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Clostridium Difficile, Colitis, and Colonoscopy: Pediatric Perspective
Randolph McConnie1,2, Arthur Kastl3
1Section of Pediatric Gastroenterology, Hepatology and Nutrition, Rush University Children's Hospital, Chicago, IL, USA. Randolph_McConnie@rush.edu.
Insights
Clostridium difficile (C. diff.) testing should only be performed on patients with diarrhea. Nucleic acid amplification testing (NAAT) is most effective for diagnosing C. diff.-induced disease in symptomatic children and adults.
Area of Science:
- Medical Diagnostics
- Microbiology
- Pediatric Gastroenterology
Background:
- Clostridium difficile (C. diff.) infection causes significant gastrointestinal distress.
- C. diff. produces toxins (A, B, and binary) that are responsible for disease pathology.
- Accurate diagnostic methods are crucial for timely and appropriate treatment.
Purpose of the Study:
- To review available diagnostic tests for Clostridium difficile-induced disease.
- To provide guidance on the appropriate use and interpretation of these tests in children.
- To clarify the role of different C. diff. toxins in disease causation.
Main Methods:
- Review of current literature on C. diff. diagnostic assays.
- Analysis of test sensitivity and specificity, including colonoscopy and stool analysis.
- Evaluation of nucleic acid amplification testing (NAAT) for toxin gene detection.
Main Results:
- Colonoscopy with biopsy is highly sensitive for colitis but invasive.
- Stool analyses vary in accuracy; presence of C. diff. or toxins alone does not confirm disease.
- NAAT on stool from patients with diarrhea is efficient for detecting toxin A and B genes.
- Infants have high C. diff. carriage rates and generally do not require testing.
- Testing is indicated only for patients with diarrhea and clinical signs of C. diff. disease.
Conclusions:
- NAAT is the most efficient diagnostic tool for C. diff.-induced disease in patients with diarrhea.
- Testing infants for C. diff. is not recommended due to high carriage rates and low disease incidence.
- Treatment decisions should be based on confirmed C. diff. toxin or toxin-producing bacteria in patients with diarrhea.
Purpose Of The Review:
Review tests available for detection of Clostridium difficile (C. Diff) induced disease, including when such tests should be done in children and how they should be interpreted.
Recent Findings:
Multiple tests are available for detecting disease due to C. diff. These include colonoscopy and stool analysis. Colonoscopy with biopsy is the most sensitive test for detecting the presence of colitis. The toxins produced by the C. diff. (toxin A, toxin B, and binary toxin) are the agents that cause injury and disease. Only toxin producing C. diff. Strains will cause disease. Binary toxin by itself is not thought to produce disease. Binary toxin causes disease in humans when present with toxin A and B producing bacteria, and has been implicated with fulminant life threatening disease. Stool analyses vary in sensitivity and specificity depending on the assay used. The presence of toxin producing strains of C diff. in the stool does not equate with disease. The presence of a toxin-producing bacteria or toxins (A or B) only equates with disease if diarrhea or a diseased colon (toxic megacolon, ileus, and sepsis) is present. Nucleic acid amplification testing (NAAT), when used in the stool from patients with diarrhea, appears to be the most efficient study to detect the gene that encodes for toxin A and B and thus to diagnose C. diff.-induced disease. Infants have a high carriage rate of C. diff. and are believed not to develop disease from it or its toxins. Infants should not be tested for C. difficile. The NAAT is most specific when done on patients with diarrhea with liquid stools. Testing for C. difficile should only be done on patients with diarrhea. One can assume that a patient who has no diarrhea and is not ill does not have C. diff.-induced disease. Treatment should be limited to patients with diarrhea who test positive for C. diff. toxin (A or B) or toxin-producing bacteria. Direct testing for binary toxin is not commercially available. Binary toxin is only thought to cause disease in humans when C. diff. toxin (A and B)-producing bacteria are present.
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