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Lo Vecchio A, Quitadamo P, Poeta M, Buccigrossi V, Siani P, Cioffi V, Ercolini D, Guarino A. Aetiology, risk factors and microbiota composition in children with prolonged diarrhoea: A prospective case-controlled cohort study. Acta Paediatr 2024; 113:598-605. [PMID: 38129967 DOI: 10.1111/apa.17073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/15/2023] [Accepted: 12/12/2023] [Indexed: 12/23/2023]
Abstract
AIM Prolonged diarrhoea (ProD) refers to acute-onset diarrhoea that persists for longer than 1 week. As the aetiology, risk factors and management are poorly defined, we prospectively enrolled children hospitalised in a high-income setting to assess these outcomes and investigate the potential role of gut microbiota. METHODS All children aged 30 days to 14 years admitted for acute-onset diarrhoea lasting 7-14 days were included. Children consecutively admitted in the same period for acute diarrhoea (AD) served as controls. High-throughput sequencing of 16S rRNA gene amplicons was used to analyse stool samples from a subset of patients and healthy controls. RESULTS Sixty-eight with ProD and 104 with AD were enrolled. Intestinal infections were the main aetiology of diarrhoea in both groups (ProD 92.9% vs. AD 97.8%). ProD children showed a higher prevalence of bacterial infections compared to AD (30.8% vs. 8.9%, p = 0.024). Neither age, host-related factors, nor microbiome alterations were specifically linked to ProD. However, ProD children had a more severe initial clinical presentation than AD. CONCLUSION ProD is often the result of an unusually severe intestinal infection that runs a course longer than expected but generally resolves without further problems. No specific management or therapies should be undertaken in most cases.
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Affiliation(s)
- Andrea Lo Vecchio
- Department of Translational Medical Science-Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - Paolo Quitadamo
- Pediatric Gastroenterology and Hepatology Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Marco Poeta
- Department of Translational Medical Science-Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - Vittoria Buccigrossi
- Department of Translational Medical Science-Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - Paolo Siani
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Valentina Cioffi
- Department of Translational Medical Science-Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - Danilo Ercolini
- Department of Agricultural Sciences, University of Naples Federico II, Portici, Italy
| | - Alfredo Guarino
- Department of Translational Medical Science-Section of Pediatrics, University of Naples Federico II, Naples, Italy
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2
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Lee P, Nemati K, Silver EJ, Cacace J, Goldman DL. Risk factors for Recurrent Clostridioides Difficile Infection in Children. Hosp Pediatr 2023; 13:1010-1017. [PMID: 37877183 DOI: 10.1542/hpeds.2023-007154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
OBJECTIVE The aims of this study were to determine the epidemiologic and treatment factors associated with recurrent C. difficile infection in children. METHODS We conducted a 13-year retrospective review of pediatric C. difficile infections at our institution focusing on the epidemiologic, clinical, and treatment factors associated with recurrent disease. Repeat episodes occurring between 4 weeks and 2 months after initial infection were defined as early recurrences, whereas repeat episodes between 2 and 12 months after initial infection were defined as late recurrences. RESULTS We identified 303 children with C. difficile infection. Recurrent infections were limited to children with chronic conditions, affecting 27.4% (68 of 248) of this cohort. Early and late recurrences occurred in 36.8 and 63.2% of children, respectively. Among children with a chronic condition, female sex and initial use of metronidazole (as opposed to vancomycin) were associated with recurrent disease in bivariate and multivariate analyses. Overall, there was a high treatment failure rate (34 of 102, 33.3%) once children had developed recurrent disease. CONCLUSIONS Findings from this study demonstrate the importance of underlying chronic conditions in the development of recurrent C. difficile disease and the shortcomings of current treatment options for recurrent cases. Additionally, our findings indicate that initial treatment selection may impact the likelihood of future disease, with metronidazole usage being associated with higher recurrence rates than vancomycin. These findings highlight the need for additional studies to better understand the implications of C. difficile treatment strategies.
