This article is more than 5 years old. Information may no longer be current.
Severe C. difficile infection becoming more common among children
Click Here to Manage Email Alerts
Incidence of severe Clostridium difficile infection appears to be increasing in frequency, according to researchers from Texas Children’s Hospital in Houston.
Jonathan Crews, MD, from the division of pediatric infectious diseases, Baylor College of Medicine, Houston, said during a presentation that CDI is occurring more frequently among children, and that complications related to pediatric CDI were not uncommon.
“A surprising proportion of severe CDI in children was community-acquired, a finding that warrants further investigation,” Crews said.
Crews and colleagues reviewed medical records of children aged 1 year and older with diarrhea who tested positive for C. difficile by real-time PCR for the toxin-encoding genes tcdA and tcdB. The investigators identified 88 patients from Feb. 1, 2011, to Aug. 31, 2011.
Nineteen children (21.6%) met criteria for severe CDI, defined as the presence of a CDI-related complication or the presence of two or more of the following clinical features: fever, bloody stools, leukocytosis, hypoalbuminemia, or elevated creatinine.
Among children with severe CDI, 31.6% had hospital-acquired CDI, 36.8% had community-acquired CDI and 31.6% had community-onset indeterminate CDI. Nearly 90% of children with severe CDI had an underlying medical condition.
Clinical symptoms of severe CDI included fever (94.7%); abdominal pain (42.1%); vomiting (42.1%); and bloody stools (36.8%).
Crews said most children in the study had antibiotic exposures 30 days prior to diagnosis: 84% in the severe group and 78% in the non-severe group.
The most common treatment for severe CDI among children in the study was metronidazole (52.7%), followed by vancomycin (15.8%), or combination therapy (26.3%). Only 42% of children with severe disease received a regimen that contained vancomycin, despite recommendations from the AAP to use vancomycin in children with severe disease from CDI, Crews said. One patient improved without antibiotic therapy.
Six children (6.8%) had CDI-related complications, including ICU admission at diagnosis (n=3); pneumatosis intestinalis (n=1); need for surgical intervention (n=1); and death (n=1). Thirteen children (14.8%) had severe CDI based on the clinical criteria.
Crews also reported a refractory disease rate of 10.5% and recurrent disease rate of 15.8%. In addition, all-cause 3-month mortality rate was 5.3%, with one death attributable to CDI.
“The clinical picture of CDI in children is similar to that in adults. CDI in children predominantly affects those with underlying medical conditions and commonly causes severe disease,” Crews said. “In children, the clinical features of severe CDI include fever, profuse diarrhea and vomiting, and complications to due severe CDI are not uncommon. And community-associated disease causes a substantial proportion of both severe and non-severe CDI in children.”
Crews J. Abstract #87.
Disclosure: Crews reports no relevant financial disclosures.
Perspective
Back to Top
W. Matthew Linam, MD, MS
Clostridium difficile infections are becoming associated with increased morbidity and mortality. A recent report from the CDC, "Antibiotic Resistance Threats in the United States, 2013," found that CDI results in roughly 250,000 hospitalizations and at least 14,000 deaths each year. Since the early 2000s a hypervirulent strain of C. difficile (BI/NAP1/027), which has increased toxin production, has contributed to the increased frequency and severity of CDI. Historically, CDI has been considered more of a problem in adults. Recent data shows that between 1997 and 2006 C. difficile-related hospitalizations in children have shown a 1.8-fold increase. Severe disease from CDI in children occasionally occurs.
In the recent study by Crews et al., they describe the epidemiology, clinical findings and outcome in children with severe CDI cared for at a large tertiary hospital. Between Feb. 1, 2013, and Aug. 31, 2013, the authors identified 88 children older than 1 year with symptomatic CDI. Of these patients, 19 (21.6%) met criteria for severe CDI. Three children required ICU admission, one required surgery and one child died as a result of the CDI. Importantly, more than one-third of children with severe CDI had community-acquired CDI. We are seeing increased incidence of CDI in children, and along with this we are seeing an increase in severe disease. Prior antibiotic use remains an important risk factor for CDIs. This study increases our understanding of severe CDI in children. Severe CDI is an important complication of antibiotic use and serves as a reminder of the continued need for judicious use of antibiotics.
Click Here to Manage Email Alerts