Impact of a Multiplexed Polymerase Chain Reaction Panel on Identifying Diarrheal Pathogens in Hematopoietic Cell Transplant Recipients

2019 ◽  
Vol 71 (7) ◽  
pp. 1693-1700 ◽  
Author(s):  
Wesley S Rogers ◽  
Lars F Westblade ◽  
Rosemary Soave ◽  
Stephen G Jenkins ◽  
Koen van Besien ◽  
...  
Keyword(s):  
Polymerase Chain Reaction ◽  
Hematopoietic Cell ◽  
Cell Transplant ◽  
Chain Reaction ◽  
Hematopoietic Cell Transplant ◽  
Clostridioides Difficile ◽  
Multiplexed Pcr ◽  
Clostridioides Difficile Infection ◽  
Polymerase Chain ◽  
The Impact

Abstract Background Diarrhea is common and associated with substantial morbidity among hematopoietic cell transplant (HCT) recipients, but the etiology is often not identified. Multiplexed polymerase chain reaction (PCR) assays increase the detection of diarrheal pathogens, but the impact of this technology in this population has not been evaluated. Methods Our center replaced stool cultures and other conventional microbiologic methods with the FilmArray Gastrointestinal Panel (GI PCR) in June 2016. We reviewed all adult patients who received an HCT from June 2014–May 2015 (pre–GI PCR, n = 163) and from June 2016–May 2017 (post–GI PCR, n = 182) and followed them for 1 year after transplantation. Clostridioides difficile infection was diagnosed by an independent PCR test in both cohorts. Results The proportion of patients with ≥1 identified infectious diarrheal pathogen increased from 25% to 37% after implementation of GI PCR (P = .01). Eight patients (5%) in the pre–GI PCR cohort tested positive for a pathogen other than C. difficile versus 49 patients (27%) in the post–GI PCR cohort (P < .001). The most common non–C. difficile diarrheal pathogens in the post–GI PCR cohort were enteropathogenic Escherichia coli (n = 14, 8%), norovirus (n = 14, 8%), and Yersinia enterocolitica (n = 7, 4%). The percentage of diarrheal episodes with an identified infectious etiology increased from 14% to 23% (P = .001). Median total costs of stool testing per patient did not increase (pre: $473; post: $425; P = .25). Conclusions Infectious etiologies of diarrhea were identified in a higher proportion of HCT recipients after replacing conventional stool testing with a multiplexed PCR assay, without an increase in testing costs.

scholarly journals Kinetics of polymerase chain reaction positivity in patients with Clostridioides difficile infection

2021 ◽  
Vol 14 ◽  
pp. 175628482110504
Author(s):  
Srishti Saha ◽  
Devvrat Yadav ◽  
Ryan Pardi ◽  
Robin Patel ◽  
Sahil Khanna ◽  
...  
Keyword(s):  
Polymerase Chain Reaction ◽  
Median Time ◽  
Median Duration ◽  
Treatment Initiation ◽  
Chain Reaction ◽  
Duration Of Treatment ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Polymerase Chain ◽  
Kinetics Of

Background: Polymerase chain reaction (PCR) is a sensitive test for diagnosing Clostridioides difficile infection (CDI) and could remain positive following resolution of CDI. The kinetics of PCR positivity following antibiotics for CDI is unknown. We studied this and whether it predicted CDI recurrence. Methods: Adults with CDI from October 2009 to May 2017 were included. Serial stool samples within 60 days of treatment were collected. Recurrent CDI was defined as diarrhea after interim symptom resolution with positive stool PCR within 56 or 90 days of treatment completion. Contingency table analysis was used to assess the risk of recurrence. Results: Fifty patients were included [median age: 51 (range = 20–86) years, 66% women]. Treatment given was metronidazole, 50% (25); vancomycin, 44% (22); both, 4% (2); and fidaxomicin, 2% (1). Median duration of treatment for all 50 patients was 14 (range = 8–60) days. The median duration of treatment in patients who got prolonged therapy (>14 days) ( n = 10) was 47 (range = 18–60) days. Median time to negative PCR was 9 (95% CI, 7–14) days from treatment initiation, which did not differ by antibiotics given ( p = 0.5). A positive PCR during or after treatment was associated with a higher risk of recurrence at 56 days ( p = 0.02) and at 90 days ( p = 0.009). Conclusion: The median time to negative PCR in CDI was 9 days from treatment initiation. The PCR positivity during or after treatment may be useful for recurrence prediction; larger studies are needed to validate these results.