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Affiliation(s)
- Philip Lee
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore/Albert Einstein College of Medicine
- Department of Pharmacy
| | - Koorosh Nemati
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore/Albert Einstein College of Medicine
| | | | | | - David L Goldman
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore/Albert Einstein College of Medicine
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
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3
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Sferra TJ, Merta T, Neely M, Murta de Oliveira C, Lassaletta A, Fortuny Guasch C, Dorr MB, Winchell G, Su FH, Perko S, Fernsler D, Waskin H, Holden SR. Double-Blind, Placebo-Controlled Study of Bezlotoxumab in Children Receiving Antibacterial Treatment for Clostridioides difficile Infection (MODIFY III). J Pediatric Infect Dis Soc 2023; 12:334-341. [PMID: 37389891 DOI: 10.1093/jpids/piad031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/19/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Therapies to prevent recurrence of Clostridioides difficile infection (CDI) in pediatric patients are needed. Bezlotoxumab is a fully human monoclonal antibody approved for prevention of recurrent CDI in adults. We assessed the pharmacokinetics, safety, tolerability, and efficacy of bezlotoxumab in pediatric patients. METHODS MODIFY III was a multicenter, double-blind, placebo-controlled study of bezlotoxumab in children (1 to <18 years) receiving antibacterial treatment for CDI. Participants were randomized 3:1 to receive a single infusion of bezlotoxumab (10 mg/kg) or placebo and were stratified by age at randomization (cohort 1: 12 to <18 years, cohort 2: 1 to <12 years). The primary objective was to characterize bezlotoxumab pharmacokinetics to support dose selection for pediatric patients; the primary endpoint was the area under the bezlotoxumab serum concentration-time curve (AUC0-inf). Safety, tolerability, and efficacy were monitored for 12 weeks post-infusion. RESULTS A total of 148 participants were randomized and 143 were treated: 107 with bezlotoxumab and 36 with placebo (cohort 1 n = 60, cohort 2 n = 83; median age 9.0 years); 52.4% of participants were male and 80.4% were white. Geometric mean ratios (90% CI) for bezlotoxumab AUC0-inf were 1.06 (0.95, 1.18) and 0.82 (0.75, 0.89) h * μg/mL for cohorts 1 and 2, respectively. Bezlotoxumab 10 mg/kg was generally well-tolerated with an adverse event profile similar to placebo, including no treatment discontinuations due to adverse events. CDI recurrence was low and comparable for bezlotoxumab (11.2%) and placebo (14.7%). CONCLUSIONS The results of this study support the bezlotoxumab dose of 10 mg/kg for pediatric patients. TRIAL REGISTRATION NCT03182907 at ClinicalTrials.gov.
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Affiliation(s)
- Thomas J Sferra
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Tomas Merta
- Department of Pediatric Oncology, University Hospital Brno, Brno, Czech Republic
| | - Michael Neely
- Division of Infectious Diseases, Children's Hospital Los Angeles, Los Angeles, California, USA
| | | | - Alvaro Lassaletta
- Pediatric Hematology-Oncology Department, Hospital Niño Jesus, Madrid, Spain
| | | | | | | | - Feng-Hsiu Su
- Clinical Operations, Merck & Co., Inc., Rahway, New Jersey, USA
| | | | | | - Hetty Waskin
- PPDM QP2, Merck & Co., Inc., Rahway, New Jersey, USA
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4
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Tashiro S, Mihara T, Okawa R, Tanaka Y, Samura M, Enoki Y, Taguchi K, Matsumoto K, Yamagishi Y. Optimal therapeutic recommendation for Clostridioides difficile infection in pediatric and adolescent populations: a systematic review and meta-analysis. Eur J Pediatr 2023:10.1007/s00431-023-04944-y. [PMID: 37000258 DOI: 10.1007/s00431-023-04944-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/15/2023] [Accepted: 03/22/2023] [Indexed: 04/01/2023]
Abstract
