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Di Bella S, Sanson G, Monticelli J, Zerbato V, Principe L, Giuffrè M, Pipitone G, Luzzati R. Clostridioides difficile infection: history, epidemiology, risk factors, prevention, clinical manifestations, treatment, and future options. Clin Microbiol Rev 2024; 37:e0013523. [PMID: 38421181 PMCID: PMC11324037 DOI: 10.1128/cmr.00135-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
SUMMARYClostridioides difficile infection (CDI) is one of the major issues in nosocomial infections. This bacterium is constantly evolving and poses complex challenges for clinicians, often encountered in real-life scenarios. In the face of CDI, we are increasingly equipped with new therapeutic strategies, such as monoclonal antibodies and live biotherapeutic products, which need to be thoroughly understood to fully harness their benefits. Moreover, interesting options are currently under study for the future, including bacteriophages, vaccines, and antibiotic inhibitors. Surveillance and prevention strategies continue to play a pivotal role in limiting the spread of the infection. In this review, we aim to provide the reader with a comprehensive overview of epidemiological aspects, predisposing factors, clinical manifestations, diagnostic tools, and current and future prophylactic and therapeutic options for C. difficile infection.
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Affiliation(s)
- Stefano Di Bella
- Clinical Department of
Medical, Surgical and Health Sciences, Trieste
University, Trieste,
Italy
| | - Gianfranco Sanson
- Clinical Department of
Medical, Surgical and Health Sciences, Trieste
University, Trieste,
Italy
| | - Jacopo Monticelli
- Infectious Diseases
Unit, Trieste University Hospital
(ASUGI), Trieste,
Italy
| | - Verena Zerbato
- Infectious Diseases
Unit, Trieste University Hospital
(ASUGI), Trieste,
Italy
| | - Luigi Principe
- Microbiology and
Virology Unit, Great Metropolitan Hospital
“Bianchi-Melacrino-Morelli”,
Reggio Calabria, Italy
| | - Mauro Giuffrè
- Clinical Department of
Medical, Surgical and Health Sciences, Trieste
University, Trieste,
Italy
- Department of Internal
Medicine (Digestive Diseases), Yale School of Medicine, Yale
University, New Haven,
Connecticut, USA
| | - Giuseppe Pipitone
- Infectious Diseases
Unit, ARNAS Civico-Di Cristina
Hospital, Palermo,
Italy
| | - Roberto Luzzati
- Clinical Department of
Medical, Surgical and Health Sciences, Trieste
University, Trieste,
Italy
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2
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Shirley DA, Tornel W, Warren CA, Moonah S. Clostridioides difficile Infection in Children: Recent Updates on Epidemiology, Diagnosis, Therapy. Pediatrics 2023; 152:e2023062307. [PMID: 37560802 PMCID: PMC10471512 DOI: 10.1542/peds.2023-062307] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 08/11/2023] Open
Abstract
Clostridioides (formerly Clostridium) difficile is the most important infectious cause of antibiotic-associated diarrhea worldwide and a leading cause of healthcare-associated infection in the United States. The incidence of C. difficile infection (CDI) in children has increased, with 20 000 cases now reported annually, also posing indirect educational and economic consequences. In contrast to infection in adults, CDI in children is more commonly community-associated, accounting for three-quarters of all cases. A wide spectrum of disease severity ranging from asymptomatic carriage to severe diarrhea can occur, varying by age. Fulminant disease, although rare in children, is associated with high morbidity and even fatality. Diagnosis of CDI can be challenging as currently available tests detect either the presence of organism or disease-causing toxin but cannot distinguish colonization from infection. Since colonization can be high in specific pediatric groups, such as infants and young children, biomarkers to aid in accurate diagnosis are urgently needed. Similar to disease in adults, recurrence of CDI in children is common, affecting 20% to 30% of incident cases. Metronidazole has long been considered the mainstay therapy for CDI in children. However, new evidence supports the safety and efficacy of oral vancomycin and fidaxomicin as additional treatment options, whereas fecal microbiota transplantation is gaining popularity for recurrent infection. Recent advancements in our understanding of emerging epidemiologic trends and management of CDI unique to children are highlighted in this review. Despite encouraging therapeutic advancements, there remains a pressing need to optimize CDI therapy in children, particularly as it pertains to severe and recurrent disease.