The impact of changing reflexive to clinician-ordered Clostridioides difficile polymerase chain reaction (PCR) testing for indeterminate cases: Cost savings without associated adverse events

2020 ◽  
Vol 41 (6) ◽  
pp. 684-690
Author(s):  
Eva L. Sullivan ◽  
Rohit Majumdar ◽  
Courtney Ortiz ◽  
Patricia K. Riggs ◽  
Nancy F. Crum-Cianflone
Keyword(s):  
Polymerase Chain Reaction ◽  
Adverse Events ◽  
Cost Savings ◽  
Primary Study ◽  
Chain Reaction ◽  
Clostridioides Difficile ◽  
Before And After ◽  
Polymerase Chain ◽  
The Impact ◽  
Pcr Test

AbstractObjective:To evaluate changing Clostridioides difficile infection (CDI) testing among inpatients with indeterminate enzyme immunoassay (EIA) results (antigen+/toxin−) from reflexive polymerase chain reaction (PCR) testing to clinician-ordered PCR testing.Design:Multicenter, before-and-after, quasi-experimental study.Setting:Four large urban tertiary-care hospitals.Methods:We evaluated two 6-month periods before and after an intervention. The primary study outcome was the change in the number of CDI diagnoses between periods. Secondary outcomes included the number of PCR tests performed, adverse events, and healthcare cost savings.Results:In total, 500 EIA-indeterminate C. difficile test results were evaluated: 281 before the intervention and 219 thereafter. CDI was diagnosed by PCR among EIA-indeterminate cases in 182 in the preintervention period versus 94 patients in the postintervention period (48% reduction; P < .01). PCR testing was performed in 99.6% of indeterminate cases (280 of 281; 1 not performed due to an inhibitor) in the preintervention period versus 66% (144 of 219) in the postintervention period (34% reduction; P < .01). We observed no differences between study periods in 30-day all-cause (P = .96), GI-related (P = .93), or C. difficile (P = .47) readmissions, nor in 30-day C. difficile infections (P > .99). No patient without a PCR test in the postintervention period and not treated was later diagnosed with CDI. Each reflexive PCR test not performed led to a cost savings of $4,498 per patient.Conclusions:Applying diagnostic stewardship to C. difficile PCR testing in the inpatient setting led to significant reductions in both testing and cases. Changing the C. difficile PCR testing algorithm for EIA-indeterminate cases from reflexive to clinician-required ordering resulted in valuable cost savings without associated adverse events.

scholarly journals Effectiveness of bezlotoxumab for prevention of recurrent Clostridioides difficile infection among transplant recipients

2021 ◽  
Author(s):  
Tanner M Johnson ◽  
Amanda H Howard ◽  
Matthew A Miller ◽  
Lorna L Allen ◽  
Misha Huang ◽  
...  
Keyword(s):  
Organ Transplant ◽  
Standard Of Care ◽  
Hematopoietic Cell ◽  
Solid Organ ◽  
Cell Transplant ◽  
Transplant Recipients ◽  
Hematopoietic Cell Transplant ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Solid Organ Transplant Recipients

