C-DIFF and UA with Reflex – New Processes

By Pradeep K. Bhagat, MD, System Chairman, Department of Pathology

New process regarding Clostridium difficile (C. diff) on inpatients at MLHS (this does not pertain to outpatients or emergency room patients)

Effective November 13th, 2018, the following process will be in place for MLHS inpatients:

  • At present, C. diff testing is performed by QuikChek.  That request is a two-step process, testing for Glutamate Dehydrogenase (GDH) antigen testing and toxin testing for C. diff toxin A and B.
  • If both antigen testing and toxin testing are positive, the report in Epic indicates a positive C. diff test. No further testing is required. This confirms the diagnosis of C. diff requiring treatment and special contact isolation.
  • If both tests are negative, C. diff is reported as negative. No further testing is completed and isolation can be terminated.
  • If testing indicates a positive GDH antigen and a negative toxin testing, this indicates a potential carrier or an indeterminate final test. This occurs in approximately 10% of C. diff testing.
  • With an indeterminate test result, in order to proceed to PCR testing by Cepheid, an infectious diseases consultation will be required. The reason behind the infectious diseases mandatory consultation is to eliminate unnecessary testing of C. diff by PCR which has become very common.
  • If a healthcare provider receives an indeterminate C. diff test indicating a potential carrier, the provider should make a determination regarding treatment for C. diff and continue special contact isolation until an infectious diseases consultation has been completed.
  • This only applies to hospitalized inpatients. This does not apply to outpatients and patients seen in our MLHS emergency rooms.

New process for urinalysis with reflex culture

  • A urinalysis with reflex culture uses a macroscopic criteria such as a positive nitrate test to automatically reflex to a urine culture.
  • Effective Nov 13th, 2018, a healthcare provider will not be given the option to order a urinalysis with reflex for MLHS inpatients.
  • The ordering healthcare providers should order a urinalysis with hold. The ordering physician must interpret the urinalysis and, if there is a high suspicion for a urinary tract infection, a urine culture can be ordered as add on order on existing specimen in Epic to avoid a separate specimen being sent.  The culture must be ordered within 24 hours of the initial sample being sent to the lab.
  • If a high suspicion of a urinary tract infection exists in a specific patient, a urinalysis and then a urine culture can be ordered.  Urine reflex testing will not be available to providers to order on inpatients.
  • A urinalysis with reflex will still be available to order by healthcare providers on outpatients and emergency room patients.

If you have any questions, please call Dr. Bhagat at 484-476-3521 or Dr. Ingerman at 484-476-2574.

Reference: ESCMID (2016), Update of the Diagnostic Guidance Document for C. diff Infection


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