Article

Clostridium difficile infection and treatment in the pediatric inflammatory bowel disease population.

Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
Journal of pediatric gastroenterology and nutrition (Impact Factor: 2.18). 03/2011; 52(4):437-41. DOI: 10.1097/MPG.0b013e3181f97209
Source: PubMed

ABSTRACT Recent changes in the epidemiology of Clostridium difficile infection include an increase in the incidence of C difficile-associated disease (CDAD) and the identification of patients with inflammatory bowel disease (IBD) as a group at risk. In addition, the effectiveness of antimicrobial therapies has been questioned. Our aim was to estimate the incidence of CDAD in a pediatric IBD population and review treatment efficacy.
We identified patients ages 18 years or younger from our center's IBD database who tested positive for C difficile toxin A and/or B between August 1, 2007 and December 31, 2008. Demographic information and treatment details were recorded. Chi-square and Fisher exact tests were used to compare categorical variables and the Student t test was used for continuous variables.
From 372 pediatric patients with IBD, we identified 29 patients who experienced a total of 40 cases of CDAD. The annualized incidence rate of CDAD was 7.2%. Initial treatment was successful in 17 cases (43%). Eventual success was documented with metronidazole in 15 cases (41%), with vancomycin in 16 cases (43%), and with other agents or a combination of agents in 6 cases (16%). Age, sex, and IBD type were not associated with initial treatment outcome or recurrence. The choice of initial antimicrobial treatment was not associated with treatment outcome. The type of IBD therapy medication was not associated with the likelihood of CDAD recurrence, although the use of anti-inflammatory therapy was positively associated with initial antimicrobial treatment success.
CDAD occurred frequently in our cohort of pediatric patients with IBD. Antimicrobial treatment success was achieved equally with either metronidazole or vancomycin. Initial treatment failed more than half of the time, regardless of medication choice. Apparent lack of antimicrobial efficacy in resolving symptoms may reflect resistant C difficile infection or increased IBD severity in a subset of patients who are C difficile carriers. Awareness of the potential for a high incidence of CDAD and frequent failure rate of initial therapy is important in the management of children with IBD.

0 Bookmarks
 · 
87 Views
  • [Show abstract] [Hide abstract]
    ABSTRACT: We aimed to determine the incidence of Clostridium difficile infection (CDI), the molecular epidemiology of circulating C. difficile strains and risk factors for CDI among hospitalised children in the Auckland region. A cross-sectional study was undertaken of hospitalised children <15 years of age in two hospitals investigated for healthcare-associated diarrhoea between November 2011 and June 2012. Stool specimens were analysed for the presence of C. difficile using a two-step testing algorithm including polymerase chain reaction (PCR). C. difficile was cultured and PCR ribotyping performed. Demographic data, illness characteristics and risk factors were compared between children with and without CDI. Non-duplicate stool specimens were collected from 320 children with a median age of 1.2 years (range 3 days to 15 years). Forty-six patients (14 %) tested met the definition for CDI. The overall incidence of CDI was 2.0 per 10,000 bed days. The percentage of positive tests among neonates was only 2.6 %. PCR ribotyping showed a range of strains, with ribotype 014 being the most common. Significant risk factors for CDI were treatment with proton pump inhibitors [risk ratio (RR) 1.74, 95 % confidence interval (CI) 1.09-5.59; p = 0.002], presence of underlying malignancy (RR 2.71, 95 % CI 1.65-4.62; p = 0.001), receiving chemotherapy (RR 2.70, 95 % CI 1.41-4.83; p = 0.003) and exposure to antibiotics (RR 1.17, 95 % CI 0.99-1.17; p = 0.03). C. difficile is an important cause of healthcare-associated diarrhoea in this paediatric population. The notion that neonatal populations will always have high rates of colonisation with C. difficile may not be correct. Several risk factors associated with CDI among adults were also found to be significant.
    European Journal of Clinical Microbiology 05/2014; · 3.02 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: The incidence of C. difficile infection (CDI) has risen among children; however, optimal management of CDI within a diverse pediatric population remains unclear. Although adult guidelines recommend oral vancomycin for treatment of second recurrence or severe CDI, dedicated pediatric data to support pediatric specific management guidelines are lacking. Our objective was to describe current CDI management practices by pediatric infectious diseases (ID) physicians. Methods: We surveyed pediatric members of the Emerging Infections Network, a network of ID physicians across North America, in October 2012. Clinical vignettes were used to determine how physicians modify CDI management based on clinical presentation, such as recurrent or severe CDI, or presence of underlying co-morbidities, including organ transplant, inflammatory bowel disease, and neutropenia. Results: Of the 285 physicians surveyed, 167 (59%) responded. There were no significant differences in geography, level of experience, or hospital type between respondents and non-respondents. All respondents (100%) used oral metronidazole for the initial occurrence of mild CDI in a normal host. Management varied substantially for mild CDI in patients with a variety of underlying co-morbidities or immunosuppression, in whom metronidazole therapy was recommended less frequently (41-79%). For management of severe CDI, 65% of respondents preferred oral vancomycin either alone or in combination with at least one other agent; however, over 30% used metronidazole alone. Oral vancomycin alone or in combination was preferred by 92% for management of a second recurrence. Among 125 respondents who reported the use of alternative therapies for recurrent or severe CDI, 23 (18%) recommend fecal microbiota transplant, most commonly for treatment of a third or later recurrence, while 20 (16%) reported ever using fidaxomicin. Conclusion: Pediatric ID physicians prefer metronidazole for the treatment of mild CDI in healthy children, but management strategies vary for patients with underlying co-morbidities or recurrent or severe disease. These findings highlight the need for pediatric comparative effectiveness studies aimed at determining the optimal treatment for children with CDI.
    Journal of the Pediatric Infectious Diseases Society. 10/2013;
  • [Show abstract] [Hide abstract]
    ABSTRACT: This article defines the risk factors for Clostridium difficile infection (CDI) in hospitalized children in light of recent studies demonstrating a change in the epidemiology of these infections in both adults and children.
    Current Opinion in Pediatrics 07/2014; · 2.74 Impact Factor

Full-text (2 Sources)

Download
10 Downloads
Available from
Jul 14, 2014