We conducted a systematic review and meta-analysis to examine the efficacy profiles of metronidazole (MNZ) and vancomycin (VCM) in pediatric and adolescent patients with Clostridioides difficile infection (CDI). A systematic review and meta-analysis was conducted using four electronic databases (PubMed, Cochrane Library, Web of Science, and Clinicaltrials.gov) through July 6, 2022. We analyzed the clinical cure and recurrence rates to determine the efficacy of MNZ and VCM. The clinical cure rates in all included studies were not significantly different between MNZ and VCM (OR = 0.63; 95% CI = 0.36-1.10; I2 = 0%; P = 0.10). Subgroup analyses were performed separately for each region to account for regional differences in the CDI. MNZ treatment achieved significantly lower clinical cure rates than did VCM in the United States of America (USA) and Europe (OR = 0.42, 95% CI = 0.19-0.93, I2 = 0%, P = 0.03). Recurrence rates were not significantly different between MNZ and VCM (OR = 1.48, 95% CI = 0.62-3.53, I2 = 28%, P = 0.38). Conclusion: MNZ exhibited significantly lower clinical cure rates than did VCM in the US and Europe; therefore, it is not recommended for the management of CDI in pediatric and adolescent populations. What is Known: • The unavailability of robust data on recommendations of therapeutic agents for the management of Clostridioides difficile infections in children precludes effective antibiotic choice. What is New: • Metronidazole exhibited significantly lower clinical cure rates than did vancomycin in the United States of America and Europe and recurrence rate was not significantly different between metronidazole and vancomycin; therefore, it is not recommended for the management of Clostridioides difficile infection in children.
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Affiliation(s)
- Sho Tashiro
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Takayuki Mihara
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Rikiya Okawa
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Yoko Tanaka
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Masaru Samura
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Yuki Enoki
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan.
| | - Kazuaki Taguchi
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Yuka Yamagishi
- Department of Clinical Infectious Diseases, Kochi Medical School, Kochi, Japan
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5
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Buonsenso D, Graffeo R, Pata D, Valentini P, Palumbo C, Masucci L, Ruggiero A, Attinà G, Onori M, Lancella L, Lucignano B, Giuseppe MD, Bernaschi P, Cursi L. Clostridioides difficile Infection in Children: A 5-Year Multicenter Retrospective Study. Front Pediatr 2022; 10:783098. [PMID: 35463889 PMCID: PMC9021549 DOI: 10.3389/fped.2022.783098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 02/17/2022] [Indexed: 11/13/2022] Open
Abstract
While there are numerous studies regarding Clostridioides difficile infection (CDI) in adults, literature on the pediatric population is scarce. Therefore, we performed a 5-year retrospective study between January 2014 and December 2018 in two referral centers in Rome, Italy. There were 359 patients tested for CDI who were enrolled: 87 resulted in positive and 272 in negative. CDI children had a higher number of previous-day hospital admissions (p = 0.024), hospitalizations (p = 0.001), and total hospital admissions (p = 0.008). Chronic comorbidities were more frequent in the CDI group (66.7% vs. 33.3%). Previous use of proton pump inhibitors and antibiotics was associated with CDI (p < 0.001). Among the antibiotics, only fluoroquinolones were significantly associated with CDI. Also, CDI children were more frequently exposed to antibiotics during the episode of hospitalization when children were tested. Our study provides an updated clinical and epidemiological analysis of children with CDI compared with a control group of children who tested negative. Further prospective studies could better define risk factors and preventive methods.