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Affiliation(s)
| | | | - Cirle A. Warren
- Infectious Diseases and International Health, Department of Medicine
- Complicated C. difficile Clinic, UVA Health, University of Virginia, Charlottesville, Virginia
| | - Shannon Moonah
- Infectious Diseases and International Health, Department of Medicine
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3
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Thabit AK, Aljedaani HJ, Alghamdi RH, Badahdah RM, Lashkar MO, Alnajjar A. An insight into Clostridioides difficile-associated diarrhea in Saudi children: diagnosis and treatment. Expert Rev Gastroenterol Hepatol 2023; 17:805-810. [PMID: 37480286 DOI: 10.1080/17474124.2023.2240704] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 07/21/2023] [Indexed: 07/23/2023]
Abstract
INTRODUCTION Clostridioides difficile infection (CDI) is a major cause for antibiotic-associated diarrhea. Specific factors put the pediatrics at risk. International guidelines lists specific recommendations for the diagnosis and treatment of pediatric CDI. The practice of diagnosing and treating pediatric CDI in Saudi Arabia is slightly different from the recommendations of the guidelines. AREAS COVERED This review summarizes pediatric CDI in Saudi Arabia in terms of epidemiology, current diagnostics, and how the practice compares to recommendations of the guidelines, and available treatment options. EXPERT OPINION Although pediatric CDI epidemiology in Saudi Arabia doesn't impose a burden on the healthcare system, it should be noted that not all hospitals follow CDI diagnostic recommendations of international guidelines, which may result in cases underreporting. However, due to the presumed low CDI prevalence, the traditional regimen of oral metronidazole for non-severe CDI remains effective, whereas vancomycin is used for severe cases. While fidaxomicin is approved for pediatrics, its high acquisition cost and low CDI rates make it challenging for hospitals to use it. Overall, pediatrics at risk of CDI recurrence should be evaluated, such as reviewing current antibiotics for potential discontinuation. Future studies evaluating the epidemiology and treatment for CDI in Saudi children are needed.
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Affiliation(s)
- Abrar K Thabit
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Huda J Aljedaani
- Department of Pharmaceutical Care, King Khalid Hospital, Ministry of Health, Najran, Saudi Arabia
| | - Rawan H Alghamdi
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Raghad M Badahdah
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Manar O Lashkar
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Abeer Alnajjar
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Navarro ML, Nieto M, Perez-Martínez A. The need for evolution in the management of febrile neutropenia in pediatric cancer: TRIIO KIDS update. Clin Transl Oncol 2023; 25:633-642. [PMID: 36244052 DOI: 10.1007/s12094-022-02971-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 09/28/2022] [Indexed: 10/17/2022]
Abstract
New treatments have increased the life expectancy of pediatric patients diagnosed with malignant hematological diseases, often at the cost of protracting their immunocompromised state in the form of prolonged neutropenia. This neutropenic state favors the development of bacterial and fungal infections. Moreover, recent years have seen a series of changes in the epidemiology of fungal and Clostridium infections. These changes necessitate adaptations to the management of pediatric patients with febrile neutropenia, who are at risk of further increases in already high rates of morbidity and mortality. This article discusses the current bases for the management of febrile neutropenia and associated emerging fungal infections, as well as the epidemiology, diagnosis, and treatment of Clostridioides difficile in pediatric patients diagnosed with malignant hematological diseases.
