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Laxative Use in the Setting of Positive Testing for Clostridium difficile Infection

Published online by Cambridge University Press:  06 December 2017

Syed M. Ahmad
Affiliation:
Division of Infectious Diseases, Department of Internal Medicine, St. Joseph Mercy Health System, Ann Arbor, Michigan
Natalia Blanco
Affiliation:
Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
Courtney M. Dewart
Affiliation:
Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio.
Anna Dobosz
Affiliation:
Division of Infectious Diseases, Department of Internal Medicine, St. Joseph Mercy Health System, Ann Arbor, Michigan
Anurag N. Malani*
Affiliation:
Division of Infectious Diseases, Department of Internal Medicine, St. Joseph Mercy Health System, Ann Arbor, Michigan Department of Infection Prevention and Control, St. Joseph Mercy Health System, Ann Arbor, Michigan
*
Address correspondence to Anurag N. Malani, MD, 5333 McAuley Drive, Suite 6007, Ypsilanti, MI 48197 (Anurag.Malani@stjoeshealth.org).
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Abstract

Type
Letters to the Editor
Copyright
© 2017 by The Society for Healthcare Epidemiology of America. All rights reserved 

To the EditorClostridium difficile infection (CDI) is the most common healthcare-associated infection in the United States.Reference Magill, Edwards and Bamberg 1 In 2011, almost half a million infections and ~29,000 deaths were estimated to be associated with C. difficile.Reference Lessa, Mu and Bamberg 2 Timely testing and treatment is critical for improving outcomes and reducing transmission.Reference Buckel, Avdic, Carroll, Gunaseelan, Hadhazy and Cosgrove 3 Given the high rate of asymptomatic C. difficile carriage, appropriate testing is also essential.Reference Alasmari, Seiler, Hink, Burnham and Dubberke 4 In healthcare settings, C. difficile colonization is reportedly 5 to 10 times more common than CDI and other noninfectious causes of diarrhea.Reference Polage, Gyorke and Kennedy 5 , Reference Polage, Chin, Leslie, Tang, Cohen and Solnick 6

Unformed stools due to laxative use are often submitted for CDI testing, although these specimens are not appropriate for CDI diagnosis. Recent laxative use has been reported in up to 44% of CDI tested specimens.Reference Buckel, Avdic, Carroll, Gunaseelan, Hadhazy and Cosgrove 3 , Reference Tehrani and Seville 7 , Reference Rineer, Dizon, Logan and Hsu 8 Interventions to reduce the testing of inappropriate specimens, including those due to laxative use, have led to a reduction of CDI rates and treatment.Reference Truong, Gombar and Wilson 9 We further examined the relationship between laxative use and patients who tested positive for CDI.

A retrospective study was conducted at a 537-bed teaching community hospital and included hospitalized patients who tested positive for CDI in 2014 and 2015. Testing for CDI comprised an enzyme immunoassay (EIA) for glutamate dehydrogenase (GDH) and an EIA for detection of toxin A/B (C. diff Quik Check Complete, Alere, Waltham, MA). If the GDH test was positive and the EIA for the toxin A/B was negative, a confirmatory polymerase chain reaction (PCR) assay (Xpert C. difficile, Cepheid, Sunnyvale, CA) was performed. Clostridium difficile infection was diagnosed using either GDH-positive and toxin-positive or PCR-positive laboratory results.

Patients who received laxatives up to 24 hours prior to positive CDI testing were identified. Laxatives included docusate sodium, senna, polyethylene glycol, bisacodyl, milk of magnesia, sodium polystyrene sulfonate, and lactulose. Sodium polystyrene and lactulose were considered laxatives if the indications for use were neither hyperkalemia nor hepatic encephalopathy, respectively. Physician and nursing notes were reviewed to determine whether diarrhea (≥3 unformed stools over 24 hours) resolved within 24 hours of positive CDI testing. The medication administration record was reviewed to determine whether laxatives were administered for greater than 24 hours after positive testing. Validation procedures were conducted for >10% of the study population to ensure reviewer consistency.

A total of 211 patients with CDI were included in the study. Overall, 82 patients (39%) had received laxatives within 7 days prior to positive CDI testing. Of these, 29 (14%) had received laxatives in the 24 hours prior to positive testing (Table 1). In the 24 hours prior to positive testing, 11 patients (38%) received 1 laxative; 12 patients (41%) received 2 laxatives; 4 patients (14%) received 3 laxatives; and 2 patients (7%) received 4 laxatives. The most commonly administered laxatives were docusate sodium (72%), polyethylene glycol (41%), senna (38%), and bisacodyl (17%). Furthermore, 15 patients (52%) continued to receive laxatives for >24 hours after positive CDI testing.

TABLE 1 Demographic and Clinical Characteristics of Hospitalized Patients with Laxative Use Within 24 Hours of Positive Testing for Clostridium difficile

NOTE. EIA, enzyme immunoassay; PCR, polymerase chain reaction.

a Unless units are otherwise specified.

Of the 29 patients, 12 (41%) had resolution of diarrhea within 48 hours of positive CDI testing, including 9 (31%) who had resolution within 24 hours. Of the 9 patients who had resolution of diarrhea within 24 hours, 2 patients (22%; both toxin EIA−/PCR+) did not receive CDI treatment, and 7 patients (78%; 3 toxin EIA+, 4 toxin EIA−/PCR+) received CDI treatment.

