Changes

=DIAGNOSIS=

=DIAGNOSIS=

* Laboratory testing cannot distinguish between asymptomatic colonization and active infection.

* Laboratory testing cannot always distinguish between asymptomatic colonization and active infection.

==Diagnostic criteria==

==Diagnostic criteria==

* Diarrhea

* Diarrhea

* Positive stool test for toxigenic C. diff or toxins or visualization of pseudomembranous colitis

* Positive stool test for toxigenic C. diff or toxins or visualization of pseudomembranous colitis

==Diagnostic approaches==

==Diagnostic approaches==

* Toxigenic Culture (TC) and/or Cell Cytotoxicity Assay (CCA)

* Gold Standard: Toxigenic Culture (TC) and/or Cell Cytotoxicity Assay (CCA)

** Anaerobic culture for 24-48 hrs followed by colony selection and culture with human cells to test for cell cytotoxicity which takes an additional 24-48 hours.

** Anaerobic culture for 24-48 hrs followed by colony selection and culture with human cells to test for cell cytotoxicity which takes an additional 24-48 hours.

** Time consuming and difficult, up to 5 days

** Time consuming and difficult, up to 5 days

** Detects a little as 3 picograms of toxin

** Detects a little as 3 picograms of toxin

* PCR / NAAT

* PCR / NAAT

** Detects tcdA/tcdB genes, mRNA for the toxins

** Detects tcdA/tcdB genes, mRNA for the toxins

*** Detects presence of toxigenic strains of C. diff

** Detects presence of toxigenic strains of C. diff

* mRNA doesn't necessarily imply active infection

** mRNA doesn't necessarily imply active infection

** EIA / ELISA

* EIA / ELISA

*** Detects toxin in stool

** Detects toxin in stool

*** Low sensitivity (0.73-0.87)

** Low sensitivity (0.73-0.87)

* Multistep algorithms, there are dozens

* Multistep algorithms, there are dozens

** EIA for GDH / Toxin A/B

** EIA for GDH / Toxin A/B

* Both positive = C. diff

*** Both positive = C. diff

* Both negative = NO C. diff

*** Both negative = NO C. diff

* Mixed results, use PCR for tcdB as tiebreaker

*** Mixed results, use PCR for tcdB as tiebreaker

** Toxin EIA 1 (Meridian), higher PPV, lower NPV

** Toxin EIA 1 (Meridian), higher PPV, lower NPV

** Toxin EIA 2 (TechLab), lower PPV, higher NPV

** Toxin EIA 2 (TechLab), lower PPV, higher NPV

* Highest NPV (99.8%) GDH EIA + NAAT

** Highest NPV (99.8%) GDH EIA + NAAT

* Highest PPV (93.5%) Toxin EIA 1 + NAAT

** Highest PPV (93.5%) Toxin EIA 1 + NAAT

=TREATMENT=

=TREATMENT=

**Clinical resolution occurred in 92% of patients (89% after a single treatment), without serious adverse effects.

**Clinical resolution occurred in 92% of patients (89% after a single treatment), without serious adverse effects.

**A recent review of 536 patients reported a 27% clinical response rate.

**A recent review of 536 patients reported a 27% clinical response rate.

**A randomized trial of fecal microbiota transplantation demonstrated symptom

**A randomized trial of fecal microbiota transplantation demonstrated symptom resolution in 94% of patients who received vancomycin for 5 days followed by either one or two treatments with fecal microbiota transplantation, versus 31% in those receiving vancomycin alone for 14 days, and 23% for those receiving vanconycin for 14 days plus bowel lavage. This study was stopped early after interim analyses demonstrated superiority of fecal microbiota transplantation, Among 18 patients in the other treatment groups who received subsequent fecal microbiota transplantation 83% had symptom resolution

resolution in 94% of patients who received vancomycin for s days followed by either

one or two treatments with fecal microbiota transplantation, versus 31% in those

receiving vancomycin alone for 14 days, and 23% for those receiving vanconycin for

14 days plus bowel lavage. This study was stopped early after interim analyses

demonstrated superiority of fecal microbiota transplantation, Among 18 patients in

the other treatment groups who received subsequent fecal microbiota transplantation

83% had symptom resolution