Use of culture- and ELISA-based toxin assay for detecting Clostridium difficile, a neglected pathogen: A single-center study from a tertiary care setting

Abstract

INTRODUCTION: Clostridium difficile is a Gram-positive spore-bearing anaerobic bacillus increasingly associated with both community- and hospital-acquired colitis and diarrhea. It is the most common identifiable bacterial cause of healthcare-associated diarrhea associated with antibiotic use and one of the most common anaerobic infections. The diagnosis of C. difficile infection includes detection of toxin A/B in stool specimens by direct enzyme immunoassay, culture of pathogen from the stool specimens using a selective agar Cycloserine-Cefoxitin fructose agar (CCFA), tissue culture assay, and detection of glutamate dehydrogenase an enzyme produced by C. difficile. With few reports from India on this disease, the present study was planned to throw more light on the prevalence and utility of laboratory diagnostic methods for C. difficile-associated diarrhea (CDAD).

MATERIAL AND METHODS: After taking approval from the Ethics Committee, 150 patients with antibiotic-associated diarrhea were taken as a study group and fifty patients with exposure to antibiotics but who did not develop diarrhea were taken as controls. Stool specimen was processed for both culture on CCFA and toxin detection by IVD Tox A + B ELISA.

RESULTS: Only four specimens were culture positive, whereas 13 were ELISA positive. All culturepositive isolates were toxigenic. C. difficile was neither isolated nor its toxin detected in the control group. Culture- and toxin-based assays may not detect all cases of CDAD.

CONCLUSION: Based on the results of the present study, culture does not provide any additional yield over toxin assay. Better diagnostic modalities would be required to prove CDAD.

