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Clin Infect Dis. 2019 Oct 4. pii: ciz978. doi: 10.1093/cid/ciz978. [Epub ahead of print]

Laxative use does not preclude diagnosis or reduce disease severity in Clostridiodes difficile infection.

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Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, USA.
Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, USA.
Department of Laboratory Medicine, Boston Children's Hospital, Massachusetts.



To optimize utility of laboratory testing for Clostridiodes difficile infection (CDI), the 2017 Infectious Diseases Society of America-Society for Healthcare Epidemiology of America (IDSA-SHEA) clinical practice guidelines recommend excluding patients from stool testing for C. difficile if they have received laxatives within the preceding 48 hours. Sparse data support this recommendation.


Patients with new-onset diarrhea (≥3 bowel movements in any 24 hour period in the 48 hours before stool collection) and a positive stool C. difficile nucleic acid amplification test (NAAT) were enrolled. Laxative use within 48 hours prior to stool testing, severity of illness (defined by four distinct scoring methods), and clinical outcomes were recorded.


209 patients with CDI were studied, 65 of whom had received laxatives. There were no significant differences in the proportion of patients meeting severe CDI criteria by four severity scoring methods, in patients receiving versus not receiving laxatives (66.2% vs 56.3%, respectively, p = 0.224) by IDSA-SHEA, the primary scoring system. Similar rates of serious outcomes attributable to CDI, including death, ICU admission, and colectomy, were observed in the laxative and no laxative groups.


Our study found similar rates of severe CDI and serious CDI-attributable clinical outcomes in CDI-diagnosed patients who did or did not receive laxatives. Precluding recent laxative users from CDI testing, as proposed by the IDSA-SHEA guideline, carries a potential for harm due to delayed diagnosis and treatment.


Clostridiodes difficile colonization; Clostridiodes difficile infection; diarrhea; laxative


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