Optimal strategies for the diagnosis of community-onset diarrhea in solid organ transplant recipients: Less is more.
Optimal strategies for the diagnosis of community-onset diarrhea in solid organ transplant recipients: Less is more.
复制标题
实体器官移植受者社区发病性腹泻诊断的最佳策略：少即是多。
DOI：
10.1111/tid.12673
复制
发表时间：
2017
期刊：
影响因子：
--
通讯作者：
Angarone,MichaelP
中科院分区：
文献类型：
--
作者：
Trinh,SonyaA;Echenique,IgnacioA;Penugonda,Sudhir;Angarone,MichaelP
腹泻是实体器官移植（SOT）后的常见并发症，与移植物衰竭和死亡有关。目前尚无评价SOT接受者腹泻的循证指南。我们进行了成本分析，以得出诊断社区发病性腹泻的测试算法，该算法在不影响诊断率的情况下最大限度地降低成本。设计：对422例在18个月内因社区发病腹泻而入院的SOT患者进行回顾性队列分析。逐步测试模型应用于人口水平，以评估测试成本相对于诊断产量。在18个月的时间里，进行了1564次诊断测试，127次（8.1%）返回阳性。诊断性检测占住院患者的95625例，其中费用降低最低的检测为粪便艰难梭菌聚合酶链反应（PCR）（156例）、血清巨细胞病毒定量PCR（1529例）、粪便诺如病毒（NV）PCR（4673例）、和粪便培养（6804）。事件发生时间分析发现，接受和未接受NV检测的患者之间的住院时间无显著差异（P=.520）。结论逐步检测策略可以降低成本而不影响诊断率。在第一阶段检测中，我们评估艰难梭菌、巨细胞病毒和食物源性细菌病原体。对于持续性腹泻，第二阶段评估应包括stoolNVPCR，贾第虫/隐孢子虫酶免疫测定、粪便和寄生虫、减少免疫抑制剂治疗以及可能的内窥镜检查。尽管NV检测相对于FOR成本较低，但我们在第二阶段评估期间进行NV检测，因为NV诊断可能不会导致临床管理的改变或住院时间的进一步缩短。
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 95625ofhospitalcosts.Thetestswiththelowestcostperdecreaseinthefalse‐omissionrate(FOR)werestoolClostridiumdifficilepolymerasechainreaction(PCR)( 156), serum cytomegalovirus quantitative PCR (1529),stoolnorovirus(NV)PCR( 4673), and stool culture (6804).Atime‐to‐eventanalysisfoundnosignificantdifferenceinthelengthofhospitalstaybetweenpatientswithandwithoutNVtesting(P=.520).ConclusionsAstepwisetestingstrategycanreducecostswithoutcompromisingdiagnosticyields.Inthefirst‐stagetesting,werecommendassessmentforC.difficile,cytomegalovirus,andfood‐bornebacterialpathogens.Forpersistentdiarrhealepisodes,second‐stageevaluationshouldincludestoolNVPCR,Giardia/Cryptosporidiumenzymeimmunoassay,stoolovaandparasite,reductionsinimmunosuppressivetherapy,andpossiblyendoscopy.AlthoughNVtestinghadarelativelylowcostperFOR,werecommendNVtestingduringsecond‐stageevaluation,asanNVdiagnosismaynotleadtochangesinclinicalmanagementorfurtherreductionsinlengthofhospitalstay.