Recent antibiotic exposure linked to C. difficile infection

Kim J. Pediatr Infect Dis J. 2011;doi:10.1097/INF.0b013e3182352e2c.

Children who are exposed to a variety of antibiotics are more prone to Clostridium difficile infection, according to a study published online this month.

Jason Kim, MD, of the University of Pennsylvania School of Medicine, and colleagues looked at risk and outcomes associated with severe C. difficile infection at two Pennsylvania-area children’s hospitals.

The researchers identified 82 children with Clostridium; 48 of whom had severe disease. They said there were some similarities among patients with severe disease, specifically that all of them with malignancies had severe disease. Also, the most common risk factors for disease included increasing age and having received three different types of antibiotics in the month previous. When the researchers excluded babies aged younger than 1 year, “only receipt of three antibiotic classes remained significantly associated with severe disease.”

There was one death among the cohort, but they said relapse and treatment failure rates were similar among those with severe and non-severe disease.

According to Kim and colleagues, there were some limitations, specifically that there are no accepted definitions of severe C. difficile in children. Also, they said their study “was assembled from two tertiary care centers and may not be generalizable to patients in community hospital or outpatient settings.”

Disclosure: The researchers report no relevant financial disclosures.

Andi L. Shane, MD, MPH

Our understanding of the epidemiology, risk factors and outcomes of Clostridium difficile infections (CDI) in children is incomplete. This is partly due to the absence of studies in children and to controversy surrounding the interpretation of diagnostic results. Authors from The Children’s Hospital of Philadelphia and Rainbow Babies and Children’s Hospital in Cleveland conducted a 21-month prospective cohort evaluation and a nested case-control study of hospitalized children to assess the outcomes and risk factors associated with CDI. Severe CDI was defined using a scoring system that correlated clinical manifestations with laboratory diagnostics.

Children with their first episode of toxin detection admitted directly to the participating hospitals were enrolled. Microbiologic and molecular analyses of stool specimens from 69 of the enrolled subjects were performed. Data from the remaining subjects were included in the analyses after determining that the children without additional stool analyses did not differ on prespecified clinical and demographic characteristics.

Rates of severe CDI and risk factors, including age and exposure to three or more classes of antimicrobials within 30 days of diagnosis, were comparable to those of adults; rates of complications were less. The presence of North American pulsed-field gel electrophoresis type I (NAP1) isolates was not associated with severe disease, relapse or treatment failure.

A majority of subjects received oral metronidazole monotherapy while 4% received oral vancomycin monotherapy and 12% received oral vancomycin with metronidazole. The streamlining of antimicrobial therapy is the first-line recommendation for the management of CDI. While this may not always be feasible, it often is not considered, and oral metronidazole or oral vancomycin is added to ongoing broad-spectrum therapy, without modification of the later.

Additional evaluations involving children from several centers and inclusion of an outpatient population would further expand our understanding of the epidemiology of pediatric CDI. This would also guide the implementation of newly introduced molecular diagnostic techniques and facilitate optimal management.

– Andi L. Shane, MD, MPH

Infectious Diseases in Children Editorial Board

Disclosure: Dr. Shane reports no relevant financial disclosures.

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