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INFECTION CONTROL
Clostridium difficile guidelines updated
The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) has produced new guidelines on best practice methods to diagnose Clostridium difficile infection (CDI). The Clinical Services Journal reports.
Clostridium difficile infection (CDI) is a severe or potentially fatal infection that occurs mainly in elderly and other vulnerable patient groups, especially those who have been exposed to antibiotic treatment. Although the NHS has worked hard to reduce the number of CDIs, the rate of improvement has slowed over recent years and it remains a leading cause of diarrhoea contracted within healthcare environments. Disease is due to strains of C. difficile that produce either toxin A or toxin B, so diagnosing the presence of these strains needs to be achieved quickly and accurately. The new ESCMID guidelines1
update
those originally published in 2009 and include recommendations concerning the use of diagnostic technologies such as nucleic acid amplification tests (NAAT), which have been developed since the publication of the 2009 guidelines, but whose accuracy has never been studied in comparison with previously validated assays. The new guidelines are intended for use by medical microbiologists, gastroenterologists, infectious disease specialists and infection control practitioners. “Our aim is to not only improve diagnosis of CDI, but also to standardise the diagnostic process across Europe to allow for improved surveillance of the disease,” said Professor Ed Kuijper of the Leiden University Medical Center, whose research group, along with Professor Monique Crobach as first author, have published the guidelines. The study that underpins the new guidelines comprises a meta-analysis of all relevant studies. Reports published after 2009 available in PubMed, Embase, Web of Science, Central and the Cochrane Library, together with pre-2009 studies included in
the original meta-analysis were considered. The primary aim was to evaluate the diagnostic accuracy of commercially available laboratory tests in diagnosing CDI, and to make recommendations for standard testing algorithms. Various laboratory assays available from commercial suppliers were also assessed for their ability to diagnose CDI accurately. A reference test, typically cell cytotoxicity neutralisation assay (CNNA) or toxigenic culture (TC) was used to investigate the
Samples to be tested for CDI should not be limited to cases in which a physician has specifically recommended a test.
OCTOBER 2016
accuracy of several tests that have emerged since 2009. These included enzyme immunoassays (EIA) that detect glutamate dehydrogenase or toxins A and B, and the new NAATs.
Sample selection
The guidelines recommend that samples to be tested for CDI should not be limited to cases in which a physician has specifically recommended a test. It is suggested that at least all submitted unformed stool samples from patients three years or older should be tested for CDI. For children under three years of age it is suggested that testing is limited to samples with a physician’s request only. Other sample selection suggestions include the fact that formed stool samples should not be tested for CDI except in case of paralytic
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