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Risk Factors for Recurrent Community-associated Clostridiodes Difficile Infection in Children
Deepika Parmar1, Rebecca Dang1, Margot Miranda-Katz2
1From the Department of Pediatrics, Division of Infectious Diseases, Kaiser Permanente Northern California, San Francisco, California.
Insights
Recurrence of community-associated Clostridiodes difficile infection (CA-CDI) in children is less common than previously thought. Inflammatory bowel disease, cancer, and certain racial backgrounds are risk factors for recurrence, not treatment type.
Area of Science:
- Pediatric Infectious Diseases
- Gastroenterology
- Epidemiology
Background:
- Community-associated Clostridiodes difficile infection (CA-CDI) recurrence rates are high, nearing 30%.
- Limited research exists on risk factors and optimal treatments for pediatric CA-CDI, leading to varied clinical recommendations.
Purpose of the Study:
- To investigate the incidence of recurrent CA-CDI in a pediatric population.
- To identify risk factors associated with recurrent CA-CDI in children.
- To evaluate treatment strategies for primary CA-CDI in pediatric patients.
Main Methods:
- Retrospective cohort study of electronic health records from Kaiser Permanente Northern California (2012-2016).
- Included children aged 1-17 with stool testing for C. difficile, confirmed CA-CDI, and consistent symptoms.
- Defined recurrent CA-CDI as symptom onset within 8 weeks of primary diagnosis.
Main Results:
- Of 408 children with primary CA-CDI, 11% (45 children) experienced recurrence.
- Risk factors for recurrence included inflammatory bowel disease (OR 7.5) and cancer (OR 6.3).
- Children of multi/other/unknown race had higher recurrence odds (OR 3.03) compared to Caucasians; treatment type/duration did not predict recurrence.
Conclusions:
- Recurrent CA-CDI in this pediatric cohort was less frequent than previously reported.
- Standard, short-course metronidazole appears effective as first-line treatment for most primary pediatric CA-CDI cases.
Background:
Recurrence of community-associated (CA) Clostridiodes difficile infection (CDI) approaches 30%. Studies on risk factors and treatment of choice for pediatric CA-CDI are scarce with variable recommendations.
Methods:
This was a retrospective cohort study of the electronic health records of children 1-17 years with stool specimens sent for C. difficile at Kaiser Permanente Northern California from January 01, 2012 to December 31, 2016. Children with (1) CA disease, (2) confirmatory C. difficile laboratory testing with no other identified causes of diarrhea and (3) clinical symptoms consistent with CDI were defined as cases. Recurrent CA-CDI was defined using the above-described case criteria and onset of diarrhea within 8 weeks of primary CA-CDI.
Results:
Of the 7350 children with stool samples sent for C. difficile testing, 408 had primary CA-CDI. Forty-five (11%) experienced a recurrence. Using multivariable logistic regression, inflammatory bowel disease [odds ratio (OR) 7.5; 95% confidence interval (CI): 2.6-21.1] and cancer (OR 6.3; 95% CI: 1.6-24.1) diagnoses were risk factors for recurrent disease. Compared with children of Caucasian race, those with multi/other/unknown race had an OR of 3.03 (95% CI: 1.04-8.82) of recurrence. There was no statistically significant difference in the type or duration of therapy as a predictor for recurrent CA CDI. Six percent of children who received metronidazole were switched to vancomycin due to subjective metronidazole allergy or intolerance or metronidazole treatment failure.
Conclusions:
Recurrent CA-CDI in children in our population is less common than previously reported. This study supports first-line treatment with the standard, short course metronidazole in most cases of primary CA-CDI.
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