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Clinical Impact of Clostridium difficile PCR Cycle Threshold-Predicted Toxin Reporting in Pediatric Patients
Hayden T Schwenk1, Laura L Bio2, Jenna F Kruger3
1Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.
Insights
Reporting Clostridium difficile toxin results predicted by PCR cycle threshold (CT) reduced CDI treatment in children by 22%. This dual reporting strategy helps avoid overdiagnosis and overtreatment of C. difficile infection.
Area of Science:
- Pediatric Infectious Diseases
- Clinical Microbiology
- Diagnostic Test Evaluation
Background:
- Overdiagnosis and overtreatment of Clostridium difficile infection (CDI) can occur when relying solely on toxigenic C. difficile detection tests.
- The C. difficile polymerase chain reaction (PCR) cycle threshold (CT) can predict free C. difficile toxins, but its clinical utility is underexplored.
Purpose of the Study:
- To evaluate the impact of dual reporting of PCR and predicted C. difficile toxin results on CDI management and patient outcomes in a pediatric population.
- To assess if incorporating CT-predicted toxin status influences treatment decisions for C. difficile infection in children.
Main Methods:
- A retrospective analysis comparing CDI treatment rates before and after implementing dual PCR and CT-predicted toxin result reporting.
- Data collection included demographic information, treatment details, and patient outcomes followed for 8 weeks post-intervention.
Main Results:
- CDI treatment rates decreased by 22% post-intervention (96% to 74%).
- Of PCR-positive results, 62% were toxin-positive. Among PCR-positive/toxin-negative results, 66% did not receive treatment.
- No CDI-related complications were observed in untreated patients.
Conclusions:
- Integrating CT-predicted C. difficile toxin results with PCR reporting significantly reduces the proportion of pediatric patients treated for CDI.
- This approach aids in more accurate diagnosis and appropriate management of C. difficile infection in children.
Background:
Reliance on tests that detect only the presence of toxigenic Clostridium difficile can result in overdiagnosis and overtreatment of C difficile infection (CDI). The C difficile polymerase chain reaction (PCR) cycle threshold (CT) can sensitively predict the presence of free C difficile toxins; however, the clinical application for this testing strategy remains unexplored. We evaluated the impact of dual PCR and toxin result reporting, as predicted by the CT, on CDI management and outcomes in children.
Methods:
Before the intervention, results for C difficile testing at Lucile Packard Children's Hospital Stanford were reported as PCR positive (PCR+) or negative (PCR-) according to the GeneXpert C diff Epi tcdB PCR assay (Cepheid, Sunnyvale, California). Beginning October 5, 2016, the presence of free toxins, as predicted by the CT, was reported also. The CDI treatment rates 1 year before and 18 months after implementation of toxin reporting were compared. Demographic and treatment-related data were collected, and patient outcomes were followed up 8 weeks later.
Results:
CDI treatment decreased 22% after the intervention (96% [preintervention] vs 74% [postintervention]; P < .001). During the postintervention period, there were 152 PCR+C difficile results, and 94 (62%) of them were toxin positive (toxin+) according to the CT. Of the 58 PCR+/toxin-negative (toxin-) results, 38 (66%) did not result in CDI treatment. Seven (18%) of the untreated PCR+/toxin- patients underwent repeat testing within 8 weeks, and 5 (13%) of them were subsequently PCR+/toxin+ and treated. No CDI-related complications were identified.
Conclusions:
Addition of the CT-predicted C difficile toxin result to PCR reporting reduces the proportion of PCR+ children treated for CDI.
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