Diagnosis of Clostridium difficile infections: Comparative study of two immuno enzyme assays with confirmation by PCR and culture followed by PCR ribotyping

Authors: M. Krůtová;  J. Matějková;  M. Zajac;  P. Hubáček;  O. Nyč
Authors‘ workplace: Ústav lékařské mikrobiologie, Univerzita Karlova, 2. lékařská fakulta a Fakultní nemocnice v Motole
Published in: Epidemiol. Mikrobiol. Imunol. 63, 2014, č. 2, s. 99-102
Category: Review articles, original papers, case report

*Výsledky této práce byly částečně prezentovány na Kongresu klinické mikrobiologie a infekčního lékařství 2013 v Olomouci.


Study objective:
Comparison of two commercially avail­able tests for the detection of Clostridium difficile Glutamate Dehydrogenase (GDH) and toxins A and B for their sensitivity and specificity.

Material and methods:
Eighty-six stool samples from patients hospitalised in the Motol University Hospital were analysed. GDH and toxins A and B were assayed in parallel by two tests: C. difficile Quik Chek Complete® (Techlab, USA) and Liaison® C. difficile GDH and Toxins AαB (DiaSorin, USA). From the stool samples, nucleic acids were also isolated using the UltraClean® Fecal DNA kit (MoBio Laboratories, USA). The commercially available C. difficile Elite MGB® kit (Nanogen, Italy) was used for the polymerase chain reaction (PCR). Anaerobic culture on C. difficile selective medium (Oxoid) was performed for all positive samples at least in one test. Pure isolates were characterized by PCR ribotyping.

Thirty-six (42%) samples were GDH negative and toxin A/B negative by both tests. Twenty (23%) samples were GDH positive and toxin A/B positive by both tests. Nine (10%) samples were GDH positive and toxin negative by both tests, but were positive by PCR. Eleven (13%) samples that were GDH positive and toxin negative by both tests remained negative by PCR. Six (7%) samples only were GDH positive and toxin positive by the Liaison® test alone. Four (5%) samples were GDH-positive by theLiaison® test alone. Culture failure was observed in 11 (13%) samples, of which seven were positive by PCR. PCR was inhibited in five (6%) samples. The following toxigenic ribotypes: AI-3, 001, 002, 012,014, 017, 020, 049, 054, 078, 176, 203, and 413 and non-toxigenic ribotypes: AI-34, AI-61, 010, 485, 495, and 596 were identified.

The Liaison® test had seven percent higher sensitivity for the detection of toxins A/B. The two-step protocol of the tests is also cost-saving. The savings can be used e.g. for incorporating the PCR techniques into the diagnostic algorithm of the laboratory.

Clostridium difficile – ribotyping – glutamate dehydrogenase – toxins A/B – Quik Chek Complete – Liaison


1. Bauer MP, Notermans DW, van Benthem BH, Brazier JS et. al. ECDIS Study Group. Clostridium difficile infection in Europe: a hospital-based survey. Lancet, 2011; Jan 1, 377(9759):63–73.

2. He M, Miyajima F, Roberts P, Ellison L et al. Emergence and global spread of epidemic healthcare-associated Clostridium difficile. Nat Genet, 2013;45:109–113.

3. Nyč O, Pituch H, Matějková J, Obuch-Woszczatynski P, Kuijper EJ. Clostridium difficile PCR ribotype 176 in the Czech Republic and Poland. Lancet, 2011; Apr 23;377(9775):1407.

4. Rupnik M, Wilcox MH, Gerding DN. Clostridium difficile ­infection: new developments in epidemiology and pathogenesis. Nat Rev Microbiol, 2009;7:526–536.

5. Department of Health. Updated guidance on the diagnosis and reporting of Clostridium difficile, 6 March 2012. Dostupný na: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_132927 (last accessed 4 May 2012)

6. Belanger SD, Boissinot M, Clairoux N, Picard FJ, Bergeron MG. Rapid detection of Clostridium difficile in feces by real-time PCR. J Clin Microbiol, 2003;41:730–734.