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Affiliation(s)
- Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy.,Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy.,Global Health Research Institute, Istituto di Igiene, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Rosalia Graffeo
- Dipartimento di Scienze di laboratorio e infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Davide Pata
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Piero Valentini
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Carla Palumbo
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Luca Masucci
- Dipartimento di Scienze di laboratorio e infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio Ruggiero
- Unità di Oncologia Pediatrica, Fondazione Policlinico Universitario Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giorgio Attinà
- Unità di Oncologia Pediatrica, Fondazione Policlinico Universitario Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Manuela Onori
- Internal Care Department, General Pediatric and Infectious Disease Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Laura Lancella
- Internal Care Department, General Pediatric and Infectious Disease Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Barbara Lucignano
- Department of Laboratories, Bambino Gesù Children's Hospital, Rome, Italy
| | | | - Paola Bernaschi
- Unit of Microbiology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Laura Cursi
- Internal Care Department, General Pediatric and Infectious Disease Unit, Bambino Gesù Children's Hospital, Rome, Italy
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6
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Nogueira HBR, Costa CL, Martins CS, Morais MLGS, Quesada-Gómez C, Carvalho CBM, de Oliveira Ferreira E, de Castro Brito GA. Infection with Clostridioides difficile ribotype 046 in a paediatric liver transplant patient. Access Microbiol 2021; 3:000268. [PMID: 34816088 PMCID: PMC8604175 DOI: 10.1099/acmi.0.000268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 08/04/2021] [Indexed: 11/18/2022] Open
Abstract
Clostridioides difficile causes nosocomial diarrhoea associated with antibiotic use and immunodeficiency. Although the number of paediatric C. difficile infections (CDIs) has increased worldwide, there are few studies on the molecular characterization of strains causing CDIs among children. We report the clinical features and strain molecular characterization of a CDI in a female child with a history of liver transplantation at 7 months of age. This is the first report of the 046 ribotype causing paediatric diarrhoea.
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Affiliation(s)
- Hildenia B R Nogueira
- Albert Sabin Children's Hospital, Fortaleza, Ceara, Brazil.,Department of Morphology, Faculty of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil.,University of Fortaleza, CE, Brazil
| | - Cecília L Costa
- Department of Morphology, Faculty of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil.,Laboratory of Bacteriology, Department of Pathology, Faculty of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil
| | - Conceição S Martins
- Department of Morphology, Faculty of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil
| | - Maria Luana G S Morais
- Department of Morphology, Faculty of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil.,Laboratory of Bacteriology, Department of Pathology, Faculty of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil
| | - Carlos Quesada-Gómez
- Facultad de Microbiología and Centro de Investigación en Enfermedades Tropicales, Universidad de Costa Rica, San José, Costa Rica
| | - Cibele B M Carvalho
- Laboratory of Bacteriology, Department of Pathology, Faculty of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil
| | - Eliane de Oliveira Ferreira
- Federal University of Rio de Janeiro, Institute of Microbiology Paulo de Góes, Laboratory of Anaerobic Biology, Rio de Janeiro, Brazil
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7
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Gonzales-Luna AJ, Carlson TJ, Garey KW. Antibiotic Therapies for Clostridioides difficile Infection in Children. J Pediatric Infect Dis Soc 2021; 10:S52-S57. [PMID: 34791393 DOI: 10.1093/jpids/piab059] [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] [Indexed: 01/04/2023]
Abstract
While rates of Clostridioides difficile infection (CDI) are increasing among children in the United States, studies assessing CDI treatment in children are severely lacking. Thus, treatment guidelines have historically relied on evidence from limited observational data in children and randomized controlled trials (RCTs) conducted in adults to form recommendations. Currently, the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) recommend metronidazole and/or vancomycin for pediatric CDI depending on disease severity. Recently however, the first and only RCT of CDI treatment in children demonstrated fidaxomicin to be non-inferior to vancomycin, proving its safety and efficacy in this population. Additionally, observational data published since the IDSA/SHEA guidelines were released suggest metronidazole has lower rates of clinical improvement when compared to vancomycin in hospitalized children with non-severe CDI. Given these recent publications, fidaxomicin and vancomycin, instead of metronidazole, appear to be more appropriate, evidence-based options for the treatment of CDI in children.
