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.