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Affiliation(s)
- Maria Luisa Navarro
- Department of Paediatric Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Montserrat Nieto
- Paediatric Intensive Care Unit, Hospital Infantil Niño Jesús, Madrid, Spain
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Alrugaib T, Alsultan A, Elbashir E, Albdah B, Alharbi M, Essa MF. Antimicrobial prophylaxis and the rate of blood stream infections and Clostridioides difficile in pediatric stem cell transplantation: A single-center retrospective study. Pediatr Transplant 2023; 27:e14375. [PMID: 35946349 DOI: 10.1111/petr.14375] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 07/07/2022] [Accepted: 07/28/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The use of prophylactic antibiotics in the pre-engraftment period to minimize the risk of bacteremia is debatable given concerns of Clostridioides difficile (C. diff), antibiotics resistance, and disruption of gut microbiota. METHODS We retrospectively reviewed the rate and characteristics of bacteremia and C. diff infections within the first 100 days post-HSCT in all pediatric patients who received routine antibacterial prophylaxis during HSCT from 2015 to 2018. C. diff infection was defined by the presence of three or more unformed stools in 24 h and positive stool test for C. diff or its toxins. RESULTS One hundred and thirty-five (100 allogeneic and 35 autologous) transplants in 123 patients were eligible for analysis. Median age at transplant was 7.1 (range 0.2-13.7), 67 (55%) were women, and diagnosis was malignant condition in 68 patients. Median time to neutrophil engraftment was 18 days (13-23). Cefepime or piperacillin-tazobactam prophylaxis was used in 105 (78%) and 28 (21%) of patients, respectively. Only five (3%) patients had bacteremia during the pre-engraftment period, and 13 (11%) patients developed bacteremia postengraftment. Septic shock was present in only one patient pre-engraftment and was due to gram-negative bacteria. All patients who developed bacteremia received MAC. Thirteen patients (10%) of patients fulfilled C. diff infection definition. There was no mortality related to bacterial infections among our patients. CONCLUSIONS The use of antibiotic prophylaxis was associated with low rate of bacteremia in the pre-engraftment period and a 10% risk of C. diff infections. More studies are needed to better evaluate the efficacy of antibiotic prophylaxis in HSCT patients.
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Affiliation(s)
- Trad Alrugaib
- Department of Pediatric Hematology/Oncology, King Abdullah Specialist Children's Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | | | - Enas Elbashir
- Department of Pediatric Hematology/Oncology, King Abdullah Specialist Children's Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Bayan Albdah
- King Abdullah International Medical Research Center, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Musaed Alharbi
- King Abdullah International Medical Research Center, National Guard Health Affairs, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Department of Pediatrics, King Abdullah Specialist Children's Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mohammed F Essa
- Department of Pediatric Hematology/Oncology, King Abdullah Specialist Children's Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, National Guard Health Affairs, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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6
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Kusma M, Little J, Kociolek L. Implementation of a Structured Process for Clinically Indicated Testing for Clostridioides difficile Infections in Pediatric Oncology and Stem Cell Transplant. JOURNAL OF PEDIATRIC HEMATOLOGY/ONCOLOGY NURSING 2023; 40:178-184. [PMID: 36691391 DOI: 10.1177/27527530221140063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background: Clostridioides difficile (C. difficile) is the primary cause of healthcare-associated infectious diarrhea. Pediatric patients with oncology and stem cell transplant (SCT) diagnoses are at greater risk of C. difficile infections (CDI) and C. difficile colonization than those without. Misdiagnosis of C. difficile colonization as infection and subsequent unnecessary treatment can lead to antibiotic resistance, increased healthcare costs, and an overestimation of CDI rates. Methods: A best practice advisory (BPA) was built into the electronic medical record to guide decision making regarding clinically indicated C. difficile testing. Tests for CDI were to be sent only if the patient met all the predefined clinical criteria for testing. The number of CDI tests ordered per 1,000 patient days, the number of tests positive per 1,000 patient days, and the proportion of positive tests were compared before and after implementation. Results: The number of tests ordered per 1,000 patient days declined from 8.2 to 5.7 after the intervention. Positive tests per 1,000 patient days increased from 2.2 to 3.5 after the intervention. This demonstrates an increase in the proportion of positive tests from 27% to 61%. Discussion: This intervention led to fewer CDI tests ordered, but CDI incidence and test positivity proportion increased. This is likely reflective of better-targeted testing for CDI and the identification of true-positive cases of infection, but we cannot rule out a coincident increase in CDI activity during the study period. Through education and electronic reminders of the clinical indicators for testing for CDI, the frequency of testing for C. difficile was reduced.