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Affiliation(s)
- Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, 4849 Calhoun Road, Houston, Texas, 77204, USA
| | - Travis J Carlson
- Department of Clinical Sciences, High Point University Fred Wilson School of Pharmacy, One University Parkway, High Point, North Carolina, 27268, USA
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, 4849 Calhoun Road, Houston, Texas, 77204, USA
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Gnocchi M, Gagliardi M, Gismondi P, Gaiani F, de’ Angelis GL, Esposito S. Updated Management Guidelines for Clostridioides difficile in Paediatrics. Pathogens 2020; 9:pathogens9040291. [PMID: 32316346 PMCID: PMC7238231 DOI: 10.3390/pathogens9040291] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/10/2020] [Accepted: 04/14/2020] [Indexed: 01/04/2023] Open
Abstract
Clostridioides difficile, formerly known as Clostridium difficile, causes infections (CDI) varying from self-limited diarrhoea to severe conditions, including toxic megacolon and bowel perforation. For this reason, a prompt diagnosis is fundamental to early treatment and the prevention of transmission. The aim of this article is to review diagnostic laboratory methods that are now available to detect C. difficile and to discuss the most recent recommendations on CDI treatment in children. Currently, there is no consensus on the best method for detecting C. difficile. Indeed, none of the available diagnostics possess at the same time high sensitivity and specificity, low cost and rapid turnaround times. Appropriate therapy is targeted according to age, severity and recurrence of the episode of infection, and the recent availability of new antibiotics opens new opportunities. De-escalation of antibiotics that are directly associated with CDI remains a priority and the cautious use of probiotics is recommended. Vancomycin represents the first-line therapy for CDI, although in children metronidazole can still be used as a first-line drug. Fidaxomicin is a new treatment option with equivalent initial response rates as vancomycin but lower relapse rates of CDI. Faecal microbiota transplantation should be considered for patients with multiple recurrences of CDI. Monoclonal antibodies and vaccines seem to represent a future perspective against CDI. However, only further studies will permit us to understand whether these new approaches could be effective in therapy and prevention of CDI in paediatric populations.
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Affiliation(s)
- Margherita Gnocchi
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (M.G.); (M.G.); (P.G.)
| | - Martina Gagliardi
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (M.G.); (M.G.); (P.G.)
| | - Pierpacifico Gismondi
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (M.G.); (M.G.); (P.G.)
| | - Federica Gaiani
- Unit of Gastroenterology and Digestive Endoscopy, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (F.G.); (G.L.d.A.)
| | - Gian Luigi de’ Angelis
- Unit of Gastroenterology and Digestive Endoscopy, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (F.G.); (G.L.d.A.)
| | - Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (M.G.); (M.G.); (P.G.)
- Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy
- Correspondence: ; Tel.: +39-0521-903524
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9
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Clostridium difficile Infection in Children: Epidemiology and Trend in a Swedish Tertiary Care Hospital. Pediatr Infect Dis J 2019; 38:1208-1213. [PMID: 31738336 DOI: 10.1097/inf.0000000000002480] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Several studies have shown an increasing trend in pediatric Clostridium difficile infection (CDI). However, the Public Health Agency in Sweden reports a decreasing incidence of CDI in the Swedish population since 2007. The main aim of this study is to analyze the epidemiology of CDI in children. METHODS Retrospective chart-review of patients 1 to <19 years old, positive for Clostridium difficile toxin B, tested at Karolinska University Hospital Units, over the time period from July 1, 2010 to June 30, 2018. Episodes were classified as recurrences (≥2 weeks, ≤8 weeks from previous episode) or new episodes (>8 weeks from previous episode). New episodes were classified as hospital- (HA-CDI) or community-associated (CA-CDI). Annual infection rates/100,000 children in the catchment area were calculated. RESULTS Three hundred twenty-eight positive tests in 206 patients were included of which 259 (79.0%) tests were new episodes and 69 (21.0%) recurrences. In 63/206 (30.6%) children, >1 episode of CDI was recorded. The mean infection rate was 8.5/100,000 children. There was an overall increasing trend in CDI-rate July 2010-June 2018, however not statistically significant (P = 0.061) nor for the incidence in HA-CDI (P = 0.720) or CA-CDI (P = 0.179). Underlying medical conditions were present in 226/259 (87.3%) new episodes of which the most common was malignancy. Of the new episodes, 188/259 (72.6%) were HA-CDI and 46/259 (17.8%) were CA-CDI. CONCLUSIONS There was an increasing trend in CDI in children in Sweden from 2010 to 2018, although not statistically significant. CDI was associated with comorbid conditions and repeated episodes were common.
