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LETTER
Diagnosis of Clostridium difficile Colitis
David A. Nardone, MD
15 September 1996 | Volume 125 Issue 6 | Page 515
TO THE EDITOR:
In the article by Manabe and colleagues [1] on Clostridium difficile colitis, only a length of stay of 5 days or longer seems to be of value in managing patients (Table 1). The "ideal" high true-positive rate and low negative likelihood ratio make this an excellent screening test for ruling out C. difficile colitis. I disagree that previous use of cephalosporin is an important predictor, because the positive likelihood ratio is too low and the negative likelihood ratio is too high. I recommend that the authors evaluate combinations of historical findings to define a positive index test result [2, 3].
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Table 1. Usefulness of Individual Historical Tests in Predicting the Presence or Absence of Clostridium difficile Colitis*
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Rarely does a provider rely on one clinical finding to rule in or rule out a diagnosis. A positive index test result could be defined as a combination of use of antibiotics, antibiotic use for at least 5 days, and semiformed or watery stool. If all three findings were positive, the false-positive rate would be very low and the positive likelihood ratio would be very high. No confirmatory laboratory test, including a C. difficile assay, would be necessary to make a definitive diagnosis. Similarly, the authors could define a positive index test result as a combination of fecal leukocytes, lactoferrin, and positive Gram stain. The use of combinations of clinical characteristics rather than individual tests is valuable in deciding whether to use expensive laboratory tests and is more characteristic of the problem-solving behavior of clinicians.
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Author and Article Information
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Veterans Health Administration, Portland, OR 97207
1. Manabe YC, Vinetz JM, Moore RD, Merz C, Charache P, Bartlett JG.Clostridium difficile colitis: an efficient clinical approach to diagnosis. Ann Intern Med. 1995; 123:835-40.
2. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992; 268:760-5.
3. Nardone DA, Roth KM, Mazur DJ, McAfee JH. Usefulness of physical examination in detecting the presence or absence of anemia. Arch Intern Med. 1990; 150:201-4.
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S. Dial, J.A. C. Delaney, V. Schneider, and S. Suissa
Proton pump inhibitor use and risk of community-acquired Clostridium difficile-associated disease defined by prescription for oral vancomycin therapy.
Can. Med. Assoc. J.,
September 26, 2006;
175(7):
745 - 748.
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