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Affiliation(s)
- Molly Kusma
- Pediatric Hematology, Oncology, and Stem Cell Transplant Nurse Practitioner, 2429Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jeanne Little
- 2468Department of Women, Family, and Children Nursing, Rush University, Chicago, IL, USA
| | - Larry Kociolek
- Department of Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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7
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Cross SJ, Morton TH, Wolf J. Epidemiology, Diagnosis, and Treatment of Clostridioides difficile Infection in Immunocompromised Children. J Pediatric Infect Dis Soc 2021; 10:S46-S51. [PMID: 34791397 PMCID: PMC8824809 DOI: 10.1093/jpids/piab078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Clostridioides difficile infection is very common in immunocompromised children. Management is confounded by frequent asymptomatic colonization, multiple alternative etiologies for gastrointestinal symptoms, and high rates of relapse. Important considerations include indications for testing, appropriate choice of diagnostic tests, antibiotic therapy for initial and subsequent episodes, and primary and secondary prevention.
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Affiliation(s)
- Shane J Cross
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Theodore H Morton
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Joshua Wolf
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Tougas SR, Lodha N, Vandermeer B, Lorenzetti DL, Tarr PI, Tarr GAM, Chui L, Vanderkooi OG, Freedman SB. Prevalence of Detection of Clostridioides difficile Among Asymptomatic Children: A Systematic Review and Meta-analysis. JAMA Pediatr 2021; 175:e212328. [PMID: 34338715 PMCID: PMC8329794 DOI: 10.1001/jamapediatrics.2021.2328] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
IMPORTANCE Detection of Clostridioides difficile has frequently been described in asymptomatic infants and children, but accurate estimates across the age spectrum are unavailable. OBJECTIVE To assess the prevalence of C difficile detection among asymptomatic children across the age spectrum. DATA SOURCES This systematic review and meta-analysis included a search of the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, Scopus, and Web of Science for articles published from January 1, 1990, to December 31, 2020. Search terms included Clostridium difficile, Peptoclostridium difficile, Clostridioides difficile, CDF OR CDI OR c diff OR c difficile, Clostridium infections OR cd positive diarrhea OR cd positive diarrhea OR Clostridium difficile OR Peptoclostridium difficile OR pseudomembranous colitis OR pseudomembranous enterocolitis, enterocolitis, and pseudomembranous. These were combined with the following terms: bacterial colonization and colonization OR colonized OR colonizing OR epidemiology OR prevalence OR seroprevalence. STUDY SELECTION Studies were screened independently by 2 authors. Studies were included if they reported testing for C difficile among asymptomatic children (ie, children without diarrhea) younger than 18 years. DATA EXTRACTION AND SYNTHESIS Data were extracted independently and in duplicate by 2 reviewers. Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines were used. Data were pooled using a random-effects model. MAIN OUTCOMES AND MEASURES The primary outcome was prevalence of C difficile detection among asymptomatic children. Secondary outcomes included prevalence of toxigenic vs nontoxigenic strains of C difficile and prevalence of C difficile detection stratified by geographic region, income status, testing method, and year of testing. RESULTS A total of 95 studies with 19 186 participants were included. Rates of detection of toxigenic or nontoxigenic C difficile were greatest among infants aged 6 to 12 months (41%; 95% CI, 32%-50%) and decreased to 12% (95% CI, 7%-18%) among children aged 5 to 18 years. The prevalence of toxigenic C difficile colonization was lower, peaking at 14% (95% CI, 8%-21%) among infants aged 6 to 12 months and decreasing to 6% (95% CI, 2%-11%) among children older than 5 years. Although prevalence differed by geographic region (ie, North and South America vs Europe: β, -0.151, P = .001; North and South America vs Western Pacific: β, 0.136, P = .007), there was no difference by testing method (ie, culture vs polymerase chain reaction: β, 0.069, P = .052; culture vs enzyme immunoassay: β, -0.178, P = .051), income class (low-middle income vs high income: β, -0.144, P = .23; upper-middle vs high income: β, -0.020, P = .64), or period (before 1990 vs 2010-2020: β, -0.125, P = .19; 1990-1999 vs 2010-2020: β, -0.037, P = .42; 2000-2009 vs 2010-2020: β, -0.006, P = .86). CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, C difficile colonization rates among children were greatest at 6 to 12 months of age and decreased thereafter. These estimates may provide context for interpreting C difficile test results among young children.