Other studies have reported the association of laxative administration with testing for CDI.Reference Buckel, Avdic, Carroll, Gunaseelan, Hadhazy and Cosgrove 3 , Reference Tehrani and Seville 7 , Reference Rineer, Dizon, Logan and Hsu 8 , Reference Truong, Gombar and Wilson 9 We reviewed this association for those patients who tested positive for CDI. Surprisingly, 82 patients (39%) received laxatives within 1 week of CDI diagnosis; 29 (14%) received laxatives (usually ≥2) within 24 hours of positive testing. Despite positive results for CDI, 15 patients (52%) continued to receive laxatives for >24 hours after diagnosis.

FIGURE 1 Laxative Use Among 211 Hospitalized Patients with Positive Testing for Clostridium difficile.

It is critical for clinicians to distinguish patients with clinically significant diarrhea from those with diarrhea due to laxatives. Of the 29 patients who received laxatives 24 hours prior to CDI diagnosis, 12 patients (41%) had resolution of diarrhea within 48 hours including 9 (31%) with resolution in 24 hours. These findings illustrate that diarrhea in the setting of laxative use and positive CDI testing may be of noninfectious etiology.Reference Polage, Solnick and Cohen 10 As further supporting evidence, 2 patients (7%) had resolution of diarrhea without any CDI treatment.

Asymptomatic colonization among hospitalized patients with C. difficile may be as high as 21%.Reference Alasmari, Seiler, Hink, Burnham and Dubberke 4 Appropriate testing for CDI is critical given the inability of current testing to distinguish between asymptomatic carrier and disease state. Truong et alReference Truong, Gombar and Wilson 9 recently reported a significant decrease in C. difficile test utilization from 208.8 to 143 tests per 10,000 patient days and a decrease in healthcare facility-onset CDI of >25% (ie, from 13.0 to 9.7 cases per 10,000 patient days) using real-time electronic data to enforce laboratory testing criteria, which they defined as the presence of diarrhea and absence of laxative use in the prior 48 hours.Reference Truong, Gombar and Wilson 9

In addition to improving testing cascades for CDI by limiting specimens from patients receiving laxatives, education must also engage the nursing staff. Nurses are integral in the stewardship of specimen collection for CDI because they are likely more aware of when laxatives are administered, especially since laxatives are often ordered as needed and through order sets.

Further interventions are urgently needed to improve testing stewardship for CDI, as restricting collection to patients not on laxatives represent potential opportunities for significant impact. Furthermore, providers must also consider receipt of other agents (eg, tube feeds, oral contrast) that may cause noninfectious diarrhea when considering testing for CDI.

ACKNOWLEDGMENTS

Financial support: No financial support was provided relevant to this article.

Potential conflicts of interest: Anurag N. Malani, MD, serves as a consultant to Vizient.

All other authors report no conflicts of interest relevant to this article.

Footnotes

PREVIOUS PRESENTATION. Select data and findings were accepted as a poster (abstract no. 352) at the Society for Healthcare Epidemiology of America Spring 2017 Conference in St. Louis, Missouri on March 30, 2017.

References

REFERENCES

1. Magill, SS, Edwards, JR, Bamberg, W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med 2014;370:11981208.Google Scholar
2. Lessa, FC, Mu, Y, Bamberg, WM, et al. Burden of Clostridium difficile infection in the United States. N Engl J Med 2015;372:825834.CrossRefGoogle ScholarPubMed
3. Buckel, WR, Avdic, E, Carroll, KC, Gunaseelan, V, Hadhazy, E, Cosgrove, SE. Gut check: Clostridium difficile testing and treatment in the molecular testing era. Infect Control Hosp Epidemiol 2015;36:217221.Google Scholar
4. Alasmari, F, Seiler, SM, Hink, T, Burnham, CA, Dubberke, ER. Prevalence and risk factors for asymptomatic Clostridium difficile carriage. Clin Infect Dis 2014;59:216222.Google Scholar
5. Polage, CR, Gyorke, CE, Kennedy, MA, et al. Overdiagnosis of Clostridium difficile infection in the molecular test era. JAMA Intern Med 2015;175:17921801.Google Scholar
6. Polage, CR, Chin, DL, Leslie, JL, Tang, J, Cohen, SH, Solnick, JV. Outcomes in patients tested for Clostridium difficile toxins. Diagn Microbiol Infect Dis 2012;74:369373.Google Scholar
7. Tehrani, L, Seville, MT. Laxative use and Clostridium difficile testing and treatment. In: Program and abstracts of the Annual Scientific Meeting of the Infectious Diseases Society of America (IDWeek); October 7–11, 2015; San Diego, CA. Abstract no. 956.Google Scholar
8. Rineer, S, Dizon, J, Logan, J, Hsu, V. Laxative use and testing delays may overestimate the true burden of Clostridium difficile. In: Program and abstracts of the Annual Scientific Meeting of the Infectious Diseases Society of America (IDWeek); October 7–11, 2015; San Diego, CA. Abstract no. 955.Google Scholar
9. Truong, CY, Gombar, S, Wilson, R, et al. Real-time electronic tracking of diarrheal episodes and laxatives therapy enables verification of Clostridium difficile clinical testing criteria and reduction of Clostridium difficile infection rates. J Clin Microbiol 2017;55:12761284.Google Scholar
10. Polage, CR, Solnick, JV, Cohen, SH. Nosocomial diarrhea: evaluation and treatment of causes other than Clostridium difficile . Clin Infect Dis 2012;55:982989.Google Scholar
Figure 0

TABLE 1 Demographic and Clinical Characteristics of Hospitalized Patients with Laxative Use Within 24 Hours of Positive Testing for Clostridium difficile

Figure 1

FIGURE 1 Laxative Use Among 211 Hospitalized Patients with Positive Testing for Clostridium difficile.