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Role of fecal Clostridium difficile load in discrepancies between toxin tests and PCR: is quantitation the next step in C. difficile testing?

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European Journal of Clinical Microbiology & Infectious Diseases Aims and scope Submit manuscript

An Erratum to this article was published on 04 August 2012

Abstract

Direct tests for Clostridium difficile are 30–50 % more sensitive than tests for C. difficile toxins but the reasons for this discrepancy are incompletely understood. In addition to toxin degradation and strain differences, we hypothesized that C. difficile concentration could be important in determining whether toxins are detected in fecal samples. We performed standard curves on an FDA-approved real-time PCR test for the C. difficile tcdB gene (Xpert C. difficile/Epi, Cepheid) during a prospective comparison of a toxin immunoassay (Meridian Premier), PCR and toxigenic culture. Immunoassay-negative, PCR-positive samples were retested with a cell cytotoxin assay (TechLab). Among 107 PCR-positive samples, 46 (43.0 %) had toxins detected by immunoassay and an additional 18 (16.8 %) had toxin detected by the cytotoxin assay yielding 64 (59.8 %) toxin-positive and 43 (40.2 %) toxin-negative samples. Overall, toxin-negative samples with C. difficile had 101–104 fewer DNA copies than toxin-positive samples and most discrepancies between toxin tests and PCR were associated with a significant difference in C. difficile quantity. Of the toxin-positive samples, 95 % had ≥4.1 log10 C. difficile tcdB DNA copies/mL; 52 % of immunoassay-negative samples and 70 % of immunoassay and cytotoxin negative samples had <4.1 log10 C. difficile tcdB DNA copies/mL. These findings suggest that fecal C. difficile concentration is a major determinant of toxin detection and C. difficile quantitation may add to the diagnostic value of existing test methods. Future studies are needed to validate the utility of quantitation and determine the significance of low concentrations of C. difficile in the absence of detectable toxin.

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References

  1. Viscidi R, Willey S, Bartlett JG (1981) Isolation rates and toxigenic potential of Clostridium difficile isolates from various patient populations. Gastroenterology 81(1):5–9

    PubMed  CAS  Google Scholar 

  2. Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, Pepin J, Wilcox MH (2010) Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol 31(5):431–455

    Article  PubMed  Google Scholar 

  3. Kufelnicka AM, Kirn TJ (2011) Effective utilization of evolving methods for the laboratory diagnosis of Clostridium difficile infection. Clin Infect Dis 52(12):1451–1457

    Article  PubMed  Google Scholar 

  4. Wilcox MH, Planche T, Fang FC, Gilligan P (2010) What is the current role of algorithmic approaches for diagnosis of Clostridium difficile infection? J Clin Microbiol 48(12):4347–4353

    Article  PubMed  Google Scholar 

  5. Dubberke ER, Han Z, Bobo L, Hink T, Lawrence B, Copper S, Hoppe-Bauer J, Burnham CA, Dunne WM Jr (2011) Impact of clinical symptoms on the interpretation of diagnostic assays for Clostridium difficile. J Clin Microbiol 49:2887–2893

    Article  PubMed  Google Scholar 

  6. Tenover FC, Novak-Weekley S, Woods CW, Peterson LR, Davis T, Schreckenberger P, Fang FC, Dascal A, Gerding DN, Nomura JH, Goering RV, Akerlund T, Weissfeld AS, Baron EJ, Wong E, Marlowe EM, Whitmore J, Persing DH (2010) Impact of strain type on detection of toxigenic Clostridium difficile: comparison of molecular diagnostic and enzyme immunoassay approaches. J Clin Microbiol 48(10):3719–3724

    Article  PubMed  Google Scholar 

  7. Freeman J, Wilcox MH (2003) The effects of storage conditions on viability of Clostridium difficile vegetative cells and spores and toxin activity in human faeces. J Clin Pathol 56(2):126–128

    Article  PubMed  CAS  Google Scholar 

  8. Reller ME, Lema CA, Perl TM, Cai M, Ross TL, Speck KA, Carroll KC (2007) Yield of stool culture with isolate toxin testing versus a two-step algorithm including stool toxin testing for detection of toxigenic Clostridium difficile. J Clin Microbiol 45(11):3601–3605

    Article  PubMed  Google Scholar 

  9. Merrigan M, Venugopal A, Mallozzi M, Roxas B, Viswanathan VK, Johnson S, Gerding DN, Vedantam G (2010) Human hypervirulent Clostridium difficile strains exhibit increased sporulation as well as robust toxin production. J Bacteriol 192(19):4904–4911

    Article  PubMed  CAS  Google Scholar 

  10. Vohra P, Poxton IR (2011) Comparison of toxin and spore production in clinically relevant strains of Clostridium difficile. Microbiology 157(Pt 5):1343–1353

    Article  PubMed  CAS  Google Scholar 

  11. Warny M, Pepin J, Fang A, Killgore G, Thompson A, Brazier J, Frost E, McDonald LC (2005) Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe. Lancet 366(9491):1079–1084

