Clostridium difficile infection in children: epidemiology and risk of recurrence in a low-prevalence country

Abstract

Clostridium difficile infection (CDI) is increasingly found in children worldwide, but limited data are available from children living in southern Europe. A 6-year retrospective study was performed to investigate the epidemiology, clinical features, treatment, and risk of recurrence in Italy. Data of children with community- and hospital-acquired CDI (CA-CDI and HA-CDI, respectively) seen at seven pediatric referral centers in Italy were recorded retrospectively. Annual infection rates/10,000 hospital admissions were calculated. Logistic regression was used to investigate risk factors for recurrence. A total of 177 CDI episodes was reported in 148 children (83 males, median age 55.3 months), with a cumulative infection rate of 2.25/10,000 admissions, with no significant variability over time. The majority of children (60.8 %) had CA-CDI. Children with HA-CDI (39.2 %) had a longer duration of symptoms and hospitalization (p = 0.003) and a more common previous use of antibiotics (p = 0.0001). Metronidazole was used in 70.7 % of cases (87/123) and vancomycin in 29.3 % (36/123), with similar success rates. Recurrence occurred in 16 children (10.8 %), and 3 (2 %) of them presented a further treatment failure. The use of metronidazole was associated with a 5-fold increase in the risk of recurrence [odds ratio (OR) 5.18, 95 % confidence interval (CI) 1.1-23.8, p = 0.03]. Short bowel syndrome was the only underlying condition associated with treatment failure (OR 5.29, 95 % CI 1.17-23.8, p = 0.03). The incidence of pediatric CDI in Italy is low and substantially stable. In this setting, there is a limited risk of recurrence, which mainly concerns children treated with oral metronidazole and those with short bowel syndrome.

Antibiotic treatment of acute gastroenteritis in children

“…In Europe, the most common bacterial pathogens are Campylobacter , Salmonella spp., enteropathogenic E. coli (EPEC), and enteroaggregative E. coli (EAEC) 5 , 6 . Clostridium difficile (Cd) has emerged as a cause of community-acquired diarrheal illness, but local data report a relatively low burden 7 – 9 . In Ecuador, sub-Saharan Africa, and South Asia, Shigella is the main agent 3 , 10 .…”

Diarrhea in Newborns;

“…The toxin intern produced by this bacterium can cause injury to the mucosa and ultimately bloody stools. 23,24 Breastmilk inhibits the growth of the bacteria and thus tend to have less severe symptoms than non-breastfed babies In patients with diarrhea, a stool pH level of 5.5 or less or presence of reducing substances indicates carbohydrate intolerance, which is usually secondary to viral illness and transient in nature. 25…”

An Updated Review of Clostridium difficile Treatment in Pediatrics

“…In a multivariate analysis, the route of metronidazole showed that the risk was not substantiated with the intravenous route, but the authors reported the lack of difference in the result could be due to the small portion of children who received the intravenous dose. 55 Although no other pediatric comparative studies of recurrence rates between metronidazole and vancomycin exist, there are several adult studies examining the difference. In a 2015 meta-analysis the superiority for vancomycin over metronidazole was significant for initial clinical cure (RR 0.91; 95% CI 0.84-0.98) and sustained cure (RR 0.88; 95% CI 0.82-0.96) rates in the treatment of CDI, whereas recurrence rates and all-cause mortality remained similar.…”