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VOLUME 22 , ISSUE 1 ( January-June, 2020 ) > List of Articles

Original Article

Polymerase chain reaction for Clostridioides difficile infection detection: Necessity or redundancy? – A pilot study in a tertiary health-care centre in Central Kerala

Ansu Sam, S Oommen

Keywords : Clostridioides difficile infection, glutamate dehydrogenase, tcdB gene, toxin assay

Citation Information : Sam A, Oommen S. Polymerase chain reaction for Clostridioides difficile infection detection: Necessity or redundancy? – A pilot study in a tertiary health-care centre in Central Kerala. 2020; 22 (1):35-40.

DOI: 10.4103/jacm.jacm_1_20

License: CC BY-NC 4.0

Published Online: 13-08-2020

Copyright Statement:  Copyright © 2020; Wolters Kluwer India Pvt. Ltd.


Abstract

INTRODUCTION: Clostridioides difficile infection (CDI) is one of the hospital-acquired infections and the most common cause for antibiotic-associated diarrhoea. Documentation of CDI is difficult, and interpretation of diagnostic results often requires consultation with clinical microbiologists. The purpose of this study was to compare the results of the combination of glutamate dehydrogenase enzyme (GDH) and toxin assay with the polymerase chain reaction (PCR) results, in order to find if the combination could substitute for the expensive molecular tests. MATERIALS AND METHODS: The sample size was statistically calculated to be 30, using an SPSS software. Both GDH and toxin assay were simultaneously tested in all the randomly selected stool samples, by simple random sampling, and irrespective of the results, they were also tested for tcdB gene by PCR in the present study. All the samples were also plated onto Brazier's C. difficile agar and incubated anaerobically. RESULTS: The sensitivity and specificity of GDH (using PCR as gold standard) were found to be 100% and 76.47%, respectively, and the sensitivity and specificity of toxin enzyme immunoassay (EIA) assay (using PCR as gold standard) were found to be 66.67% and 92.86%, respectively. However, when the toxin-equivocal results were also considered as positive, the sensitivity of toxin EIA was found to be 100%. The overall agreeability, using Cohen's Kappa statistic between GDH and toxin detection by enzyme-linked fluorescence assay, showed that they had moderate and substantial agreement, respectively, when compared to PCR. CONCLUSIONS: In this study, each of the toxin negatives and positives was also PCR negative and positive, respectively. All the toxin-equivocal samples tested positive on PCR, so it is our conclusion that in the settings where they cannot be taken for further molecular testing, those samples be considered as harbouring toxigenic C. difficile.