    Article  PubMed  CAS  Google Scholar 

  12. Kaltsas A, Simon M, Unruh LH, Son C, Wroblewski D, Musser KA, Sepkowitz K, Babady NE, Kamboj M (2012) Clinical and laboratory characteristics of Clostridium difficile infection in patients with discordant diagnostic test results. J Clin Microbiol 50:1303–1307

    Article  PubMed  Google Scholar 

  13. Aichinger E, Schleck CD, Harmsen WS, Nyre LM, Patel R (2008) Nonutility of repeat laboratory testing for detection of Clostridium difficile by use of PCR or enzyme immunoassay. J Clin Microbiol 46(11):3795–3797

    Article  PubMed  CAS  Google Scholar 

  14. Cardona DM, Rand KH (2008) Evaluation of repeat Clostridium difficile enzyme immunoassay testing. J Clin Microbiol 46(11):3686–3689

    Article  PubMed  Google Scholar 

  15. Deshpande A, Pasupuleti V, Patel P, Ajani G, Hall G, Hu B, Jain A, Rolston DD (2011) Repeat stool testing to diagnose Clostridium difficile infection using enzyme immunoassay does not increase diagnostic yield. Clin Gastroenterol Hepatol 9(8):665–669, e661

    Article  PubMed  Google Scholar 

  16. Khanna S, Pardi DS, Rosenblatt JE, Patel R, Kammer PP, Baddour LM (2012) An evaluation of repeat stool testing for Clostridium difficile infection by polymerase chain reaction. J Clin Gastroenterol. 2012 Feb 13 [Epub ahead of print]

  17. Nemat H, Khan R, Ashraf MS, Matta M, Ahmed S, Edwards BT, Hussain R, Lesser M, Pekmezaris R, Dlugacz Y, Wolf-Klein G (2009) Diagnostic value of repeated enzyme immunoassays in Clostridium difficile infection. Am J Gastroenterol 104(8):2035–2041

    Article  PubMed  CAS  Google Scholar 

  18. Gerding DN, Olson MM, Peterson LR, Teasley DG, Gebhard RL, Schwartz ML, Lee JT Jr (1986) Clostridium difficile-associated diarrhea and colitis in adults. A prospective case-controlled epidemiologic study. Arch Intern Med 146(1):95–100

    Article  PubMed  CAS  Google Scholar 

  19. Davies KA, Planche T, Coen P, Crook D, Shetty N, Wren M, Wilcox MH (2012) The largest ever study to define a testing algorithm to optimise the laboratory diagnosis of C. difficile infection. 22nd European Congress of Clinical Microbiology and Infectious Diseases (ECCMID), March 31–April 4, 2012, London, UK

  20. Department of Health, United Kingdom (2012) Updated guidance on the diagnosis and reporting of Clostridium difficile. National Health Service, Department of Health, UK. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_132927. Accessed 5 May 2012

  21. Naaber P, Stsepetova J, Smidt I, Ratsep M, Koljalg S, Loivukene K, Jaanimae L, Lohr IH, Natas OB, Truusalu K, Sepp E (2011) Quantification of Clostridium difficile in antibiotic-associated-diarrhea patients. J Clin Microbiol 49(10):3656–3658

    Article  PubMed  Google Scholar 

  22. Delmee M, Van Broeck J, Simon A, Janssens M, Avesani V (2005) Laboratory diagnosis of Clostridium difficile-associated diarrhoea: a plea for culture. J Med Microbiol 54(Pt 2):187–191

    Article  PubMed  CAS  Google Scholar 

  23. Bartlett JG, Moon N, Chang TW, Taylor N, Onderdonk AB (1978) Role of Clostridium difficile in antibiotic-associated pseudomembranous colitis. Gastroenterology 75(5):778–782

    PubMed  CAS  Google Scholar 

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Acknowledgments

This work was supported by Grant Number UL1 RR024146 from the National Center for Research Resources (C.R.P.).

C.R.P. has received materials from Cepheid, Meridian and TechLab. All other authors report no conflicts.

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Authors and Affiliations

  1. Department of Pathology and Laboratory Medicine, University of California, Davis, School of Medicine, Davis, CA, USA

    J. L. Leslie & C. R. Polage

  2. Department of Internal Medicine, Division of Infectious Diseases, University of California, Davis, School of Medicine, Davis, CA, USA

    S. H. Cohen, J. V. Solnick & C. R. Polage

  3. Department of Medical Microbiology and Immunology, University of California, Davis, School of Medicine, Davis, CA, USA

    J. V. Solnick

Authors
  1. J. L. Leslie
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  2. S. H. Cohen
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  3. J. V. Solnick
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  4. C. R. Polage
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Correspondence to C. R. Polage.

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Leslie, J.L., Cohen, S.H., Solnick, J.V. et al. Role of fecal Clostridium difficile load in discrepancies between toxin tests and PCR: is quantitation the next step in C. difficile testing?. Eur J Clin Microbiol Infect Dis 31, 3295–3299 (2012). https://doi.org/10.1007/s10096-012-1695-6

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  • DOI: https://doi.org/10.1007/s10096-012-1695-6

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