Missed Diagnoses Common for C. Diff Infections

Ioannis M. Zacharioudakis, MD (NYU Langone)

New research suggests more attention paid to missed Clostridioides difficile infections (C diff).

A team, led by Ioannis M. Zacharioudakis, MD, Division of Infectious Diseases and Immunology, Department of Medicine, NYU School of Medicine, examined the rate of missed community-onset C diff infection diagnosis and associated outcomes.

Microbiology laboratories often blind the C diff BioFire FilmArray GI Panel due to fear of an over-diagnosis.

C. Diff Patients

The study included 144 adult patients with FilmArray GI Panel positives for C diff on hospital admission, but lacked dedicated C diff testing. Of this group, 18 individuals did not have concurrent dedicated C diff testing, while 8 patients were categorized as possible, 5 were deemed probably, and 4 were identified as definite missed CDI diagnosis.

The researchers found associated delays in initiation of appropriate therapy, intensive care unit admissions, hospital re-admission, colorectal surgery, and death or discharge to hospice.

In addition, 5 of 17 individuals lacked true risk factors for a C diff infection.

“The practice of concealing C. difficile FilmArray GI Panel results needs to be re-considered in patients presenting with community-onset colitis,” the authors wrote.

Common Complications

Recently, researchers found sepsis was a common C diff complication throughout a 12-month follow-up period and was most commonly observed in the cohort of patients with 3 or more C diff infection recurrences.

Investigators from around New England conducted a retrospective analysis of more than 46,000 adult patients with C diff infection in order to evaluate the clinical complications of C diff in patients with index and recurrent cases.

The investigators used the IQVIA PharMetrics Plus database to looks for patients aged 18-64 years with an index C diff episode that required inpatient stay or an outpatient visit, followed by a treatment for the infection. Treatments included vancomycin, fidaxomicin, metronidazole, rifaximin, or bezlotoxumab, or fecal microbiota transplant (FMT – though it was rare).

A total of 3129 patients (6.7%) experienced 1 recurrence, while 1% had 2 recurrences, and 0.3% had 3 or more recurrences. The study authors also noted that autoimmune diseases, such as ulcerative colitis, Crohn’s disease, type 1 diabetes, rheumatoid arthritis and multiple sclerosis, were present in 18%, 23%, 24%, and nearly 40% of patients, respectively, in patients with 0, 1, 2, or 3 or more C diff infection recurrences.

Antibiotics were prescribed for three-quarters of all patients in all groups in the 6 months preceding the index C diff infection, the investigators found. Gastric acid-suppressing agents were prescribed in 28%, 33%, 39%, and 38%, respectively, in patients with 0, 1, 2, or 3 or more C diff infection recurrences, the study authors also noted.

During the 12-month follow-up period, the investigators observed sepsis in 16%, 27%, 33%, and 43%, respectively, in patients with 0, 1, 2, or 3 or more C diff infection recurrences. No patient had more than 2 sepsis episodes during the 12-month follow-up period. Additionally, subtotal colectomy or diverting loop ileostomy was performed in 4%, 7%, 9%, and 10% of patients, respectively, in patients with 0, 1, 2, or 3 or more C diff infection recurrences.

The study, “Rate and Consequences of Missed Clostridioides (Clostridium) difficile Infection Diagnosis from Non-reporting of Clostridioides difficile Results of the Multiplex GI PCR Panel: Experience from Two-Hospitals,” was published online in Diagnostic Microbiology and Infectious Disease.