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Affiliation(s)
- Sarah R Tougas
- Cumming School of Medicine, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Nidhi Lodha
- Cumming School of Medicine, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Ben Vandermeer
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Diane L Lorenzetti
- Department of Community Health Sciences and the Health Sciences Library, University of Calgary, Calgary, Alberta, Canada
| | - Phillip I Tarr
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri.,Department of Molecular Microbiology, Washington University in St Louis, St Louis, Missouri
| | - Gillian A M Tarr
- Division of Environmental Health Sciences, School of Public Health, University of Minnesota, Minneapolis
| | - Linda Chui
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Otto G Vanderkooi
- Alberta Children's Hospital, Division of Pediatric Infectious Disease, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, Microbiology, Immunology and Infectious Diseases, Community Health Sciences, and Pathology & Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen B Freedman
- Alberta Children's Hospital, Divisions of Pediatric Emergency Medicine and Gastroenterology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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9
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Barbar R, Hayden R, Sun Y, Tang L, Hakim H. Epidemiologic and Clinical Characteristics of Clostridioides difficile Infections in Hospitalized and Outpatient Pediatric Oncology and Hematopoietic Stem Cell Transplant Patients. Pediatr Infect Dis J 2021; 40:655-662. [PMID: 34097657 DOI: 10.1097/inf.0000000000003126] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The epidemiology and clinical course of Clostridioides difficile infection (CDI) in children, especially with cancer, are poorly defined. We aim to describe the epidemiology, clinical features and outcomes of CDI and to identify risk factors for recurrence in a pediatric oncology center. METHODS This is a retrospective cohort study of CDI in pediatric oncology and hematopoietic stem cell transplant (HSCT) patients in 2016 and 2017. CDI cases were identified by positive C. difficile test in symptomatic patients. CDI episodes were classified as incident, duplicate or recurrent and community-onset, hospital-onset or community-onset healthcare facility-associated. Data about clinical course and outcomes were abstracted. Risk factors for CDI recurrence were assessed by logistic regression. RESULTS One hundred seventy-eight patients 1 year of age and older developed 291 CDI episodes; 78% were incident and 22% recurrent. Underlying diagnoses were leukemia/lymphoma (57%) and solid/brain tumors (41%); 30% were HSCT recipients. Antibiotics, chemotherapy, antacids, steroids and laxatives were received by 96%, 82%, 70%, 47% and 15%, respectively. Half of the patients were neutropenic. Twenty-two percent of outpatients with CDI required hospitalization. Chemotherapy was delayed in 25%. There were no intensive care unit admissions nor deaths due to CDI. Exposure to H2-antagonists was identified as an independent risk factor for CDI recurrence. CONCLUSIONS Although CDI in pediatric oncology and HSCT patients was associated with chemotherapy delay and hospitalization in approximately a quarter of patients, it was not associated with morbidity or mortality because patients had no attributable intensive care unit admission nor death. H2-antagonists are independent risk factors for CDI recurrence.
