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Universal molecular Clostridioides difficile screening and overtreatment in solid organ transplant recipients
Margaret Newman McCort1, Cassandra Oehler2, Matthew Enriquez2
1Section of Infectious Diseases, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA.
Background:
Screening for Clostridioides difficile (CD) colonization can be performed using molecular testing to identify the presence of microbial DNA of the toxin gene. Colonization rates for hospitalized patients are as high as 20% and may be considerably higher in solid organ transplant (SOT) recipients. Treatment for CD should be based on clinical disease and not colonization, yet clinicians may misinterpret a positive CD screen resulting in overtreatment.
Objectives:
The objective of this analysis is to determine how often positive CD screens resulted in inappropriate treatment with oral vancomycin.
Methods:
Clostridioides difficile screens were performed using the Xpert C difficile assay (Cepheid), a nucleic acid amplification testing method utilizing polymerase chain reaction (PCR), on peri-rectal swabs for newly admitted patients. This was a single-center cohort study of adult patients with CD screens hospitalized between July 2015 and November 2018. The primary outcome was the rate of inappropriate oral vancomycin treatment in all patients and in SOT recipients, defined as therapy in the absence of diarrhea.
Results:
Of the 47 076 total CD screens reviewed, 1,921 were positive. In the SOT cohort, 58 of 329 screens were positive (4.1% vs 17.9%, P < .01). Of all patients with a positive CD screen, 20.1% (386/1921) were treated with oral vancomycin within 48 hours of swab collection. In the SOT cohort, 39.6% (23/58) with positive CD screens were treated with oral vancomycin within 48 hours. Of the SOT patients who received oral vancomycin, 39% (9/23) did not have true CD infection.
Conclusion:
Solid organ transplant recipients were more likely to have CD colonization detected by peri-rectal screening than the general inpatient population. SOT and non-SOT patients were treated with oral vancomycin at similar rates in response to the positive screen. Nearly half of the oral vancomycin use in SOT recipients was likely overtreatment, but this finding is limited by the low number of patients in this cohort.
Insights
Clostridioides difficile (CD) screening identifies colonization, but positive results in solid organ transplant (SOT) recipients often lead to unnecessary oral vancomycin treatment. Nearly half of SOT patients treated after a positive CD screen did not have a true infection.
Area of Science:
- Infectious Diseases
- Clinical Microbiology
- Pharmacology
Background:
- Clostridioides difficile (CD) colonization screening uses molecular methods to detect toxin genes.
- Hospitalized patients have colonization rates up to 20%, with higher rates in solid organ transplant (SOT) recipients.
- Positive CD screens can be misinterpreted, leading to inappropriate treatment for colonization instead of active infection.
Purpose of the Study:
- To determine the frequency of inappropriate oral vancomycin treatment following positive CD screening.
- To analyze treatment patterns in the general inpatient population and specifically in SOT recipients.
Main Methods:
- A single-center cohort study analyzed adult patients screened for CD using the Xpert C. difficile assay (PCR-based) on peri-rectal swabs.
- Data were collected from July 2015 to November 2018.
- Inappropriate treatment was defined as oral vancomycin administration in the absence of diarrhea.
Main Results:
- Out of 47,076 total screens, 1,921 were positive for CD.
- Positive screens were more common in SOT recipients (17.9%) compared to the general inpatient population (4.1%).
- 20.1% of all patients with positive screens received oral vancomycin; this rate was 39.6% in SOT recipients. 39% of treated SOT patients lacked true infection.
Conclusions:
- SOT recipients show higher rates of detected CD colonization via screening.
- Oral vancomycin treatment rates post-screening were similar between SOT and non-SOT patients.
- A significant portion of oral vancomycin use in SOT recipients following positive screens was likely overtreatment, though this requires further investigation due to cohort size.
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