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10
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Campbell CT, Poisson MO, Hand EO. An Updated Review of Clostridium difficile Treatment in Pediatrics. J Pediatr Pharmacol Ther 2019; 24:90-98. [PMID: 31019401 DOI: 10.5863/1551-6776-24.2.90] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Clostridium difficile infection (CDI) continues to have clinical and economic impact across all health care settings. Pediatrics accounts for a small percentage of worldwide infection; however, screening and diagnosis are confounded by asymptomatic colonization in young infants. Metronidazole and oral vancomycin have historically been the agents used to manage CDI in both pediatrics and adults. Newer agents and alternative therapies, such as fecal microbiota transplantation, may offer additional benefit. Recent guidelines updates from the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America separate pediatric and adult recommendations for epidemiology, diagnosis, and treatment. This review will discuss the risk factors, management, prevention, and updated guideline recommendations for CDI in the pediatric population.
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11
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Clostridioides difficile in the environment, food, animals and humans in southern Italy: Occurrence and genetic relatedness. Comp Immunol Microbiol Infect Dis 2018; 59:41-46. [PMID: 30290886 DOI: 10.1016/j.cimid.2018.08.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 05/09/2018] [Accepted: 08/29/2018] [Indexed: 12/19/2022]
Abstract
One hundred and thirty-eight C. difficile isolates from different sources (66 from the environment, 36 from animals, 9 from food and 27 from humans) were ribotyped by capillary electrophoresis PCR ribotyping (CE-PCR). A multilocus variable tandem repeat analysis (MLVA) was carried out on a sample subset. The most frequently isolated PCR ribotypes were 126 (15.9%), 078 (14.5%), 011/018 (11.6%), 014/020/077 (10.1%), and 010 (2.8%). In particular, strains of PCR ribotype 011/018 were isolated from human, raw milk and environmental samples. The hypervirulent PCR ribotype 027 was isolated from two human samples. The majority of the strains were toxigenic (34.1% showed the toxigenic profile A+B+CDT+ and 38.9% the profile A+B+CDT-). MLVA allowed to identify 4 clonal complexes of genetically related isolates: complex n. 1 grouped together human, environmental and food strains, whereas complex n. 3 included human and environmental isolates. The use of MLVA gave further evidence to the possible role of environment, animals and food as routes of transmission of C. difficile infections to human.
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Abstract
Antibiotic therapy is not necessary for acute diarrhea in children, as rehydration is the key treatment and symptoms resolve generally without specific therapy. Searching for the etiology of gastroenteritis is not usually needed; however, it may be necessary if antimicrobial treatment is considered. The latter is left to the physician evaluation in the absence of clear indications. Antimicrobial treatment should be considered in severely sick children, in those who have chronic conditions or specific risk factors or in specific settings. Traveler’s diarrhea, prolonged diarrhea, and antibiotic-associated diarrhea may also require antibiotic therapy. Depending on the severity of symptoms or based on risk of spreading, empiric therapy may be started while awaiting the results of microbiological investigations. The choice of antibiotic depends on suspected agents, host conditions, and local epidemiology. In most cases, empiric therapy should be started while awaiting such results. Empiric therapy may be started with oral co-trimoxazole or metronidazole, but in severe cases parenteral treatment with ceftriaxone or ciprofloxacin might be considered.
