Ann Lab Med.  2016 Mar;36(2):131-137. 10.3343/alm.2016.36.2.131.

Evaluation of Xpert C. difficile, BD MAX Cdiff, IMDx C. difficile for Abbott m2000, and Illumigene C. difficile Assays for Direct Detection of Toxigenic Clostridium difficile in Stool Specimens

• Shin BM
• Yoo SM
• Shin WC

• KMID: 2373512
• DOI: http://doi.org/10.3343/alm.2016.36.2.131

Abstract

BACKGROUND
We evaluated the performance of four commercial nucleic acid amplification tests (NAATs: Xpert C. difficile, BD MAX Cdiff, IMDx C. difficile for Abbott m2000, and Illumigene C. difficile) for direct and rapid detection of Clostridium difficile toxin genes.
METHODS
We compared four NAATs on the same set of 339 stool specimens (303 prospective and 36 retrospective specimens) with toxigenic culture (TC).
RESULTS
Concordance rate among four NAATs was 90.3% (306/339). Based on TC results, the sensitivity and specificity were 90.0% and 92.9% for Xpert; 86.3% and 89.3% for Max; 84.3% and 94.4% for IMDx; and 82.4% and 93.7% for Illumigene, respectively. For 306 concordant cases, there were 11 TC-negative/NAATs co-positive cases and 6 TC-positive/NAATs co-negative cases. Among 33 discordant cases, 18 were only single positive in each NAAT (Xpert, 1; Max, 12; IMDx, 1; Illumigene, 4). Positivity rates of the four NAATs were associated with those of semi-quantitative cultures, which were maximized in grade 3 (>100 colony-forming unit [CFU]) compared with grade 1 (<10 CFU).
CONCLUSIONS
Commercial NAATs may be rapid and reliable methods for direct detection of tcdA and/or tcdB in stool specimens compared with TC. Some differences in the sensitivity of the NAATs may partly depend on the number of toxigenic C. difficile in stool specimens.

Keyword

Clostridium difficile; NAAT; Culture; Evaluation; Performance

MeSH Terms

Bacterial Proteins/genetics
Bacterial Toxins/genetics
Clostridium Infections/*diagnosis/microbiology
Clostridium difficile/*genetics/isolation & purification
DNA, Bacterial/*analysis/metabolism
Enterotoxins/genetics
Feces/*microbiology
Humans
*Multiplex Polymerase Chain Reaction
Reagent Kits, Diagnostic
Sensitivity and Specificity
Bacterial Proteins
Bacterial Toxins
DNA, Bacterial
Enterotoxins
Reagent Kits, Diagnostic

Reference

1. Shin BM, Kuak EY, Lee EJ, Songer JG. Algorithm combining toxin immunoassay and stool culture for diagnosis of Clostridium difficile infection. J Clin Microbiol. 2009; 47:2952–2956. PMID: 19625481.

2. Schmit ML, Gilligan PH. Clostridium difficile testing algorithms: what is practical and feasible? Anaerobe. 2009; 15:270–273. PMID: 19853666.

3. Chapin K. Discrepancies in testing recommendations for Clostridium difficile infection: updated review favors amplification test systems. Expert Rev Mol Diagn. 2012; 12:223–226. PMID: 22468811.

4. Le Guern R, Herwegh S, Courcol R, Wallet F. Molecular methods in the diagnosis of Clostridium difficile infections: an update. Expert Rev Mol Diagn. 2013; 13:681–692. PMID: 24063396.

5. Buchan BW, Mackey TL, Daly JA, Alger G, Denys GA, Peterson LR, et al. Multicenter clinical evaluation of the portrait toxigenic C. difficile assay for detection of toxigenic Clostridium difficile strains in clinical stool specimens. J Clin Microbiol. 2012; 50:3932–3936. PMID: 23015667.

6. Shin BM, Mun SJ, Yoo SJ, Kuak EY. Comparison of BD GeneOhm Cdiff and Seegene Seeplex ACE PCR assays using toxigenic Clostridium difficile culture for direct detection of tcdB from stool specimens. J Clin Microbiol. 2012; 50:3765–3767. PMID: 22952270.

7. Geric B, Rupnik M, Gerding DN, Grabnar M, Johnson S. Distribution of Clostridium difficile variant toxinotypes and strains with binary toxin genes among clinical isolates in an American hospital. J Med Microbiol. 2004; 53:887–894. PMID: 15314196.

8. Bauer MP, Notemans DW, van Benthem BH, Brazier JS, Wilcox MH, Rupnik M, et al. Clostridium difficile infection in Europe: a hospital based survey. Lancet. 2011; 377:63–73. PMID: 21084111.

9. Shin BM, Kuak EY, Yoo HM, Kim EC, Lee K, Kang JO, et al. Multicentre study of the prevalence of toxigenic Clostridium difficile in Korea; results of a retrospective study 2000-2005. J Med Microbiol. 2008; 57:697–701. PMID: 18480325.

10. Komatsu M, Kato H, Aihara M, Shimakawa K, Iwasaki M, Nagasaka Y, et al. High frequency of antibiotic-associated diarrhea due to toxin A-negative, toxin B-positive Clostridium difficile in a hospital in Japan and risk factors for infection. Eur J Clin Microbiol Infect Dis. 2003; 22:525–529. PMID: 12938013.

11. Kozak K, Elagin V, Norén T, Unemo M. Targeting the tcdA gene: is this appropriate for detection of A and/or B Clostridium difficile toxin-producing strains? J Clin Microbiol. 2011; 49:2383–2384. PMID: 21617002.

12. Miller BA, Chen LF, Sexton DJ, Anderson DJ. Comparison of the burdens of hospital-onset, healthcare facility-associated Clostridium difficile infection and of healthcare-associated infection due to methicillin-resistant Staphylococcus aureus in community hospitals. Infect Control Hosp Epidemiol. 2011; 32:387–390. PMID: 21460491.

