Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Oct 5;77(7):1043-1049.
doi: 10.1093/cid/ciad334.

Assessing the Impact of 2-Step Clostridioides difficile Testing at the Healthcare Facility Level

Nicholas A Turner  1   2 , Jay Krishnan  1   2 , Alicia Nelson  1   2 , Christopher R Polage  3 , Ronda L Cochran  4 , Lucy Fike  4 , David T Kuhar  4 , Preeta K Kutty  4 , Rachel L Snyder  4 , Deverick J Anderson  1   2
Affiliations

Assessing the Impact of 2-Step Clostridioides difficile Testing at the Healthcare Facility Level

Nicholas A Turner et al. Clin Infect Dis. .

Abstract

Background: Two-step testing for Clostridioides difficile infection (CDI) aims to improve diagnostic specificity but may also influence reported epidemiology and patterns of treatment. Some providers fear that 2-step testing may result in adverse outcomes if C. difficile is underdiagnosed.

Methods: Our primary objective was to assess the impact of 2-step testing on reported incidence of hospital-onset CDI (HO-CDI). As secondary objectives, we assessed the impact of 2-step testing on C. difficile-specific antibiotic use and colectomy rates as proxies for harm from underdiagnosis or delayed treatment. This longitudinal cohort study included 2 657 324 patient-days across 8 regional hospitals from July 2017 through March 2022. Impact of 2-step testing was assessed by time series analysis with generalized estimating equation regression models.

Results: Two-step testing was associated with a level decrease in HO-CDI incidence (incidence rate ratio, 0.53 [95% confidence interval {CI}, .48-.60]; P < .001), a similar level decrease in utilization rates for oral vancomycin and fidaxomicin (utilization rate ratio, 0.63 [95% CI, .58-.70]; P < .001), and no significant level (rate ratio, 1.16 [95% CI, .93-1.43]; P = .18) or trend (rate ratio, 0.85 [95% CI, .52-1.39]; P = .51) change in emergent colectomy rates.

Conclusions: Two-step testing is associated with decreased reported incidence of HO-CDI, likely by improving diagnostic specificity. The parallel decrease in C. difficile-specific antibiotic use offers indirect reassurance against underdiagnosis of C. difficile infections still requiring treatment by clinician assessment. Similarly, the absence of any significant change in colectomy rates offers indirect reassurance against any rise in fulminant C. difficile requiring surgical management.

Keywords: Clostridioides difficile; 2-step testing; interrupted time series analysis.

PubMed Disclaimer

Conflict of interest statement

Potential conflicts of interest. N. A. T. reports grant funding from the CDC, NIH/ARLG, and Rockefeller Foundation; research contract funding from PDI, Purio, and Basilea; and consulting fees for Techspert. D. J. A. reports grant funding from the CDC and Agency for Healthcare Research and Quality; contracts from CDC; interests as owner of Infection Control Education for Major Sports, LLC; and royalties from UpToDate. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

Figures

Figure 1.
Figure 1.
Hospital-onset Clostridioides difficile infection incidence rate by testing strategy. Abbreviations: HO-CDI, hospital-onset Clostridioides difficile infection; NAAT, nucleic acid amplification testing.
Figure 2.
Figure 2.
Clostridioides difficile infection treatment rate by testing strategy. Abbreviations: CDI, Clostridioides difficile infection; NAAT, nucleic acid amplification testing.
Figure 3.
Figure 3.
Emergent colectomy rate by testing strategy. Abbreviation: NAAT, nucleic acid amplification testing.
See this image and copyright information in PMC

Comment in

References

    1. Echenique IA, Penugonda S, Stosor V, Ison MG, Angarone MP. Diagnostic yields in solid organ transplant recipients admitted with diarrhea. Clin Infect Dis 2015; 60:729–37. - PMC - PubMed
    1. Mawer D, Byrne F, Drake S, et al. . Cross-sectional study of the prevalence, causes and management of hospital-onset diarrhoea. J Hosp Infect 2019; 103:200–9. - PubMed
    1. Abt MC, McKenney PT, Pamer EG. Clostridium difficile colitis: pathogenesis and host defence. Nat Rev Microbiol 2016; 14:609–20. - PMC - PubMed
    1. Polage CR, Gyorke CE, Kennedy MA, et al. . Overdiagnosis of Clostridium difficile infection in the molecular test era. JAMA Internal Med 2015; 175:1792–801. - PMC - PubMed
    1. Fang FC, Polage CR, Wilcox MH, Gilligan P. Point-counterpoint: what is the optimal approach for detection of Clostridium difficile infection? J Clin Microbiol 2017; 55:670–80. - PMC - PubMed

Publication types

MeSH terms

Substances