Infection Control & Hospital Epidemiology (2019), 40,276–280 doi:10.1017/ice.2018.347
Original Article
Healthcare provider diagnostic testing practices for identification of Clostridioides (Clostridium) difficile in children: an Emerging Infections Network survey
Larry K. Kociolek MD, MSCI1,2 , Preeta K. Kutty MD, MPH3, Philip M. Polgreen MD, MPH4,5 and
Susan E. Beekmann RN, MPH4,5 1Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, 2Division of Infectious Diseases, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, 3Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, 4Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa and 5Emerging Infections Network, Iowa City, Iowa
Abstract
Objective: To characterize healthcare provider diagnostic testing practices for identifying Clostridioides (Clostridium) difficile infection (CDI) and asymptomatic carriage in children. Design: Electronic survey.
Methods: An 11-question survey was sent by e-mail or facsimile to all pediatric infectious diseases (PID) members of the Infectious Diseases Society of America’s Emerging Infections Network (EIN).
Results: Among 345 eligible respondents who had ever responded to an EIN survey, 196 (57%) responded; 162 of these (83%) were aware of their institutional policies for CDI testing and management. Also, 159 (98%) respondents knew their institution’s C. difficile testing method: 99 (62%) utilize NAATwithout toxin testing and 60 (38%) utilize toxin testing, either as a single test or amultistep algorithm. Of 153 respondents, 10 (7%) reported that formed stools were tested for C. difficile at their institution, and 76 of 151 (50%) reported that their institution does not restrict C. difficile testing in infants and young children. The frequency of symptom- and age-based testing restric- tions did not vary between institutions utilizing NAAT alone compared to those utilizing toxin testing for C. difficile diagnosis. Of 143 respondents, 26 (16%) permit testing of neonatal intensive care unit patients and 12 of 26 (46%) treat CDI with antibiotics in this patient population.
Conclusions: These data suggest that there are opportunities to improve CDI diagnostic stewardship practices in children, including among hospitals using NAATs alone for CDI diagnosis in children.
(Received 18 October 2018; accepted 11 December 2018)
Clinical microbiologic diagnosis of Clostridioides (formerly Clostridium) difficile infection (CDI) remains a significant chal- lenge in both adults and children.1 Frequent misuse of C. difficile diagnostic tests by healthcare providers leads to frequent misclas- sification of asymptomatic C. difficile carriers as having CDI.2 This leads to unnecessary CDI antibiotic therapy and inaccurate CDI surveillance, making interfacility comparisons of CDI rates a major challenge. Because CDI is caused by secreted C. difficile toxins in the gut, diagnostic tests that detect toxins A and/or B in stool sample are
Author for correspondence: Larry K. Kociolek, Email: larry-kociolek@
northwestern.edu Cite this article: Kociolek LK, et al. (2019). Healthcare provider diagnostic testing
practices for identification of Clostridioides (Clostridium) difficile in children: an Emerging Infections Network survey. Infection Control & Hospital Epidemiology,40: 276–280,
https://doi.org/10.1017/ice.2018.347
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved.
highly specific forCDI. However, because of reportedly suboptimal sensitivity of stool toxin enzyme immunoassays (EIAs), many clinical microbiology laboratories no longer use toxin EIA as the primary method for diagnosing CDI. Stool nucleic acid amplifica- tion tests (NAATs), such as polymerase chain reaction (PCR) assay or loop-mediated isothermal amplification of the genes for toxins A and/or B (tcdA, tcdB), detect C. difficile strains that have the potential to produce toxins. However, because NAATs do not detect secreted toxin in stool, these tests do not differentiate asymptomatic carriage of C. difficile and CDI. Thus, compared to toxin EIAs, NAATs have poor diagnostic predictive value for CDI.2 As such, NAATs have the potential to misdiagnose CDI in asymptomatic carriers, particularly among patients with low likelihood of CDI. This includes patients without diarrhea, patients with a more likely diarrheal etiology (eg, viral etiologies, laxatives, etc), and children with high probability of carriage (eg, infants and young children).2 For this reason, many hospitals have adopted
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