13. Pancholi P, Kelly C, Raczkowski M, Balada-Llasat JM. Detection of toxigenic Clostridium difficile: comparison of the cell culture neutralization, Xpert C. difficile, Xpert C. difficile/Epi, and Illumigene C. difficile assays. J Clin Microbiol. 2012; 50:1331–1335. PMID: 22278839.

14. Stellrecht KA, Espino AA, Maceira VP, Nattanmai SM, Butt SA, Wroblewski D, et al. Premarket evaluations of the IMDx C. difficile for Abbott m2000 Assay and the BD Max Cdiff Assay. J Clin Microbiol. 2014; 52:1423–1428. PMID: 24554744.

15. Lemee L, Dhalluin A, Testelin S, Mattrat MA, Maillard K, Lemeland JF, et al. Multiplex PCR targeting tpi (triose phosphate isomerase), tcdA (Toxin A), and tcdB (ToxinB) genes for toxigenic culture of Clostridium difficile. J Clin Microbiol. 2004; 42:5710–5714. PMID: 15583303.

16. Planche TA, Aghaizu R, Holliman R, Riley P, Poloniecki J, Breathnach A, et al. Diagnosis of Clostridium difficile infection by toxin detection kits: a systemic review. Lancet Infect Dis. 2008; 8:777–784. PMID: 18977696.

17. Eastwood K, Else P, Charlett A, Wilcox M. Comparison of nine commercially available Clostridium difficile toxin detection assays, a real-time PCR assay for C. difficile tcdB, and a glutamate dehydrogenase detection assay to cytotoxin testing and cytotoxigenic culture methods. J Clin Microbiol. 2009; 47:3211–3217. PMID: 19710274.

18. Jensen MB, Olsen KE, Nielsen XC, Hoegh AM, Dessau RB, Atlung T, et al. Diagnosis of Clostridium difficile: real time PCR detection of toxin genes in faecal samples is more sensitive compared to toxigenic culture. Eur J Clin Microbiol Infect Dis. 2015; 34:727–736. PMID: 25421216.

19. Baker I, Leeming JP, Reynolds R, Ibrahim I, Darley E. Clinical relevance of a positive molecular test in the diagnosis of Clostridium difficile infection. J Hosp Infect. 2013; 84:311–315. PMID: 23831282.

20. Humphries RM, Uslan DZ, Rubin Z. Performances of Clostridium difficile toxin enzyme immunoassay and nucleic acid amplification tests stratified by patient diseases severity. J Clin Microbiol. 2013; 51:869–873. PMID: 23269736.

21. Gilbreath JJ, Verma P, Abbott AN, Butler-Wu SM. Comparison of the Verigene Clostridium difficile, Simplexa C. difficile Universal Direct, BD Max Cdiff, and Xpert C. difficile assays for the detection of toxigenic C. difficile. Diagn Microbiol Infect Dis. 2014; 80:13–18. PMID: 25027069.

22. Walkty A, Lagacé-Wiens PR, Manickam K, Adam H, Pieroni P, Hoban D, et al. Evaluation of an algorithmic approach in comparison with the Illumigene assay for laboratory diagnosis of Clostridium difficile infection. J Clin Microbiol. 2013; 51:1152–1157. PMID: 23363829.

23. Viala C, Le Monnier A, Maataoui N, Rousseau C, Collignon A, Poilane I. Comparison of commercial molecular assays for toxigenic Clostridium difficile detection in stools: BD GeneOhm Cdiff, Xpert C.diff and illumigene C. difficile. J Microbiol Methods. 2012; 90:83–85. PMID: 22565213.

24. Gyorke CE, Wang S, Leslie JL, Cohen SH, Solnick JV, Polage CR. Evaluation of Clostridium difficile fecal load and limit of detection during a prospective comparison of two molecular tests, the illumigene C. difficle and Xpert C. difficile/Epi tests. J Clin Microbiol. 2013; 51:278–280. PMID: 23052320.

25. Dalpke AH, Hofko M, Zorn M, Zimmermann S. Evaluation of the fully automated BD Max Cdiff and Xpert C. difficile assays for direct detection of Clostridium difficile in stool specimens. J Clin Microbiol. 2013; 51:1906–1908. PMID: 23515539.

26. Shin BM, Lee EJ. Comparison of ChromID agar and Clostridium difficile selective agar for effective isolation of C. difficile from stool specimens. Ann Lab Med. 2014; 34:15–19. PMID: 24422190.

27. Hink T, Burnham CA, Dubberke ER. A systemic evaluation of methods to optimize culture-based recovery of Clostridium difficile from stool specimens. Anaerobe. 2013; 19:39–43. PMID: 23247066.

28. Dionne LL, Raymond F, Corbeil J, Longtin J, Gervais P, Longtin Y. Correlation between Clostridium difficile bacterial load, commercial real-time PCR cycle thresholds, and results of diagnostic tests based on enzyme immunoassay and cell culture cytotoxicity assay. J Clin Microbiol. 2013; 51:3624–3630. PMID: 23966497.

29. Babady NE, Stiles J, Ruggiero P, Khosa P, Huang D, Shuptar S, et al. Evaluation of the Cepheid Xpert Clostridium difficile Epi assay for diagnosis of Clostridium difficile infection and typing of the NAP1 strain at a cancer hospital. J Clin Microbiol. 2010; 48:4519–4524. PMID: 20943860.

30. Tenover FC, Akerlund T, Gerding DN, Goering RV, Boström T, Jonsson AM, et al. Comparison of strain typing results for Clostridium difficile isolates from North America. J Clin Microbiol. 2011; 49:1831–1837. PMID: 21389155.