Abstract Background Bezlotoxumab significantly reduces the incidence of recurrent Clostridioides difficile infection; however, limited data is available in solid-organ and hematopoietic-cell transplant recipients. Methods We conducted a single-center retrospective analysis comparing recurrent Clostridioides difficile infection in solid-organ and hematopoietic-cell transplant recipients receiving standard of care alone (oral vancomycin, fidaxomicin, or metronidazole) or bezlotoxumab plus standard of care. The primary outcome was 90-day incidence of recurrent Clostridioides difficile infection, and secondary outcomes included 90-day hospital readmission, mortality, and incidence of heart failure exacerbation. Results Overall, 94 patients received bezlotoxumab plus standard of care (n=38) or standard of care alone (n=56). The mean age was 53 years, patients had a median of 3 prior Clostridioides difficile episodes, and 4 risk factors for recurrent infection. Most patients were solid-organ transplant recipients (76%), with median time to index Clostridioides difficile infection occurring 2.7 years post-transplantation. Ninety-day recurrent Clostridioides difficile infection occurred in 16% (6/38) in the bezlotoxumab cohort compared to 29% (16/56) in the standard of care cohort (p=0.13). Multivariable regression revealed bezlotoxumab was associated with significantly lower odds of 90-day recurrent Clostridioides difficile infection (Odds Ratio [95% CI]: 0.28 [0.08-0.91]). There were no differences in secondary outcomes, and no heart failure exacerbations were observed. Conclusions In a cohort of primarily solid-organ transplant recipients, bezlotoxumab was well tolerated and associated with lower odds of recurrent Clostridioides difficile infection at 90-days. Larger, prospective trials are needed to confirm these findings amongst solid-organ and hematopoietic-cell transplant populations.

scholarly journals Changes in the Association Between Diagnostic Testing Method, Polymerase Chain Reaction Ribotype, and Clinical Outcomes From Clostridioides difficile Infection: One Institution’s Experience

2020 ◽  
Author(s):  
Anitha Menon ◽  
D Alex Perry ◽  
Jonathan Motyka ◽  
Shayna Weiner ◽  
Alexandra Standke ◽  
...  
Keyword(s):  
Polymerase Chain Reaction ◽  
Diagnostic Testing ◽  
Adverse Outcomes ◽  
Clinical Severity ◽  
Diagnostic Strategy ◽  
Chain Reaction ◽  
Ribotype 027 ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Polymerase Chain

Abstract Background In Clostridioides difficile infection (CDI), the relationship between clinical, microbial, and temporal/epidemiological trends, disease severity and adverse outcomes is incompletely understood. In a follow-up to our study from 2010–2013, we evaluate stool toxin levels and C. difficile polymerase chain reaction (PCR) ribotypes. We hypothesized that elevated stool toxins and infection with ribotype 027 associate with adverse outcomes. Methods In 565 subjects at the University of Michigan with CDI diagnosed by positive testing for toxins A/B by enzyme immunoassay (EIA) or PCR for the tcdB gene, we quantified stool toxin levels via a modified cell cytotoxicity assay (CCA), isolated C. difficile by anaerobic culture, and performed PCR ribotyping. Severe CDI was defined by Infectious Diseases Society of America (IDSA) criteria, and primary outcomes were all-cause 30-day mortality and a composite of colectomy, intensive care unit admission, and/or death attributable to CDI within 30 days. Analyses included bivariable tests and logistic regression. Results 199 samples were diagnosed by EIA; 447 were diagnosed by PCR. Toxin positivity associated with IDSA severity but not primary outcomes. In 2016, compared with 2010–2013, ribotype 106 newly emerged, accounting for 10.6% of strains, ribotype 027 fell from 16.5% to 9.3%, and ribotype 014–027 remained stable at 18.9%. Ribotype 014–020 associated with IDSA severity and 30-day mortality (P = .001). Conclusions Toxin positivity by EIA and CCA associated with IDSA severity but not with subsequent adverse outcomes. The molecular epidemiology of C. difficile has shifted, which may have implications for the optimal diagnostic strategy for and clinical severity of CDI.

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