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Published on: December 8, 2014
The impact of Clostridium difficile on paediatric surgical practice: a systematic review
D Mc Laughlin1, F Friedmacher, P Puri
1National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland.
Insights
Clostridium difficile infection (CDI) poses a significant risk in pediatric surgical patients, especially those with Hirschsprung's disease (HD). Early suspicion and intervention are crucial due to high mortality rates associated with severe CDI.
Area of Science:
- Pediatric Surgery
- Infectious Diseases
- Gastroenterology
Background:
- Clostridium difficile is an enteropathogen in children, particularly with antibiotic-associated diarrhea.
- Pediatric surgical patients, including those with Hirschsprung's disease (HD), are vulnerable to C. difficile infection (CDI).
- Hyper-virulent C. difficile strains necessitate evaluating CDI's impact on pediatric surgical practice.
Purpose of the Study:
- To assess the impact of Clostridium difficile infection (CDI) on pediatric surgical practice.
- To examine the role of CDI in Hirschsprung's associated enterocolitis (HAEC) and complicated CDI in non-HD patients.
- To analyze clinical parameters, diagnostics, surgical interventions, and outcomes related to CDI in pediatric surgical patients.
Main Methods:
- Literature search using MESH terms: "hirschsprung's disease", "enterocolitis", "clostridium difficile", and "children".
- Analysis of cases of HAEC with C. difficile and complicated CDI in non-HD patients.
- Evaluation of clinical parameters, diagnostic evaluations, surgical interventions, and outcomes.
Main Results:
- C. difficile was infrequently isolated in HAEC; only 98 cases reported over 40 years.
- 34 cases of pseudomembranous colitis complicating HD had a 50% mortality rate.
- Over 20% of non-HD patients with severe CDI required surgery, associated with co-morbidity and high mortality.
Conclusions:
- Severe or complicated CDI in pediatric patients, with or without HD, is linked to high mortality and often necessitates surgery.
- Early diagnosis and prompt surgical intervention for CDI are vital, especially in immunocompromised children or those with prior antibiotic use.
- Despite low case numbers, CDI should be suspected in pediatric enterocolitis to ensure timely management.
Purpose:
The pathogenic potential of Clostridium difficile in children remains a controversial subject as healthy infants can be colonised by this organism. However recent analyses have clarified that C. difficile is an important enteropath in paediatric populations, particularly in antibiotic-associated diarrhoea. Paediatric surgical patients including those with Hirschsprung's disease (HD) may be especially vulnerable to C. difficile infection (CDI) and complicated C. difficile enterocolitis such as pseudomembranous colitis may require surgical management if refractory to medical therapy. Reports of increasing prevalence and emergence of hyper-virulent strains of C. difficile worldwide prompted an examination of the literature to assess the impact of CDI on current paediatric surgical practise.
Methods:
The literature was searched using a combination of the MESH terms "hirschsprung's disease", "enterocolitis", "clostridium difficile", and "children". Cases of Hirschsprung's associated enterocolitis (HAEC) investigated for C. difficile and complicated CDI in non HD patients were identified and analysed for clinical parameters, diagnostic evaluations, surgical interventions and outcome.
Results:
Pathogen isolation in HAEC was infrequently described. Only 98 children have been reported with C. difficile during an episode of HAEC over the last 40 years and aetiology remains unclear as asymptomatic carriage of C. difficile in HD occurs. Nonetheless 34 confirmed cases of pseudomembranous colitis complicating HD are reported in the literature with an associated 50 % mortality rate. Over 20 % of non Hirschsprung's patients with reported severe or complicated CDI required operative intervention. The need for surgery was associated with the presence of co-morbidity and high mortality occurred in this group.
Conclusion:
Severe or complicated CDI in both HD and non HD paediatric patients is associated with high mortality and often requires surgical intervention. Although these patient cohorts represent a small number of cases, CDI should be suspected in children presenting with enterocolitis to enable early diagnosis and timely surgical intervention, particularly in patients with co-morbid conditions or preceding antibiotic use.
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