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Journal of Clinical Microbiology, November 2007, p. 3601-3605, Vol. 45, No. 11
0095-1137/07/$08.00+0     doi:10.1128/JCM.01305-07
Copyright © 2007, American Society for Microbiology. All Rights Reserved.

Yield of Stool Culture with Isolate Toxin Testing versus a Two-Step Algorithm Including Stool Toxin Testing for Detection of Toxigenic Clostridium difficile{triangledown}

Megan E. Reller,1* Clara A. Lema,1 Trish M. Perl,2 Mian Cai,1 Tracy L. Ross,1 Kathleen A. Speck,2 and Karen C. Carroll1

Division of Medical Microbiology, Department of Pathology,1 Department of Hospital Epidemiology and Infection Control, The Johns Hopkins Medical Institutions, Baltimore, Maryland2

Received 28 June 2007/ Returned for modification 10 August 2007/ Accepted 27 August 2007

We examined the incremental yield of stool culture (with toxin testing on isolates) versus our two-step algorithm for optimal detection of toxigenic Clostridium difficile. Per the two-step algorithm, stools were screened for C. difficile-associated glutamate dehydrogenase (GDH) antigen and, if positive, tested for toxin by a direct (stool) cell culture cytotoxicity neutralization assay (CCNA). In parallel, stools were cultured for C. difficile and tested for toxin by both indirect (isolate) CCNA and conventional PCR if the direct CCNA was negative. The "gold standard" for toxigenic C. difficile was detection of C. difficile by the GDH screen or by culture and toxin production by direct or indirect CCNA. We tested 439 specimens from 439 patients. GDH screening detected all culture-positive specimens. The sensitivity of the two-step algorithm was 77% (95% confidence interval [CI], 70 to 84%), and that of culture was 87% (95% CI, 80 to 92%). PCR results correlated completely with those of CCNA testing on isolates (29/29 positive and 32/32 negative, respectively). We conclude that GDH is an excellent screening test and that culture with isolate CCNA testing detects an additional 23% of toxigenic C. difficile missed by direct CCNA. Since culture is tedious and also detects nontoxigenic C. difficile, we conclude that culture is most useful (i) when the direct CCNA is negative but a high clinical suspicion of toxigenic C. difficile remains, (ii) in the evaluation of new diagnostic tests for toxigenic C. difficile (where the best reference standard is essential), and (iii) in epidemiologic studies (where the availability of an isolate allows for strain typing and antimicrobial susceptibility testing).

* Corresponding author. Mailing address: Division of Medical Microbiology, Department of Pathology, Johns Hopkins Medical Institutions, 600 N. Wolfe St., Baltimore, MD 21287. Phone: (410) 955-5077. Fax: (410) 614-8087. E-mail: mreller1{at}jhmi.edu

{triangledown} Published ahead of print on 5 September 2007.

Journal of Clinical Microbiology, November 2007, p. 3601-3605, Vol. 45, No. 11
0095-1137/07/$08.00+0     doi:10.1128/JCM.01305-07
Copyright © 2007, American Society for Microbiology. All Rights Reserved.



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