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Affiliation(s)
| | | | - Yilun Sun
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Li Tang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Hana Hakim
- From the Department of Infectious Diseases
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10
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Gates V, Best E, Roberts S, Swager T, Voss L. Diagnosis and management of paediatric Clostridioides difficile infection in a tertiary centre: A prospective audit. J Paediatr Child Health 2021; 57:500-506. [PMID: 33145899 DOI: 10.1111/jpc.15246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 09/05/2020] [Accepted: 09/20/2020] [Indexed: 12/23/2022]
Abstract
AIM The optimisation of diagnosis and management of paediatric Clostridioides (formerly Clostridium) difficile (C. difficile) infection (CDI) has importance on multiple levels, from individual patient to population disease management and infection control. This study aimed to evaluate current practice at a paediatric tertiary hospital against Australasian Society for Infectious Diseases 2016 guidelines. METHODS Prospective audit was undertaken. All positive C. difficile tests (by two step immunoassay then polymerase chain reaction) over 6 month period were reviewed for appropriateness of testing, including review of clinical characteristics and treatment of appropriately requested positive tests (CDI cases). Consecutive test requests for C. difficile over 2 month period were reviewed for appropriateness of testing. RESULTS Of 70 consecutive test requests, 64 met laboratory criteria for processing. Of these, 31 (48%) out of 64 were asymptomatic or had clinically insignificant or laxative-associated diarrhoea. Overall, 44 (63%) out of 70 were deemed inappropriate requests. Of 45 positive tests, 17 (38%) were appropriately requested. Amongst inappropriate requests, 13 (46%) out of 28 were treated; those aged >2 years were significantly more likely to be treated (P < 0.05). Thirteen children were treated unnecessarily. Only one out of seven positive tests in infants (<1 year) was appropriately requested. Haematology/oncology patients accounted for 41% of cases. Treatment was in accordance with guidelines in 58% of cases. CONCLUSIONS Inappropriate testing for C. difficile and variable clinical response to positive tests have sequelae including unnecessary antibiotics for hospitalised children. Areas for improvement have been identified and this study confirms the need for establishment of national paediatric CDI guidelines with increased awareness of these by clinicians.
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Affiliation(s)
- Victoria Gates
- Department of Paediatric Infectious Diseases, Starship Children's Health, Auckland, New Zealand
| | - Emma Best
- Department of Paediatric Infectious Diseases, Starship Children's Health, Auckland, New Zealand.,Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Sally Roberts
- Department of Microbiology, LabPlus, Auckland City Hospital, Auckland, New Zealand
| | - Terri Swager
- Department of Microbiology, LabPlus, Auckland City Hospital, Auckland, New Zealand
| | - Lesley Voss
- Department of Paediatric Infectious Diseases, Starship Children's Health, Auckland, New Zealand
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11
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Mayer EF, Maron G, Dallas RH, Ferrolino J, Tang L, Sun Y, Danziger-Isakov L, Paulsen GC, Fisher BT, Vora SB, Englund J, Steinbach WJ, Michaels M, Green M, Yeganeh N, Gibson JE, Dominguez SR, Nicholson MR, Dulek DE, Ardura MI, Rajan S, Gonzalez BE, Beneri C, Herold BC. A multicenter study to define the epidemiology and outcomes of Clostridioides difficile infection in pediatric hematopoietic cell and solid organ transplant recipients. Am J Transplant 2020; 20:2133-2142. [PMID: 32064754 DOI: 10.1111/ajt.15826] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 01/14/2020] [Accepted: 01/31/2020] [Indexed: 01/25/2023]
Abstract
Hematopoietic cell transplant (HCT) and solid organ transplant (SOT) recipients are at increased risk for Clostridioides difficile infection (CDI). We conducted a multicenter retrospective study to describe the incidence of CDI in children transplanted between January 2010 and June 2013. Nested case-control substudies, matched 1:1 by transplant type, institution, patient age, and time of year (quartile) of transplant, identified CDI risk factors. Cohorts included 1496 HCT and 1090 SOT recipients. Among HCT recipients, 355 CDI episodes were diagnosed in 265 recipients (18.2%). Nested case-control study identified prior history of CDI (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.5-4.7), proton pump inhibitors (PPIs; OR 2.1, 95% CI 1.3-3.4), and exposure to third- (OR 2.4, 95% CI 1.4-4.2) or fourth-generation (OR 2.1, 95% CI 1.2-3.7) cephalosporins as risk factors. Notably, fluoroquinolone exposure appeared protective (OR 0.6, 95% CI 0.3-0.9). Ninety-two episodes of CDI were diagnosed among 79 SOT recipients (7.3%), and exposure to PPIs (OR 2.4, 95% CI 1.1-5.4) and third-generation cephalosporin therapy (OR 3.9, 95% CI 1.4-10.5) were identified as risk factors. Strategies to decrease PPI use and changes in the class of prophylactic antibiotics may impact CDI incidence and warrant further study.
