Clostridium difficile: An Emerging Pathogen in Children
Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, Texas 77030, USA.Discovery medicine (Impact Factor: 3.63). 08/2012; 14(75):105-13.
Clostridium difficile is emerging as an important enteric pathogen in children. Historically considered as an asymptomatic colonizer of the gastrointestinal tract, C. difficile infection (CDI) has not been well-studied in pediatric populations. While asymptomatic carriage remains high among infants, recent epidemiological surveillance has demonstrated a rise in the prevalence of CDI in both healthcare and community settings, particularly in children 1-5 years of age. The pathogenesis of pediatric CDI, including the factors underlying the absence of toxin-mediated effects among colonized infants, remains ill-defined. Studies suggest that traditional adult CDI risk factors such as antibiotic and healthcare exposure may not be as important for children who acquire CDI in the community. As recognition of the significant impact of CDI in children increases, the pressing need for deepening our understanding of this disease and identifying optimal therapeutic and preventative strategies is becoming apparent.
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ABSTRACT: Objective: To provide a comprehensive review of the literature relating to Clostridium difficile (C. difficile) infection (CDI) in the pediatric population. Methods: Two investigators conducted independent searches of PubMed, Web of Science, and Scopus until March 31st, 2013. All databases were searched using the terms 'Clostridium difficile infection', 'Clostridium difficile associated diarrhea' 'antibiotic associated diarrhea', 'C. difficile', in combination with 'pediatric' and 'paediatric'. Articles which discussed pediatric CDI were reviewed and relevant cross references also read and evaluated for inclusion. Selection bias could be a possible limitation of this approach. Findings: There is strong evidence for an increased incidence of pediatric CDI. Increasingly, the infection is being acquired from the community, often without a preceding history of antibiotic use. The severity of the disease has remained unchanged. Several medical conditions may be associated with the development of pediatric CDI. Infection prevention and control with antimicrobial stewardship are of paramount importance. It is important to consider the age of the child while testing for CDI. Traditional therapy with metronidazole or vancomycin remains the mainstay of treatment. Newer antibiotics such as fidaxomicin appear promising especially for the treatment of recurrent infection. Conservative surgical options may be a life-saving measure in severe or fulminant cases. Conclusions: Pediatric providers should be cognizant of the increased incidence of CDI in children. Early and judicious testing coupled with the timely institution of therapy will help to secure better outcomes for this disease.
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ABSTRACT: Acute gastroenteritis, characterized by the onset of diarrhea with or without vomiting, continues to be a major cause of morbidity and mortality in children in mostly resource-constrained nations. Although generally a mild and self-limiting disease, gastroenteritis is one of the most common causes of hospitalization and is associated with a substantial disease burden. Worldwide, up to 40% of children aged less than 5 years with diarrhea are hospitalized with rotavirus. Also, some microorganisms have been found predominantly in resource-constrained nations, including Shigella spp, Vibrio cholerae, and the protozoan infections. Prevention remains essential, and the rotavirus vaccines have demonstrated good safety and efficacy profiles in large clinical trials. Because dehydration is the major complication associated with gastroenteritis, appropriate fluid management (oral or intravenous) is an effective and safe strategy for rehydration. Continuation of breastfeeding is strongly recommended. New treatments such as antiemetics (ondansetron), some antidiarrheal agents (racecadotril), and chemotherapeutic agents are often proposed, but not yet universally recommended. Probiotics, also known as "food supplement," seem to improve intestinal microbial balance, reducing the duration and the severity of acute infectious diarrhea. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition and the European Society of Paediatric Infectious Diseases guidelines make a stronger recommendation for the use of probiotics for the management of acute gastroenteritis, particularly those with documented efficacy such as Lactobacillus rhamnosus GG, Lactobacillus reuteri, and Saccharomyces boulardii. To date, the management of acute gastroenteritis has been based on the option of "doing the least": oral rehydration-solution administration, early refeeding, no testing, no unnecessary drugs.
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ABSTRACT: In children, asymptomatic colonization with Clostridium difficile is well known, but its prevalence in Japanese children is not fully understood. The objective of this study was to determine the colonization rate of C. difficile and to identify the risk factors for C. difficile colonization in Japanese children. Single fecal samples were prospectively collected from children hospitalized in Saitama City Hospital between August 1, 2012, and March 31, 2013. Samples were obtained from neonates, at 4-14 days after birth, and from non-neonatal children, principally within 2 days after admission, to determine community-associated colonization. The fecal samples were cultured for C. difficile, and isolated strains were tested for production of Clostridial toxins A/B. In 95 neonates, the colonization rate of C. difficile was 0%. The 251 non-neonatal children were divided into two subgroups, depending on the presence or absence of underlying disease. In the subgroup without underlying disease, the colonization rates of C. difficile and toxin-positive C. difficile were 21.6% and 9.0%, respectively, while in the subgroup with underlying disease, values were 30.8% and 23.1%, respectively. The proportion of toxin-positive C. difficile in all of the culture-isolated strains from the latter subgroup (75.0%) was statistically higher than that from the former subgroup (41.9%) (P = 0.049). Multivariate logistic regression analysis indicated an association of tube feeding with significantly higher colonization rates of C. difficile (Odds Ratio(OR) = 24.28; 95% confidence interval(CI)[4.70-125.34]; P < 0.001) and toxin-positive C. difficile (OR = 8.29; 95%CI[1.87-36.84]; P = 0.005). Further evaluations are recommended to assess the epidemiology and the role of C. difficile in Japanese children.
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