Table 5.
Case Series and Time Delays of Positive C. difficile Results Within 7 Days of an Initial Prevented or Negative Test
| No. | Time Delay (H:M) | Prior CDI | Age, Pertinent Conditions, Diagnoses | Clinical CDI Determinationa Initially Positive | NAAT Cycle Thresholdb | Clinical Changes During Delay | Subsequent Hospital Course | |
|---|---|---|---|---|---|---|---|---|
| Initial prevented test (n = 11) | ||||||||
| 1b | 00:01 | Yes | 75 y, chronic leukemia, septic shock | Yes GI-GE (I, VII, VIII, IX) | Yes GI-GE (I, VII, VIII, IX) | 21.7 | None | Multiple comorbid conditions, respiratory failure due to multifocal pneumonia, and poor prognosis; aggressive care withdrawn; died on HD 15. |
| 2 | 00:01 | No | 45 y, paraplegia, hip abscess | No (III) | No (III) | 26.4 | None | Abscess drained. Due to incidental bowel wall thickening on CT, chronic diarrhea, and anticipated antibiotics, team decided to treat if +. Remained stable through discharge HD 12. |
| 3 | 00:24 | Yes | 65 y, end-stage renal disease, confusion, and diarrhea | Yes GI-GE (I, VII, VIII) | Yes GI-GE (I, VII, VIII) | 24.3 | None | Confusion quickly improved (thought due to polypharmacy). Discharged HD 3. |
| 4c | 00:24 | Yes | 22 y, cystic fibrosis status post–lung transplant <1 y ago, shock, respiratory failure | No (IX) | No (IX) | 20.2 | None | Fungal pneumonia discovered on admission. Diarrhea in setting of tube feeds prompted + test on HD 6. Discharged home HD 86. Readmitted for progressive respiratory failure, rejection, and discharged to hospice 5 months later. |
| 5 | 7:27 | No | 57 y, hypertension, aortic dissection (emergent repair) | No (VII) | No (III, VII) | 31.0 | Abdominal pain prompted abdominal CT with finding of colitis. | No significant diarrhea noted but treated in light of CT finding, + test, and history of CDI. Discharged home in stable condition HD 13. |
| 6c | 7:41 | Yes | 59 y, dementia, alcohol withdrawal, and electrolyte abnormalities | Yes GI-GE (I, VII, VIII) | Yes GI-GE (I, VII, VIII) | 24.5 | Poor clinical historian. Team learned of recent undertreated CDI diagnosis. | Resumed CDI treatment and discharged on HD2. Diarrhea continued and lymphocytic colitis diagnosed (endoscopy/biopsy) on subsequent admission. Cardiac arrest, died 1 month later related to new-onset CHF. |
| 7 | 18:26 | No | 52 y, leukemia, chemotherapy (elective) | No (VIII) | Yes GI-GE (I, VIII) | 22.3 | Additional loose stool overnight. | Discharged same day as positive result with outpatient CDI treatment. |
| 8 | 19:11 | No | 45 y, hypothyroidism, diarrhea, and hypokalemia | Yes GI-GIT (III, V, VI, VII) | Yes GI-GE (I), GI-GIT (III, V, VII) | 35.0 | Persistent abdominal pain, CT finding of nonspecific bowel wall thickening. | CDI treatment started empirically after CT and before test resulted +. Hypokalemia and diarrhea improved before discharge home HD 7. |
| 9 | 66:51 | No | 59 y, ulcerative colitis, toxic ingestion, and UTI | No (IX) | Yes GI-GE (I) | 18.6 | Intervening antibiotic started for UTI followed by worsening of chronic diarrhea. | CT of abdomen, done for abdominal pain, was normal. Pain/diarrhea improved with treatment of UTI and CDI. Discharged home. |
| 10c | 128:44 | No | 44 y, acute leukemia, blast crisis | No (V) | Yes GI-GE (I, VIII, IX) | 23.8 | Fever and acute-onset diarrhea on the day of completed test order. | Febrile neutropenia due to multidrug-resistant bacteremia. Small bowel obstruction due to neoplastic mesenteric infiltration (confirmed on laparotomy). Ultimately discharged to hospice HD 36 with refractory leukemia and died. |
| 11 | 180:23 | No | 55 y, mechanical heart valve, subarachnoid hemorrhage | No | No | 21.3 | New diarrhea after tube feed initiation, laxatives. | Diarrhea improved. Slow recovery from subarachnoid hemorrhage. Discharged home 3 weeks later. |
| Initial negative test (n = 1) | ||||||||
| 12 | 156:05 | No | 76 y, colon cancer, diarrhea, and renal failure | Yes GI-GE (I, VIII) | Yes GI-GE (I), GI-GIT (III, VII, VIII) | 20.3 | Worsening diarrhea and new colitis compared with CT 7 d prior. | Renal failure improved and discharged following initial negative test. A positive test occurred 6 d later on subsequent admission with diarrhea. Improved after treatment. |
Abbreviations: CDI, C. difficile infection; CHF, congestive heart failure; CT, computed tomography; GI-GE, gastroenteritis; GI, gastrointestinal; GTI, gastrointestinal tract infection; HD, hospital day; NAAT, nucleic acid amplification test; UTI, urinary tract infection.
aBased on 2014 National Healthcare Safety Network surveillance clinical criteria for gastrointestinal system infections due to C. difficile, gastroenteritis, and/or gastrointestinal tract infection [28]: gastroenteritis: (I) acute-onset diarrhea (>12 hours) without a likely noninfectious cause; gastrointestinal tract infection: (II) histopathologic evidence of infection (ie, pseudomembranous colitis) OR pathologic findings on (III) imaging or (IV) endoscopy plus at least 2 of the following without a recognized cause other than C. difficile: (V) nausea, (VI) vomiting, (VII) abdominal pain or tenderness, (VIII) diarrhea, or (IX) fever (temperature ≥38°C, regardless of cause) [28].
bInpatient mortality.
cDischarged to hospice or death within 6 months of initial test attempt.