Risk Factors and Outcomes Associated With Severe Clostridium difficile Infection in Children

Abstract

Background:The incidence and severity of Clostridium difficile infection (CDI) is increasing among adults; however, little is known about the epidemiology of CDI among children. Methods: We conducted a nested case-control study to identify the risk factors for and a prospective cohort study to determine the outcomes associated with severe CDI at 2 children's hospitals. Severe CDI was defined as CDI and at least 1 complication or Ն2 laboratory or clinical indicators consistent with severe disease. Studied outcomes included relapse, treatment failure, and CDI-related complications. Isolates were tested to determine North American pulsed-field gel electrophoresis type 1 lineage. Results: We analyzed 82 patients with CDI, of whom 48 had severe disease. Median age in years was 5.93 (1.78 -12.16) and 1.83 (0.67-8.1) in subjects with severe and nonsevere CDI, respectively (P ϭ 0.012). All patients with malignancy and CDI had severe disease. Nine subjects (11%) had North American pulsed-field gel electrophoresis type 1 isolates. Risk factors for severe disease included age (adjusted odds ratio ͓95% confidence interval͔: 1.12 ͓1.02, 1.24͔) and receipt of 3 antibiotic classes in the 30 days before infection (3.95 ͓1.19, 13.11͔). If infants less than 1 year of age were excluded, only receipt of 3 antibiotic classes remained significantly associated with severe disease. Neither the rate of relapse nor treatment failure differed significantly between patients with severe and nonsevere CDI. There was 1 death. Conclusions: Increasing age and exposure to multiple antibiotic classes were risk factors for severe CDI. Although most patients studied had severe disease, complications were infrequent. Relapse rates were similar to those reported in adults.

Prevalence of Clostridium Difficile Among Paediatric Patients in a Tertiary Care Hospital, Coastal Karnataka, South India

“…*When the occurrence of positivity of culture, latex agglutination and EIA was compared among different age groups, the culture and EIA positivity were significant in the age group 1-5 years when compared to other age groups under the definition of CDI according to the reference standard method employed in our study. Those specimens will be tested for glutamate dehydrogenase antigen before considering them as false positive [26]. Seventeen isolates of C. difficile (out of 21 isolates, 4 were toxigenic) which were isolated by anaerobic culture could be regarded only as colonizers because they were non toxigenic [27].…”

Clostridium Difficile in Children- A Multifaceted Infection

“…Even if the burden of disease regards the adult age, a concomitant increase of number of hospitalizations, hospital length of stay, medical expenses, colectomy rate for CDI have been reported also in children [8,9]. In spite of this phenomenon, CDI infection is rarely severe at this age, and severity is strongly related to the presence of multiple antibiotic courses [4]. Other risk factors of CDI, as a particular age group, the presence of tube feedings, PPI use and abuse, intestinal surgery, have not been associated with a more severe course of disease [4].…”

“…In spite of this phenomenon, CDI infection is rarely severe at this age, and severity is strongly related to the presence of multiple antibiotic courses [4]. Other risk factors of CDI, as a particular age group, the presence of tube feedings, PPI use and abuse, intestinal surgery, have not been associated with a more severe course of disease [4].…”

“…The first risk factor for CDI is antibiotic exposure and administration of 3 antibiotic classes in the 30 days before infection was significantly associated with severe disease [4]. For this reason, it is curious that the mainstay of treatment of CDI is still antibiotic treatment (Table) [5,11].…”

“…It is the case of concomitant colonic diseases, or previous digestive surgery, or excessive exposure to health-care admissions, or disequilibrium of intestinal microflora caused by repeated antibiotic courses or immunosuppressive drugs [3,4]. In such conditions, rapid growth of Clostridium difficile may occur, and production of toxins A and/or B, as well as other less-known toxins, produces colonic epithelial injury leading to diarrhea, mainly mild to moderate, erosions with bloody diarrhea, up to pseudomembranous colitis with severe colonic and systemic impairment and death, which rarely occurs in children.…”