Key words

Clostridium difficile - culture - ELISA

Publication History

Received: 27 November 2016

Accepted: 27 April 2017

Article published online:
19 February 2020

• References

• 1 Vaishnavi C. Established and potential risk factors for Clostridium difficile infection. Indian J Med Microbiol 2009;27:289-300.
• 2 Vaishnavi C. Clostridium difficile infection: Clinical spectrum and approach to management. Indian J Gastroenterol 2011;30:245-54.
• 3 Lyerly DM, Krivan HC, Wilkins TD. Clostridium difficile: Its disease and toxins. Clin Microbiol Rev 1988;1:1-18.
• 4 Vaishnavi C. Clinical spectrum and pathogenesis of Clostridium difficile associated diseases. Indian J Med Res 2010;131:487-99.
• 5 Goorhuis A, Van der Kooi T, Vaessen N, Dekker FW, Van den Berg R, Harmanus C, et al. Spread and epidemiology of Clostridium difficile polymerase chain reaction ribotype 027/toxinotype III in the Netherlands. Clin Infect Dis 2007;45:695-703.
• 6 Jobe BA, Grasley A, Deveney KE, Deveney CW, Sheppard BC. Clostridium difficile colitis: An increasing hospital-acquired illness. Am J Surg 1995;169:480-3.
• 7 Delmée M, Van Broeck J, Simon A, Janssens M, Avesani V. Laboratory diagnosis of Clostridium difficile-associated diarrhoea: A plea for culture. J Med Microbiol 2005;54(Pt 2):187-91.
• 8 Vaishnavi C. Diagnostic approach to Clostridium difficile infection. Indian J Gastroenterol 2010;29:137-9.
• 9 Ayyagari A, Sharma P, Venkateswarlu, Mehta S, Agarwal KC. Prevalence of Clostridium difficile in pseudomembranous and antibiotic-associated colitis in North India. J Diarrhoeal Dis Res 1986;4:157-60.
• 10 Niyogi SK, Bhattacharya SK, Dutta P, Naik TN, De SP, Sen D, et al. Prevalence of Clostridium difficile in hospitalised patients with acute diarrhoea in Calcutta. J Diarrhoeal Dis Res 1991;9:16-9.
• 11 Dhawan B, Chaudhry R, Sharma N. Incidence of Clostridium difficile infection: A prospective study in an Indian hospital. J Hosp Infect 1999;43:275-80.
• 12 Chaudhry R, Joshy L, Kumar L, Dhawan B. Changing pattern of Clostridium difficile associated diarrhoea in a tertiary care hospital: A 5 year retrospective study. Indian J Med Res 2008;127:377-82.
• 13 Ingle M, Deshmukh A, Desai D, Abraham P, Joshi A, Rodrigues C, et al. Prevalence and clinical course of Clostridium difficile infection in a tertiary-care hospital: A retrospective analysis. Indian J Gastroenterol 2011;30:89-93.
• 14 Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol 2010;31:431-55.
• 15 Gerding DN, Johnson S, Peterson LR, Mulligan ME, Silva J Jr. Clostridium difficile-associated diarrhea and colitis. Infect Control Hosp Epidemiol 1995;16:459-77.
• 16 Nayak C, Singh V, Singh K, Singh H, Sharma A, Oberai P, et al. A prospective multicentric observational study to evolve the usefulness of the predefined homoeopathic medicines in the management of acute diarrheal disease in children. Indian J Res Homoeopathy 2009;3:21-8.
• 17 Dutta P, Niyogi SK, Mitra U, Rasaidy R, Bhattacharya MK, Chakraborty S, et al. Clostridium difficile in antibiotic associated paediatric diarrhea. Indian Pediatr 1994;31:121-6.
• 18 Gogate A, De A, Nanivadekar R, Mathur M, Saraswathi K, Jog A, et al. Diagnostic role of stool culture and toxin detection in antibiotic associated diarrhoea due to Clostridium difficile in children. Indian J Med Res 2005;122:518-24.
• 19 Gravel D, Miller M, Simor A, Taylor G, Gardam M, McGeer A, et al. Health care-associated Clostridium difficile infection in adults admitted to acute care hospitals in Canada: A Canadian Nosocomial Infection Surveillance Program Study. Clin Infect Dis 2009;48:568-76.
• 20 Kaneria MV, Paul S. Incidence of Clostridium difficile associated diarrhoea in a tertiary care hospital. J Assoc Physicians India 2012;60:26-8.
• 21 Vishwanath S, Singhal A, D'Souza A, Mukhopadhyay C, Varma M, Bairy I. Clostridium difficile infection at a tertiary care hospital in South India. J Assoc Physicians India 2013;61:804-6.
• 22 Heimesaat MM, Granzow K, Leidinger H, Liesenfeld O. Prevalence of Clostridium difficile toxins A and B and Clostridium perfringens enterotoxin A in stool samples of patients with antibiotic-associated diarrhea. Infection 2005;33:340-4.
• 23 Jamal W, Rotimi VO, Brazier J, Duerden BI. Analysis of prevalence, risk factors and molecular epidemiology of Clostridium difficile infection in Kuwait over a 3-year period. Anaerobe 2010;16:560-5.
• 24 George WL, Sutter VL, Citron D, Finegold SM. Selective and differential medium for isolation of Clostridium difficile. J Clin Microbiol 1979;9:214-9.
• 25 Pawar D, Bhandari P, Allenby K. Clostridium difficile-associated diarrhea: A review. Indian Med Gaz 2011;145:481-94.
• 26 Perry JD, Asir K, Halimi D, Orenga S, Dale J, Payne M, et al. Evaluation of a chromogenic culture medium for isolation of Clostridium difficile within 24 hours. J Clin Microbiol 2010;48:3852-8.
• 27 Bhattacharya MK, Niyogi SK, Rasaily R, Bhattacharya SK, Dutta P, Nag A, et al. Clinical manifestation of Clostridium difficile enteritis in Calcutta. J Assoc Physicians India 1991;39:683-4.
• 28 Vaishnavi C, Kochhar R, Bhasin DK, Thapa BR, Singh K. Detection of Clostridium difficile toxin by an indigenously developed latex agglutination assay. Trop Gastroenterol 1999;20:33-5.
• 29 Thompson CM Jr., Gilligan PH, Fisher MC, Long SS. Clostridium difficile cytotoxin in a pediatric population. Am J Dis Child 1983;137:271-4.
• 30 Gupta U, Yadav RN. Clostridium difficile in hospital patients. Indian J Med Res 1985;82:398-401.
• 31 Bartlett JG. Clinical practice. Antibiotic-associated diarrhea. N Engl J Med 2002;346:334-9.