Point-Counterpoint: What is the optimal approach for detection of Clostridium difficile infection?

In 2010, we published an initial point-counterpoint on laboratory diagnosis of C. difficile infection (CDI). At that time, nucleic acid amplification tests (NAATs) were just becoming commercially available, and the idea of algorithmic approaches to CDI was being explored. Now there are numerous NAATs in the marketplace and based on recent proficiency test surveys, they have become the predominant method used for CDI diagnosis in the United States. At the same time, there is a body of literature that suggests that NAATs lack clinical specificity and thus inflate CDI rates. Hospital administrators are taking note of institutional CDI rates because they are publicly reported. They have become an important metric impacting hospital safety ratings and value-based purchasing where hospitals may have millions of dollar of reimbursement at risk. In this point-counterpoint using a Frequently Asked Question approach, Ferric Fang of the University of Washington, who has been a consistent advocate for NAAT-only approach for CDI diagnosis, will discuss the value of a NAAT-only approach, while Christopher Polage of the University of California-Davis and Mark Wilcox of Leeds University, UK, who have each recently written important articles on the value of toxin detection in the diagnosis, will discuss the impact of toxin detection in CDI diagnosis.