7. Peterson LR, Manson RU, Paule SM, Hacek DM, Robicsek A, Thomson RB, Jr, Kaul KL. Detection of toxigenic Clostridium difficile in stool samples by real-time polymerase chain reaction for the diagnosis of C. difficile-associated diarrhea. Clin Infect Dis, 2007;45:1152–1160.

8. Barbut F, Braun M, Burghoffer B, Lalande V, Eckert C. Rapid detection of toxigenic strains of Clostridium difficile in diarrheal stools by real-time PCR. J Clin Microbiol, 2009;47:1276–1277.

9. Stamper PD, Babiker W, Alcabasa R, Aird D et. al. Evaluation of a new commercial TaqMan PCR assay for direct detection of the Clostridium difficile toxin B gene in clinical stool specimens. J Clin Microbiol, 2009;47:3846–3850.

10. Terhes G, Urban E, Soki J, Nacsa E, Nagy E. Comparison of a rapid molecular method, the BD GeneOhm Cdiff assay, to the most frequently used laboratory tests for detection of toxin-producing Clostridium difficile in diarrheal feces. J Clin Microbiol, 2009;47:3478–3481.

11. Goldenberg SD, Dieringer T, French GL. Detection of toxigenic Clostridium difficile in diarrheal stools by rapid real-time polymerase chain reaction. Diagn Microbiol Infect Dis, 2010;67:304–307.

12. de Jong E, de Jong AS, Bartels CJ, van der Rijt-van den Biggelaar C et. al. Clinical and laboratory evaluation of a real-time PCR for Clostridium difficile toxin A and B genes. Eur J Clin Microbiol Infect Dis, 2012;31:2219–2225.

13. Le Guern R, Herwegh S, Grandbastien B, Courcol R, Wallet F. Evaluation of a new molecular test, the BD Max Cdiff, for detection of toxigenic Clostridium difficile in fecal samples. J Clin Microbiol, 2012;50:3089–3090.

14. Quinn CD, Sefers SE, Babiker W, He Y et. al. C. Diff Quik Chek complete enzyme immunoassay provides a reliable first-line method for detection of Clostridium difficile in stool specimens. J Clin Microbiol, 2010;48(2):603–605.

15. Sharp SE, Ruden LO, Pohl JC, Hatcher PA et. al. Evaluation of the C.Diff Quik Chek Complete Assay, a new glutamate dehydrogenase and A/B toxin combination lateral flow assay for use in rapid, simple diagnosis of clostridium difficile disease. J Clin Microbiol, 2010;48(6):2082–20826.

16. Kawada M, Annaka M, Kato H, Shibasaki S et. al. Evaluation of a simultaneous detection kit for the glutamate dehydrogenase antigen and toxin A/B in feces for diagnosis of Clostridium difficile infection. J Infect Chemother, 2011;17(6):807–811.

17. Orellana-Miguel MA, Alcolea-Medina A, Barrado-Blanco L, Rodriguez-Otero J, Chaves-Sánchez F. Algorithm proposal based on the C. Diff Quik Chek Complete ICT device for detecting Clostridium difficile infection. Enferm Infecc Microbiol Clin, 2013;31(2):97-9.

18. Coltella L, Mancinelli L, Onori M, Lucignano B et. al. Advancement in the routine identification of anaerobic bacteria by MALDI-TOF mass spectrometry. Eur J Clin Microbiol Infect Dis, 2013;32(9):1183–1192.

19. Valiente E, Dawson LF, Cairns MD, Stabler RA, Wren BW. Emergence of new PCR ribotypes from the hypervirulent Clostridium difficile 027 lineage. Journal of Medical Microbiology, 2012;61:49–56.

20. Persson S, Torpdahl M, Olsen KEP. New multiplex PCR method for the detection of Clostridium difficile toxin A (tcdA) and toxin B (tcdB) and the binary toxin (cdtA/cdtB) genes applied to a Danish strain collection. Clinical Microbiology and Infection, 2008;14: 1057–1064.

Hygiene and epidemiology Medical virology Clinical microbiology

Article was published in

Epidemiology, Microbiology, Immunology

Issue 2

2014 Issue 2

Most read in this issue
Forgotten password

Don‘t have an account?  Create new account

Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.


Don‘t have an account?  Create new account