In the JournalsPerspective

Few ID physicians screen patients for asymptomatic C. difficile

Preeta K. Kutty, MD, MPH
Preeta K. Kutty

Infectious disease physicians in the United States do not commonly screen patients for asymptomatic carriage of Clostridioides difficile, according to results from a nationwide survey.

Researchers said it is critical to understand the role that asymptomatic carriers have in C. difficile transmission, “and of the measures available to reduce that risk.”

“Although much is known about the contribution of symptomatic patients to transmission of C. difficile in health care settings, asymptomatic C. difficile colonization has recently garnered attention as a potential reservoir for transmission,” Preeta K. Kutty, MD, MPH, a medical epidemiologist in the CDC’s Division of Healthcare Quality Promotion, and colleagues wrote. “Asymptomatic carriage is being increasingly recognized among hospitalized adults, which has resulted in anecdotal reports of identification and isolation of these patients despite a lack of recommendations on testing or management.”

Between Nov. 29 and Dec. 23, 2017, the Emerging Infections Network — a provider-based emerging infections sentinel network sponsored by the Infectious Diseases Society of America and funded by the CDC — surveyed 1,309 adult ID specialists, asking nine questions concerning the identification, isolation and management of asymptomatic carriers of C. difficile.

The response rate was 52%, with 679 physicians completing the survey. According to the study, Kutty and colleagues excluded the 15% of respondents who indicated they had not seen patients with symptomatic C. difficile infection, or CDI, in the past 6 months.

The analysis included responses from 574 physicians who said they had seen patients with symptomatic CDI within in the past 6 months, including 29% who worked in a hospital with more than 600 beds and 91% who indicated that nucleic acid amplification testing “was either conducted as a single step or in multistep algorithm laboratory testing for symptomatic C. difficile.”

The testing of patients for asymptomatic carriage of C. difficile was reported by only 4% of surveyed physicians, of which 36% said they practiced in a university-affiliated hospital and 32% said they practiced in a hospital with more than 600 beds, Kutty and colleagues reported.

Physicians reported numerous reasons for testing patients for asymptomatic carriage of C. difficile, including a history of being cared for on a select unit, such as an ICU or oncology/hematopoietic cell transplant units; a history of being in a long-term care facility before hospital admission; and patients being part of a hospitalwide, nonselective screening approach, according to the study.

Most respondents reported that contact precautions and enhanced environmental cleaning were implemented once asymptomatic carriage of C. difficile was detected. Antibiotic prophylaxis was ordered for 10 patients, and at a rate of 80%, oral vancomycin was the most commonly prescribed antibiotic for this purpose.

“Screening to detect asymptomatic carriers appears to be an uncommon practice among surveyed infectious disease physicians,” Kutty told Infectious Disease News. “Published literature has shown that treatment of carriers did not eradicate carriage or reduce rates of hospital-associated CDI, and research suggests that oral vancomycin could be disruptive to the gut microbiome. A healthy microbiome may offer protection against developing CDI, and taking oral vancomycin could inadvertently increase the risk for CDI.” – by Marley Ghizzone

Disclosures: Kutty reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Preeta K. Kutty, MD, MPH
Preeta K. Kutty

Infectious disease physicians in the United States do not commonly screen patients for asymptomatic carriage of Clostridioides difficile, according to results from a nationwide survey.

Researchers said it is critical to understand the role that asymptomatic carriers have in C. difficile transmission, “and of the measures available to reduce that risk.”

“Although much is known about the contribution of symptomatic patients to transmission of C. difficile in health care settings, asymptomatic C. difficile colonization has recently garnered attention as a potential reservoir for transmission,” Preeta K. Kutty, MD, MPH, a medical epidemiologist in the CDC’s Division of Healthcare Quality Promotion, and colleagues wrote. “Asymptomatic carriage is being increasingly recognized among hospitalized adults, which has resulted in anecdotal reports of identification and isolation of these patients despite a lack of recommendations on testing or management.”

Between Nov. 29 and Dec. 23, 2017, the Emerging Infections Network — a provider-based emerging infections sentinel network sponsored by the Infectious Diseases Society of America and funded by the CDC — surveyed 1,309 adult ID specialists, asking nine questions concerning the identification, isolation and management of asymptomatic carriers of C. difficile.

The response rate was 52%, with 679 physicians completing the survey. According to the study, Kutty and colleagues excluded the 15% of respondents who indicated they had not seen patients with symptomatic C. difficile infection, or CDI, in the past 6 months.

The analysis included responses from 574 physicians who said they had seen patients with symptomatic CDI within in the past 6 months, including 29% who worked in a hospital with more than 600 beds and 91% who indicated that nucleic acid amplification testing “was either conducted as a single step or in multistep algorithm laboratory testing for symptomatic C. difficile.”

The testing of patients for asymptomatic carriage of C. difficile was reported by only 4% of surveyed physicians, of which 36% said they practiced in a university-affiliated hospital and 32% said they practiced in a hospital with more than 600 beds, Kutty and colleagues reported.

Physicians reported numerous reasons for testing patients for asymptomatic carriage of C. difficile, including a history of being cared for on a select unit, such as an ICU or oncology/hematopoietic cell transplant units; a history of being in a long-term care facility before hospital admission; and patients being part of a hospitalwide, nonselective screening approach, according to the study.

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Most respondents reported that contact precautions and enhanced environmental cleaning were implemented once asymptomatic carriage of C. difficile was detected. Antibiotic prophylaxis was ordered for 10 patients, and at a rate of 80%, oral vancomycin was the most commonly prescribed antibiotic for this purpose.

“Screening to detect asymptomatic carriers appears to be an uncommon practice among surveyed infectious disease physicians,” Kutty told Infectious Disease News. “Published literature has shown that treatment of carriers did not eradicate carriage or reduce rates of hospital-associated CDI, and research suggests that oral vancomycin could be disruptive to the gut microbiome. A healthy microbiome may offer protection against developing CDI, and taking oral vancomycin could inadvertently increase the risk for CDI.” – by Marley Ghizzone

Disclosures: Kutty reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

    Perspective
    Gregory Madden

    Gregory Madden

    The issue of C. difficile colonization is central to the diagnostic dilemma of CDI. Screening patients for C. difficile before infection may suggest whether infections are endogenous or acquired from spores in the environment, thus allowing hospital epidemiologists to target resources toward antimicrobial stewardship or infection control. However, more work needs to be done examining the appropriate detection, clinical/epidemiologic implications and management (if any) of C. difficile colonization. This study reflects general adherence to current consensus guidelines that recommend against routine C. difficile screening.

    • Gregory Madden, MD
    • PGY-5 fellow
      Division of infectious diseases and international health
      University of Virginia Medical Center

    Disclosures: Madden reports no relevant financial disclosures.