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Diagnosis of Clostridium difficile Colitis
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
TO THE EDITOR:
In the article by Manabe and colleagues [1] on Clostridium difficile colitis, only a length of stay of 5 days or longer seems to be of value in managing patients (Table 1). The “ideal” high true-positive rate and low negative likelihood ratio make this an excellent screening test for ruling out C. difficile colitis. I disagree that previous use of cephalosporin is an important predictor, because the positive likelihood ratio is too low and the negative likelihood ratio is too high. I recommend that the authors evaluate combinations of historical findings to define a positive index test result [2, 3].
Rarely does a provider rely on one clinical finding to rule in or rule out a diagnosis. A positive index test result could be defined as a combination of use of antibiotics, antibiotic use for at least 5 days, and semiformed or watery stool. If all three findings were positive, the false-positive rate would be very low and the positive likelihood ratio would be very high. No confirmatory laboratory test, including a C. difficile assay, would be necessary to make a definitive diagnosis. Similarly, the authors could define a positive index test result as a combination of fecal leukocytes, lactoferrin, and positive Gram stain. The use of combinations of clinical characteristics rather than individual tests is valuable in deciding whether to use expensive laboratory tests and is more characteristic of the problem-solving behavior of clinicians.
David A. Nardone, MD
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
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