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Affiliation(s)
- Erick F Mayer
- Department of Pediatrics, Albert Einstein College of Medicine and Children's Hospital at Montefiore, Bronx, New York, USA
| | - Gabriela Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Ronald H Dallas
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jose Ferrolino
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Li Tang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Yilun Sun
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Lara Danziger-Isakov
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Grant C Paulsen
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Brian T Fisher
- Division of Infectious Diseases and Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Surabhi B Vora
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Janet Englund
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
| | - William J Steinbach
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Marian Michaels
- Department of Pediatrics & Surgery, Division of Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael Green
- Department of Pediatrics & Surgery, Division of Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nava Yeganeh
- Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Joy E Gibson
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Samuel R Dominguez
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Maribeth R Nicholson
- Department of Pediatrics, Monroe Carell Jr Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Daniel E Dulek
- Department of Pediatrics, Monroe Carell Jr Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Monica I Ardura
- Department of Pediatrics & Host Defense Program, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Sujatha Rajan
- Cohen Children's Medical Center, Northwell Health, New Hyde Park, New York, USA
| | | | - Christy Beneri
- Department of Pediatric, Stony Brook School of Medicine, Stony Brook, New York, USA
| | - Betsy C Herold
- Department of Pediatrics, Albert Einstein College of Medicine and Children's Hospital at Montefiore, Bronx, New York, USA.,Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York, USA
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12
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Spruit JL, Knight T, Sweeney C, Salimnia H, Savaşan S. Clostridium difficile infection in a children's hospital with specific patterns among pediatric oncology and hematopoietic stem cell transplantation populations. Pediatr Hematol Oncol 2020; 37:211-222. [PMID: 31994977 DOI: 10.1080/08880018.2019.1711473] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background: Clostridium difficile (CD) is often classified as a healthcare-associated infection (HAI) and a hospital-acquired condition (HAC) in the hospital setting. However, pediatric oncology patients comprise a significant portion of Clostridium difficile infections (CDI), with hematopoietic stem cell transplant (HSCT) recipients constituting a major subset of this group due to unique, non-modifiable risk factors. We evaluated patterns of clostridium difficile infections at our institution to provide an accurate evaluation of the vulnerability of pediatric oncology and HSCT patients to clostridium difficile infections in comparison to the general pediatric population and underscore the non-tenability of classifying clostridium difficile infections as a hospital-acquired condition in HSCT patients. Methods: Single-center retrospective review of all clostridium difficile stool tests performed over an 11-year period; data analyzed and statistical comparisons performed between patient groups. Results: 5271 total samples were obtained during the study time period from 3127 patients. At least one positive test result was found in 18.6% of patients. Oncology and HSCT patients (38.2%) were more likely to have a positive test result than hematology (17.5%) and other patients (16.8%) (p < 0.001). Sixty-percent of patients who underwent HSCT were tested during this time frame. Of those, 39.3% had a positive test result and 48.5% of those patients went on to have a subsequent infection that met the criteria to be defined as recurrent. Conclusions: The high incidence rate and frequency of recurrence underscores the current near-inevitable nature of clostridium difficile infections in oncology and HSCT patients. We conclude that a blanket designation of clostridium difficile infections as an hospital-acquired condition is therefore questionable in this population.
