifty samples of a total of 2308 samples tested in an acute healthcare facility over a 15-month period had negative PCR and positive stool culture for toxigenic C. difficile. C. difficile isolated from the discrepant samples resulted in diverse ribotyping patterns suggesting they were derived from different strains. The samples belonged to patients who were distributed evenly between age groups and wards in the hospital. In the majority of cases, the false negative C. difficile test results did not seem to impact the clinical outcome in these patients.
  
  
  
  The PCR limit of detection may impact the results of molecular methods for C. difficile detection. Both clinical and analytical sensitivity of C. difficile tests should be considered when deciding which diagnostic assay to use, and clinical correlates should be examined carefully before excluding CDI as a cause of disease.
authors.affiliation: Current Address: Advanced Medical Research Institute of Canada, 41 Ramsey Lake Road, Sudbury, ON, P3E 5J1, Canada. yamurad@nosm.ca.|Northern Ontario School of Medicine, 935 Ramsey Lake Road, Sudbury, ON P3E 2C6, Canada. yamurad@nosm.ca.
authors.forename: Yanal M
authors.initials: YM
authors.lastname: Murad
authors.affiliation: Current Address: Advanced Medical Research Institute of Canada, 41 Ramsey Lake Road, Sudbury, ON, P3E 5J1, Canada.
authors.forename: Justo
authors.initials: J
authors.lastname: Perez
authors.affiliation: Current Address: Advanced Medical Research Institute of Canada, 41 Ramsey Lake Road, Sudbury, ON, P3E 5J1, Canada.
authors.forename: Gustavo
authors.initials: G
authors.lastname: Ybazeta
authors.affiliation: Northern Ontario School of Medicine, 935 Ramsey Lake Road, Sudbury, ON P3E 2C6, Canada.
authors.forename: Sarah
authors.initials: S
authors.lastname: Mavin
authors.affiliation: Current Address: Advanced Medical Research Institute of Canada, 41 Ramsey Lake Road, Sudbury, ON, P3E 5J1, Canada.
authors.forename: Sebastien
authors.initials: S
authors.lastname: Lefebvre
authors.affiliation: Centre for Public Health and Zoonoses, University of Guelph, Guelph, ON, N1G 2W1, Canada.
authors.forename: J Scott
authors.initials: JS
authors.lastname: Weese
authors.affiliation: Centre for Public Health and Zoonoses, University of Guelph, Guelph, ON, N1G 2W1, Canada.
authors.forename: Joyce
authors.initials: J
authors.lastname: Rousseau
authors.affiliation: Current Address: Advanced Medical Research Institute of Canada, 41 Ramsey Lake Road, Sudbury, ON, P3E 5J1, Canada.|Northern Ontario School of Medicine, 935 Ramsey Lake Road, Sudbury, ON P3E 2C6, Canada.|Health Sciences North, 41 Ramsey Lake Road, Sudbury, ON P3E 5J1, Canada.
authors.forename: Francisco
authors.initials: F
authors.lastname: Diaz-Mitoma
authors.affiliation: Current Address: Advanced Medical Research Institute of Canada, 41 Ramsey Lake Road, Sudbury, ON, P3E 5J1, Canada. rnokhbeh@amric.ca.|Northern Ontario School of Medicine, 935 Ramsey Lake Road, Sudbury, ON P3E 2C6, Canada. rnokhbeh@amric.ca.
authors.forename: Reza
authors.initials: R
authors.lastname: Nokhbeh
mesh_terms: D001426:Bacterial Proteins / Q000235:genetics / Q000378:metabolism; D001427:Bacterial Toxins / Q000235:genetics / Q000378:metabolism; D016360:Clostridioides difficile / Q000235:genetics* / Q000302:isolation & purification; D003015:Clostridium Infections / Q000175:diagnosis* / Q000382:microbiology; D004768:Enterotoxins / Q000235:genetics / Q000378:metabolism; D005188:False Negative Reactions; D005243:Feces / Q000382:microbiology; D006801:Humans; D060885:Multiplex Polymerase Chain Reaction; D011933:Reagent Kits, Diagnostic; D021521:Ribotyping
chemical_list: D001426:Bacterial Proteins; D001427:Bacterial Toxins; D004768:Enterotoxins; D011933:Reagent Kits, Diagnostic; C041348:tcdA protein, Clostridium difficile; C031815:toxB protein, Clostridium difficile
keywords: Clostridium difficile; False negative; Molecular testing