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  1. Mullish BH, Williams HR. Clostridium difficile infection and antibiotic-associated diarrhoea. Clin Med (Lond) 2018;18:237-41.
  2. McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2018;66:e1-48.
  3. Burnham CA, Carroll KC. Diagnosis of Clostridium difficile infection: An ongoing conundrum for clinicians and for clinical laboratories. Clin Microbiol Rev 2013;26:604-30.
  4. Tenover FC, Baron EJ, Peterson LR, Persing DH. Laboratory diagnosis of Clostridium difficile infection can molecular amplification methods move us out of uncertainty? J Mol Diagn 2011;13:573-82.
  5. Fang FC, Polage CR, Wilcox MH. Point-counterpoint: What is the optimal approach for detection of Clostridium difficile Infection? J Clin Microbiol 2017;55:670-80.
  6. Goldenberg SD, Cliff PR, Smith S, Milner M, French GL. Two-step glutamate dehydrogenase antigen real-time polymerase chain reaction assay for detection of toxigenic Clostridium difficile. J Hosp Infect 2010;74:48-54.
  7. Martínez-Meléndez A, Camacho-Ortiz A, Morfin-Otero R, Maldonado-Garza HJ, Villarreal-Treviño L, Garza-González E. Current knowledge on the laboratory diagnosis of Clostridium difficile infection. World J Gastroenterol 2017;23:1552-67.
  8. Humphries RM, Uslan DZ, Rubin Z. Performance of Clostridium difficile toxin enzyme immunoassay and nucleic acid amplification tests stratified by patient disease severity. J Clin Microbiol 2013;51:869-73.
  9. Polage CR, Gyorke CE, Kennedy MA, Leslie JL, Chin DL, Wang S, et al. Overdiagnosis of Clostridium difficile infection in the molecular test era. JAMA Intern Med 2015;175:1792-801.
  10. Crobach MJ, Planche T, Eckert C, Barbut F, Terveer EM, Dekkers OM, et al. European Society of clinical microbiology and infectious diseases: Update of the diagnostic guidance document for Clostridium difficile infection. Clin Microbiol Infect 2016;22 Suppl 4:S63-81.
  11. Lee NY, Huang YT, Hsueh PR, Ko WC. Clostridium difficile bacteremia, taiwan1. Emerg infect Dis 2010;16:1204.
  12. Claro T, Daniels S, Humphreys H. Detecting Clostridium difficile spores from inanimate surfaces of the hospital environment: Which method is best? J Clin Microbiol 2014;52:3426-8.
  13. Carter GP, Awad MM, Kelly ML, Rood JI, Lyras D. TcdB or not TcdB: A tale of two Clostridium difficile toxins. Future Microbiol 2011;6:121-3.
  14. Sam AS, Jacob AM, Oommen S. Prevalence and outcome of clostridioides difficile infection in a tertiary care hospital in Kerala, India. National Journal of Laboratory Medicine 2019;8:MO01-4.
  15. Riggs MM, Sethi AK, Zabarsky TF, Eckstein EC, Jump RL, Donskey CJ. Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents. Clin Infect Dis 2007;45:992-8.
  16. Eastwood K, Else P, Charlett A, Wilcox M. Comparison of nine commercially available Clostridium difficile toxin detection assays, a real-time PCR assay for C. difficile tcdB, and a glutamate dehydrogenase detection assay to cytotoxin testing and cytotoxigenic culture methods. J Clin Microbiol 2009;47:3211-7.
  17. Brown NA, Lebar WD, Young CL, Hankerd RE, Newton DW. Diagnosis of Clostridium difficile infection: Comparison of four methods on specimens collected in Cary-Blair transport medium and tcdB PCR on fresh versus frozen samples. Infect Dis Rep 2011;3:e5.
  18. Davies KA, Berry CE, Morris KA, Smith R, Young S, Davis TE, et al. Comparison of the Vidas C. difficile GDH automated enzyme-linked fluorescence immunoassay (ELFA) with another commercial enzyme immunoassay (EIA) (Quik Chek-60), Two selective media, and a PCR assay for gluD for detection of Clostridium difficile in fecal samples. J Clin Microbiol 2015;53:1931-4.
  19. Cheng JW, Xiao M, Kudinha T, Xu ZP, Sun LY, Hou X, et al. The role of glutamate dehydrogenase (GDH) testing assay in the diagnosis of Clostridium difficile infections: A high sensitive screening test and an essential step in the proposed laboratory diagnosis workflow for developing countries like China. PLoS One 2015;10:e0144604.
  20. Planche T, Wilcox MH. Diagnostic pitfalls in Clostridium difficile infection. Infect Dis Clin North Am 2015;29:63-82.
  21. Davies KA, Ashwin H, Longshaw CM, Burns DA, Davis GL, Wilcox MH, EUCLID Study Group. Diversity of Clostridium difficile PCR ribotypes in Europe: results from the European, multicentre, prospective, biannual, point-prevalence study of Clostridium difficile infection in hospitalised patients with diarrhoea (EUCLID), 2012 and 2013. Eurosurveillance. 2016;21:30294.
  22. Murad YM, Perez J, Ybazeta G, Mavin S, Lefebvre S, Weese JS, et al. False negative results in Clostridium difficile testing. BMC Infect Dis 2016;16:430.
  23. Qutub M, Govindan P, Vattappillil A. Effectiveness of a Two-Step Testing Algorithm for Reliable and Cost-Effective Detection of Clostridium difficile Infection in a Tertiary Care Hospital in Saudi Arabia. Med Sci (Basel). 2019;7:6. Published 2019 Jan 8. doi: 10.3390/medsci7010006.
  24. Scottish Health Protection Network. Guidance on Prevention and Control of Clostridium difficile Infection (CDI) in health and social care settings in Scotland. Health Protection Network Scottish Guidance. (2017 Edition). Health Protection Scotland, Glasgow, 2017.
  25. Curry SR. Clostridium difficile. Clin Lab Med 2017;37:341-69.
  26. Peterson LR, Mehta MS, Patel PA, Hacek DM, Harazin M, Nagwekar PP, et al. Laboratory testing for Clostridium difficile infection: Light at the end of the tunnel. Am J Clin Pathol 2011;136:372-80.
  27. Yoldaş Ö, Altındiş M, Cufalı D, Aşık G, Keşli R. A diagnostic algorithm for the detection of Clostridium difficile-associated diarrhea. Balkan Med J 2016;33:80-6.
  28. Deshpande A, Pasupuleti V, Rolston DD, Jain A, Deshpande N, Pant C, et al. Diagnostic accuracy of real-time polymerase chain reaction in detection of Clostridium difficile in the stool samples of patients with suspected Clostridium difficile Infection: A meta-analysis. Clin Infect Dis 2011;53:e81-90.
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