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Optimal strategies for the diagnosis of community‐onset diarrhea in solid organ transplant recipients: Less is more
Author(s) -
Trinh Sonya A.,
Echenique Ignacio A.,
Penugonda Sudhir,
Angarone Michael P.
Publication year - 2017
Publication title -
transplant infectious disease
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.69
H-Index - 67
eISSN - 1399-3062
pISSN - 1398-2273
DOI - 10.1111/tid.12673
Subject(s) - medicine , diarrhea , norovirus , cytomegalovirus , retrospective cohort study , population , cohort , cryptosporidium , intensive care medicine , feces , immunology , human immunodeficiency virus (hiv) , viral disease , virus , herpesviridae , environmental health , paleontology , biology
Abstract Background Diarrhea, a common complication after solid organ transplant ( SOT ), is associated with allograft failure and death. No evidence‐based guidelines exist for the evaluation of diarrhea in SOT recipients. We performed a cost analysis to derive a testing algorithm for the diagnosis of community‐onset diarrhea that minimizes costs without compromising diagnostic yields. Design A cost analysis was performed on a retrospective cohort of 422 SOT admissions for community‐onset diarrhea over an 18‐month period. A stepwise testing model was applied on a population level to assess test costs relative to diagnostic yields. Results Over an 18‐month period, 1564 diagnostic tests were performed and 127 (8.1%) returned positive. Diagnostic testing accounted for $95 625 of hospital costs. The tests with the lowest cost per decrease in the false‐omission rate ( FOR ) were stool C lostridium difficile polymerase chain reaction ( PCR ) ($156), serum cytomegalovirus quantitative PCR ($1529), stool norovirus ( NV ) PCR ($4673), and stool culture ($6804). A time‐to‐event analysis found no significant difference in the length of hospital stay between patients with and without NV testing ( P =.520). Conclusions A stepwise testing strategy can reduce costs without compromising diagnostic yields. In the first‐stage testing, we recommend assessment for C . difficile , cytomegalovirus, and food‐borne bacterial pathogens. For persistent diarrheal episodes, second‐stage evaluation should include stool NV PCR , Giardia / Cryptosporidium enzyme immunoassay, stool ova and parasite, reductions in immunosuppressive therapy, and possibly endoscopy. Although NV testing had a relatively low cost per FOR , we recommend NV testing during second‐stage evaluation, as an NV diagnosis may not lead to changes in clinical management or further reductions in length of hospital stay.