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Affiliation(s)
- Jessica L Spruit
- Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA.,Division of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation Program, Barbara Ann Karmanos Center, Detroit, MI, USA
| | - Tristan Knight
- Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA.,Division of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation Program, Barbara Ann Karmanos Center, Detroit, MI, USA
| | - Colleen Sweeney
- Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA.,Division of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation Program, Barbara Ann Karmanos Center, Detroit, MI, USA
| | - Hossein Salimnia
- Department of Pathology, Wayne State University, Detroit, MI, USA
| | - Süreyya Savaşan
- Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA.,Division of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation Program, Barbara Ann Karmanos Center, Detroit, MI, USA
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13
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Karim S, Begum F, Islam A, Tarafdar MA, Begum M, Islam MJ, Malik B, Ahsan MS, Khatami A, Rashid H. Pathogens causing diarrhoea among Bangladeshi children with malignancy: Results from two pilot studies. World J Clin Cases 2020; 8:276-283. [PMID: 32047775 PMCID: PMC7000943 DOI: 10.12998/wjcc.v8.i2.276] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/27/2019] [Accepted: 12/13/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Diarrhoea is a frequent symptom in children with cancer, and occurs due to a composite effect of underlying disease and immunosuppression consequent to therapy, malnutrition, and non-infective aetiologies such as mucositis. In a large proportion of cases, the aetiology of diarrhoea remains unknown but is often attributed to multiple pathogens including parasites.
AIM To identify and describe the pathogens causing diarrhoea in Bangladeshi children with cancer.
METHODS Two cross-sectional pilot studies were conducted involving paediatric oncology patients with diarrhoea. Stool samples were collected from children who were hospitalised with or without being treated with chemotherapy during the study period, and had diarrhoea at any stage during their admission. In the first study, stool samples were tested by conventional microbiological methods and by polymerase chain reaction for parasites, and by immunoassays for Clostridium difficile. In the second study, conventional microbiology was conducted for bacteria and parasites including an enzyme-linked immunosorbent assay for Cryptosporidium antigen, and in a subset, immunoassays for Clostridium
difficile.
RESULTS In the first study Giardia lamblia was detected in 68.5% of samples, Entamoeba histolytica in 13%, Cryptosporidium in 5.6%, non-toxigenic C. difficile in 22.4%, and other bacteria in 5.2%. In the second study, E. histolytica was detected in 10% of samples, Cryptosporidium in 4.3%, G. lamblia in 1.4%, C. difficile in 5.1%, and other bacteria in 5.7% of samples.
CONCLUSION These pilot data suggest that parasites are important aetiologies of diarrhoea in Bangladeshi children with malignancy. While molecular diagnostic tools detect an array of stool pathogens with greater sensitivity, conventional diagnostic methods are also useful.
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Affiliation(s)
- Sabina Karim
- Department of Paediatric Haematology and Oncology, National Institute of Cancer Research and Hospital, Mohakhali, Dhaka 1212, Bangladesh
| | - Ferdousi Begum
- Department of Paediatric Haematology and Oncology, National Institute of Cancer Research and Hospital, Mohakhali, Dhaka 1212, Bangladesh
| | - Afiqul Islam
- Department of Pediatric Hematology and Oncology, Bangabandhu Sheikh Mujib Medical University, Dhaka 1212, Bangladesh
| | - Monowar Ahmad Tarafdar
- Department of Community Medicine, Z. H. Sikder Women’s Medical College, Dhaka 1212, Bangladesh
| | - Mamtaz Begum
- Department of Paediatric Haematology and Oncology, National Institute of Cancer Research and Hospital, Mohakhali, Dhaka 1212, Bangladesh
| | - Md Johirul Islam
- Department of Cancer Epidemiology, National Institute of Cancer Research and Hospital, Mohakhali, Dhaka 1212, Bangladesh
| | - Bushra Malik
- National Centre for Immunisation Research and Surveillance, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
| | - Md Shamim Ahsan
- Medical Services, Rangpur Cantonment, Rangpur 5400, Bangladesh
| | - Ameneh Khatami
- Department of Infectious Diseases and Microbiology, The Children’s Hospital at Westmead, NSW 2145, Australia
- Discipline of Child and Adolescent Health, Faculty of Medicine and Health, University of Sydney, NSW 2145, Australia
| | - Harunor Rashid
- National Centre for Immunisation Research and Surveillance, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
- Discipline of Child and Adolescent Health, Faculty of Medicine and Health, University of Sydney, NSW 2145, Australia
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