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Published on: May 25, 2017
Clinical and Microbiologic Assessment of Cases of Pediatric Community-associated Clostridium difficile Infection
Larry K Kociolek1, Sameer J Patel, Xiaotian Zheng
1From the *Division of Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago; Departments of †Pediatrics and ‡Pathology, Northwestern University Feinberg School of Medicine; §Department of Pathology and Laboratory Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago; ¶Division of Infectious Diseases, Edward Hines, Jr. Veterans Affairs Hospital, Chicago, Illinois; ‖Department of Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois.
Insights
Many children diagnosed with community-associated Clostridium difficile infection (CDI) lack typical risk factors and show varied test results, suggesting overdiagnosis. More targeted testing is needed to avoid unnecessary antibiotic treatment for pediatric CDI.
Area of Science:
- Pediatric Infectious Diseases
- Microbiology
- Diagnostic Accuracy
Background:
- Clostridium difficile infection (CDI) commonly presents in the community among children.
- Accurate diagnosis of community-associated CDI (CA-CDI) in pediatric populations is crucial.
Purpose of the Study:
- To compare hospital-onset healthcare facility-associated CDI with community-associated CDI in children.
- To evaluate the diagnostic accuracy of PCR testing for CA-CDI in pediatric patients.
- To identify risk factors and diagnostic discrepancies in pediatric CA-CDI cases.
Main Methods:
- Retrospective comparison of hospital-onset healthcare facility-associated CDI and CA-CDI cases diagnosed via Cepheid Xpert tcdB PCR.
- Analysis of stool samples using anaerobic culture and multiplex gastrointestinal pathogen PCR.
- Review of patient demographics, clinical history, and risk factors.
Main Results:
- CA-CDI cases were younger and less likely to have antibiotic or proton pump inhibitor exposure compared to hospital-onset cases.
- A significant proportion of children diagnosed with CA-CDI lacked identified risk factors.
- Discordant results were observed between initial PCR testing and further stool analysis for C. difficile detection.
- Nearly all positive tcdB PCR results led to CDI antibiotic therapy, regardless of risk factors.
Conclusions:
- PCR-based diagnosis of CA-CDI in children may lead to overdiagnosis, particularly in those with community-onset diarrhea and no clear risk factors.
- The findings suggest a need for more selective CDI testing strategies in low-risk pediatric patients.
- Reducing unnecessary antibiotic treatment for CDI in children requires improved diagnostic selectivity.
Background:
Most children with Clostridium difficile infection (CDI) experience community onset of CDI symptoms.
Methods:
We retrospectively compared hospital-onset healthcare facility-associated CDI cases to community-associated (CA) CDI cases diagnosed by Cepheid Xpert tcdB polymerase chain reaction (PCR) at an academic children's hospital over a 1-year period. Saved stools from CDI cases additionally underwent anaerobic stool culture and multiplex gastrointestinal pathogen PCR testing.
Results:
Compared with 25 hospital-onset healthcare facility-associated CDI cases, the 74 CA-CDI cases were more frequently <2 years old (18% vs. 0%, P = 0.034) and less frequently had antibiotic exposure in the past 30 days (26% vs. 88%, P < 0.0001), proton pump inhibitor exposure (16% vs. 36%, P = 0.036) or a gastrostomy tube (11% vs. 32%, P = 0.013). Among children diagnosed with CA-CDI, 19 (26%) had no identified CDI risk factors (immunocompromised; gastrostomy tube; recent antibiotic, proton pump inhibitor or inpatient/outpatient healthcare exposures). Clinical testing for viral pathogens was uncommon among children thought to have CA-CDI. Multiplex PCR testing of saved stool samples failed to identify C. difficile among 23% of cases diagnosed with CA-CDI by the Cepheid Xpert tcdB PCR assay. CDI antibiotic therapy was provided to nearly all patients testing positive by tcdB PCR irrespective of CDI risk factors.
Conclusions:
Many children diagnosed with CA-CDI by PCR lack CDI risk factors and have discordant results when additional CDI testing methods are performed, suggesting overdiagnosis of CDI in children with community-onset diarrhea. More selective CDI testing of low-risk pediatric patients is needed to more accurately diagnose CDI and limit unnecessary CDI antibiotic treatment in children.
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