Overdiagnosis of Clostridium difficile Infection in the Molecular Test Era.

IMPORTANCE: Clostridium difficile is a major cause of health care-associated infection, but disagreement between diagnostic tests is an ongoing barrier to clinical decision making and public health reporting. Molecular tests are increasingly used to diagnose C difficile infection (CDI), but many molecular test-positive patients lack toxins that historically defined disease, making it unclear if they need treatment. OBJECTIVE: To determine the natural history and need for treatment of patients who are toxin immunoassay negative and polymerase chain reaction (PCR) positive (Tox-/PCR+) for CDI. DESIGN, SETTING, AND PARTICIPANTS: Prospective observational cohort study at a single academic medical center among 1416 hospitalized adults tested for C difficile toxins 72 hours or longer after admission between December 1, 2010, and October 20, 2012. The analysis was conducted in stages with revisions from April 27, 2013, to January 13, 2015. MAIN OUTCOMES AND MEASURES: Patients undergoing C difficile testing were grouped by US Food and Drug Administration-approved toxin and PCR tests as Tox+/PCR+, Tox-/PCR+, or Tox-/PCR-. Toxin results were reported clinically. Polymerase chain reaction results were not reported. The main study outcomes were duration of diarrhea during up to 14 days of treatment, rate of CDI-related complications (ie, colectomy, megacolon, or intensive care unit care) and CDI-related death within 30 days. RESULTS: Twenty-one percent (293 of 1416) of hospitalized adults tested for C difficile were positive by PCR, but 44.7% (131 of 293) had toxins detected by the clinical toxin test. At baseline, Tox-/PCR+ patients had lower C difficile bacterial load and less antibiotic exposure, fecal inflammation, and diarrhea than Tox+/PCR+ patients (P < .001 for all). The median duration of diarrhea was shorter in Tox-/PCR+ patients (2 days; interquartile range, 1-4 days) than in Tox+/PCR+ patients (3 days; interquartile range, 1-6 days) (P = .003) and was similar to that in Tox-/PCR- patients (2 days; interquartile range, 1-3 days), despite minimal empirical treatment of Tox-/PCR+ patients. No CDI-related complications occurred in Tox-/PCR+ patients vs 10 complications in Tox+/PCR+ patients (0% vs 7.6%, P < .001). One Tox-/PCR+ patient had recurrent CDI as a contributing factor to death within 30 days vs 11 CDI-related deaths in Tox+/PCR+ patients (0.6% vs 8.4%, P = .001). CONCLUSIONS AND RELEVANCE: Among hospitalized adults with suspected CDI, virtually all CDI-related complications and deaths occurred in patients with positive toxin immunoassay test results. Patients with a positive molecular test result and a negative toxin immunoassay test result had outcomes that were comparable to patients without C difficile by either method. Exclusive reliance on molecular tests for CDI diagnosis without tests for toxins or host response is likely to result in overdiagnosis, overtreatment, and increased health care costs.

The mechanism of action of the antidiuretic peptide Tenmo ADFa in Malpighian tubules of Aedes aegypti.

The mechanism of action of Tenebrio molitor antidiuretic factor 'a' (Tenmo ADFa) was explored in isolated Malpighian tubules of Aedes aegypti. In the Ramsay assay of fluid secretion, Tenmo ADFa (10(-9) mol l(-1)) significantly inhibited the rate of fluid secretion from 0.94 nl min(-1) to 0.44 nl min(-1) without significant effects on the concentrations of Na+, K+ and Cl- in secreted fluid. In isolated perfused tubules, Tenmo ADFa had no effect on the transepithelial voltage (Vt) and resistance (Rt). In principal cells of the tubule, Tenmo ADFa had no effect on the basolateral membrane voltage (Vbl) and the input resistance of principal cells (Rpc). Tenmo ADFa significantly increased the intracellular concentration of cyclic guanosine monophosphate (cGMP) from 2.9 micromol l(-1) (control) to 7.4 micromol l(-1). A peritubular [cGMP] of 20 micromol l(-1) duplicated the antidiuretic effects of Tenmo ADFa without inducing electrophysiological effects. In contrast, 500 micromol l(-1) cGMP significantly depolarized V(bl), hyperpolarized Vt, and reduced Rt and Rpc, without increasing antidiuretic potency beyond that of 20 micromol l(-1) cGMP. A plot of peritubular cGMP concentration vs Vbl revealed a steep dose-response between 300 micromol l(-1) and 700 micromol l(-1) with an EC50 of 468 micromol l(-1). These observations suggest a receptor- and cGMP-mediated mechanism of action of Tenmo ADFa. Tenmo ADFa and physiological concentrations of cGMP (< 20 micromol l(-1)) reduce the rate of isosmotic fluid secretion by quenching electroneutral transport systems. The inhibition reveals that as much as 50% of the normal secretory solute and water flux can stem from electrically silent mechanisms in this highly electrogenic epithelium.

Mechanisms of K+ transport across basolateral membranes of principal cells in Malpighian tubules of the yellow fever mosquito, Aedes aegypti.

The mechanisms of K(+) entry from the hemolymph into principal cells of Malpighian tubules were investigated in the yellow fever mosquito, Aedes aegypti. The K(+) channel blocker Ba(2+) (5 mmol l(-1)) significantly decreased transepithelial (TEP) fluid secretion (V(s)) from 0.84 nl min(-1) to 0.37 nl min(-1) and decreased the K(+) concentration in secreted fluid from 119.0 mmol l(-1) to 54.3 mmol l(-1) with no change in the Cl(-) concentration. Even though the Na(+) concentration increased significantly from 116.8 mmol l(-1) to 144.6 mmol l(-1), rates of TEP ion secretion significantly decreased for all three ions. In addition, Ba(2+) had the following significant electrophysiological effects: it depolarized the TEP voltage (V(t)) from 19.4 mV to 17.2 mV, increased the TEP resistance (R(t)) from 6.4 kOhmscm to 6.9 kOhmscm, hyperpolarized the basolateral membrane voltage of principal cells (V(bl)) from -75.2 mV to -88.2 mV and increased the cell input resistance from 363.7 kOhms to 516.3 kOhms. These effects of Ba(2+) reflect the block of K(+) channels that, apparently, are also permeable to Na(+). Bumetanide (100 micro mol l(-1)) had no effect on TEP fluid secretion and electrical resistance but significantly decreased TEP K(+) secretion, consistent with the inhibition of electroneutral Na(+)/K(+)/2Cl(-) cotransport. TEP Na(+) secretion significantly increased because other Na(+) entry pathways remained active. Bumetanide plus Ba(2+) completely inhibited TEP electrolyte and fluid secretion, with fast and slow kinetics reflecting the Ba(2+) block of basolateral membrane K(+) channels and the inhibition of Na(+)/K(+)/2Cl(-) cotransport, respectively. The single and combined effects of Ba(2+) and bumetanide suggest that (1) K(+) channels and Na(+)/K(+)/2Cl(-) cotransport are the primary mechanisms for bringing K(+) into cells, (2) K(+) channels mediate a significant Na(+) influx, (3) Na(+) has as many as four entry pathways and (4) the mechanisms of TEP K(+) and Na(+) secretion are coupled such that complete block of TEP K(+) renders the epithelium unable to secrete Na(+).