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Affiliation(s)
- Eugenia Bruzzese
- Department of Translational Medical Sciences-Section of Pediatrics, University of Naples Federico II, Via S. Pansini 5, Naples, 80131, Italy
| | - Antonietta Giannattasio
- Department of Translational Medical Sciences-Section of Pediatrics, University of Naples Federico II, Via S. Pansini 5, Naples, 80131, Italy
| | - Alfredo Guarino
- Department of Translational Medical Sciences-Section of Pediatrics, University of Naples Federico II, Via S. Pansini 5, Naples, 80131, Italy
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13
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Spigaglia P, Barbanti F, Castagnola E, Diana MC, Pescetto L, Bandettini R. Clostridium difficile causing pediatric infections: New findings from a hospital-based study in Italy. Anaerobe 2017; 48:262-268. [PMID: 29066337 DOI: 10.1016/j.anaerobe.2017.10.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 10/18/2017] [Accepted: 10/20/2017] [Indexed: 02/07/2023]
Abstract
Recent studies support a change of Clostridium difficile infections (CDIs) epidemiology in pediatric patients. Since limited information is available about C. difficile in this population, we investigated the epidemiology of CDI in a large pediatric hospital that acts as reference centre in Italy and analyzed C. difficile isolates to identify the prevalent PCR-ribotypes (RTs), the binary toxin (CDT)-positive strains and the antibiotic susceptibility patterns. The CDI incidence was 6.6 cases/1000 admissions and the majority (92%) of CDI were healthcare-associated (47% occurred in the Hematology-Oncology and in the Gastroenterology units). Most of symptomatic children <3 years with a positive culture for C. difficile were negative for other gastrointestinal pathogens, supporting C. difficile as cause of disease in these patients, including those showing recurrences. Strains RT020 (16%) and RT014 (14%) were identified as the main cause of infection, while RT356/607 and RT018, predominant in Italian adult patients, were absent (RT356/607) or rarely found (RT018) among children. CDT-positive strains represented the 20% of the total number of isolates analyzed. In particular, two emerging types, RT033 and RT442, were recognized as Toxin A-/Toxin B-/CDT+. Resistance to antibiotics characterized almost 50% of the toxigenic isolates analyzed in this study and, in particular, 20% of them were multidrug resistant (MDR). The emergence and circulation of strains with peculiar toxins profiles and/or MDR strongly highlight the necessity of a rapid CDI diagnosis, a careful monitoring of C. difficile in pediatric patients and a more strict control of antibiotics usage in the Italian pediatric hospitals.
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Affiliation(s)
- Patrizia Spigaglia
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy.
| | - Fabrizio Barbanti
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Elio Castagnola
- Infectious Diseases Unit, Istituto Giannina Gaslini, Genoa, Italy
| | - Maria Cristina Diana
- Pediatric Neurology and Muscle Disease Unit, Istituto Giannina Gaslini, Genoa, Italy
| | - Luisa Pescetto
- Clinical Pathology Laboratory Unit, Istituto Giannina Gaslini, Genoa, Italy
| | - Roberto Bandettini
- Clinical Pathology Laboratory Unit, Istituto Giannina Gaslini, Genoa, Italy
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14
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D'Ostroph AR, So TY. Treatment of pediatric Clostridium difficile infection: a review on treatment efficacy and economic value. Infect Drug Resist 2017; 10:365-375. [PMID: 29089778 PMCID: PMC5655036 DOI: 10.2147/idr.s119571] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The incidence of Clostridium difficile infection (CDI) in pediatric patients continues to rise. Most of the pediatric recommendations for CDI treatment are extrapolated from the literature and guidelines for adults. The American Academy of Pediatrics recommends oral metronidazole as the first-line treatment option for an initial CDI and the first recurrence if they are mild to moderate in severity. Oral vancomycin is recommended to be used for severe CDI and the second recurrent infection. Additional pulsed regimen of oral vancomycin, which is tapered, may increase efficacy in refractory patients. However, there is lack of large studies evaluating the use of fidaxomicin in pediatrics to know whether it could be a safe and effective treatment option for difficult-to-treat patients. Fidaxomicin is associated with higher total drug costs compared to metronidazole and vancomycin, but the literature supports its use due to a lower rate of CDI recurrence, which may result in cost savings. Further studies are warranted to evaluate the use of fidaxomicin in patients <18 years old and to understand its role in the standard of care for pediatric patients with CDI.
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Affiliation(s)
- Amanda R D'Ostroph
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill
| | - Tsz-Yin So
- Department of Pharmacy, Moses H Cone Memorial Hospital, Greensboro, NC, USA
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