Improving Pediatric Clostridioides difficile Testing Practices: Implementation of a 2-Tier Diagnostic Pathway

Abstract

Introduction: Clostridioides difficile (C. difficile) is a significant concern for children, especially for those who are hospitalized or who have underlying medical conditions. Diagnosis of C. difficile infection (CDI) in these patients can be challenging due to asymptomatic colonization. Inappropriate testing and non-adherence to laboratory testing guidelines can result in increased false-positive rates precipitating unnecessary isolation precautions and antibiotic treatment for these patients.     Methods: This retrospective cohort study aimed to evaluate the effectiveness of a new diagnostic pathway for C. difficile testing that was implemented in two pediatric hospitals. The study design collected data for two years, one year before and one year after pathway implementation. The study highlighted the importance of appropriate testing and the need for interventions to improve testing practices in pediatric patients. A 2-tier testing algorithm was implemented, consisting of polymerase chain reaction (PCR) for the presence or absence of the toxin B gene and an enzyme immunoassay for toxin A/B production. The best practice advisory was used to determine when C. difficile testing should not be performed. The chi-square test and Fisher's Exact Test analyzed the data using SPSS version 29.   Results: The study found a significant association between the implementation of the C. difficile testing pathway and the test positivity rates for both inpatient and emergency department (ED) patients at both hospitals. Out of 159,434 Hospital A inpatients, 71 had positive C. difficile test results, and out of 11,109 Hospital B inpatients, nine had positive test results. Similarly, out of 121,951 Hospital A ED patients, eight had positive test results, and out of 67,999 Hospital B ED patients, 16 had positive test results. The study found a statistically significant association between the pre and post pathway implementation years for both hospitals (p<0.001 for Hospital B inpatient and ED, p=0.033 for Hospital A inpatient, and p=0.004 for Hospital A ED).   Conclusion: Adherence to laboratory testing guidelines, appropriate testing based on factors such as the patient's age, underlying health conditions, recent antibiotic use, and the presence of other infections or illnesses can reduce unnecessary testing and false-positive rates. False-positive results can occur in pediatric patients due to the high rate of asymptomatic colonization, making it essential to use a combination of clinical symptoms, history, and appropriate diagnostic testing to minimize the risk of misdiagnosis.