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3 Diagnosis S, strong ; W, weak; C, conditional; H, high; M, moderate; L, low; VL, very low quality of evidence; GP, good practice; NR, no recommendation Adult ➤ Patients with ≥3 unexplained and new onset unformed stools in 24 h are the preferred target population for testing for CDI (W-VL). ➤ Use a stool toxin test as part of a multiple step algorithm (i.e., glutamate dehydrogenase [GDH] plus toxin; GDH plus toxin, arbitrated by nucleic acid amplification test [NAAT]; or NAAT plus toxin) rather than a NAAT alone for all specimens received in the clinical laboratory when there are no pre-agreed institutional criteria for patient stool submission (see Figure 1) (W-L). ➤ Use a NAAT alone or multiple step algorithm for testing (i.e., GDH plus toxin; GDH plus toxin, arbitrated by NAAT; or NAAT plus toxin) rather than a toxin test alone when there are pre-agreed institutional criteria for patient stool submission (see Figure 1) (W-L). ➤ Do not perform repeat testing (within 7 days) during the same episode of diarrhea and do not test stool from asymptomatic patients, except for epidemiological studies (S-M). ➤ There are insufficient data to recommend use of biologic markers as an adjunct to diagnosis (NR). Pediatric ➤ Because of the high prevalence of asymptomatic carriage of toxigenic C. difficile in infants, testing for CDI should never be routinely recommended for neonates or infants ≤12 months of age with diarrhea (S-M). ➤ C. difficile testing should not be routinely performed in children with diarrhea who are 1–2 years of age unless other infectious or non- infectious causes have been excluded (W-L). ➤ In children 2 years and older, C. difficile testing is recommended for patients with prolonged or worsening diarrhea and risk factors (such as underlying inflammatory bowel disease or immunocompromising conditions) or relevant exposures (such as contact with the healthcare system or recent antibiotics) (W-M).

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