Risk Factors for Community-Associated Clostridium difficile Infection in Children

Epidemiologic and Clinical Characteristics and Risk Factors for Severe Community-acquired Clostridium difficile Infection in Children

Although children most frequently suffer from milder forms of community-acquired Clostridium difficile infection, severe cases and fatal outcomes have been recorded. In this study we identified older children (>12 years of age) and patients who had surgery up to 6 months before Clostridium difficile infection onset as a subgroup at somewhat higher risk for severe community-acquired Clostridium difficile infection.

Antibiotic Diversity Index: A novel metric to assess antibiotic variation among hospitalized children

BACKGROUND

Despite nationally endorsed treatment guidelines and stewardship programs, variation and deviation from evidence-based antibiotic prescribing occur, contributing to inappropriate use and medication-related adverse events. Measures of antibiotic prescribing variability can aid in quantifying this problem but are not adequate.

OBJECTIVE

The objective of this study is to develop a standardized metric to quantify antibiotic prescribing variability (diversity) within and across children's hospitals, and to examine its association with outcomes.

METHODS

We performed a cross-sectional study of empiric antibiotic exposure among children hospitalized during 2017-2019 with one of 15 common pediatric infections using the Pediatric Health Information System database. Encounters for children with complex chronic conditions, transfers in, and birth hospitalizations were excluded. Using the Shannon-Weiner entropy index, we quantified antibiotic diversity for each infection type using the d-measure of diversity. Generalized linear mixed-effects models were used to examine the association between hospital-level antibiotic diversity and risk-adjusted length of stay and costs.

RESULTS

A total of 79,515 hospitalizations for common pediatric infections were included. Antibiotic diversity varied within and across hospitals. Infections with low mean antibiotic diversity included appendicitis (mean diversity [mDiv] = 4.9, SD = 2.5) and deep neck space infections (mDiv = 5.9, SD = 1.9). Infections with high mean antibiotic diversity included pneumonia (mDiv = 23.4, SD = 5.6) and septicemia/bacteremia (mDiv = 28.5, SD = 12.1). There was no statistically significant association between hospital-level antibiotic diversity and risk-adjusted LOS or costs.

CONCLUSIONS

We developed and applied a novel metric to quantify diversity in antibiotic prescribing that permits comparisons across hospitals and can be leveraged to identify high-priority areas for local and national stewardship interventions.

Outcomes associated with initial narrow-spectrum versus broad-spectrum antibiotics in children hospitalized with urinary tract infections

OBJECTIVE

The aim of this study is to describe the proportion of children hospitalized with urinary tract infections (UTIs) who receive initial narrow- versus broad-spectrum antibiotics across children's hospitals and explore whether the use of initial narrow-spectrum antibiotics is associated with different outcomes.

DESIGN, SETTING AND PARTICIPANTS

We performed a retrospective cohort analysis of children aged 2 months to 17 years hospitalized with UTI (inclusive of pyelonephritis) using the Pediatric Health Information System (PHIS) database.

MAIN OUTCOME AND MEASURES

We analyzed the proportions of children initially receiving narrow- versus broad-spectrum antibiotics; additionally, we compiled antibiogram data for common uropathogenic organisms from participating hospitals to compare with the observed antibiotic susceptibility patterns. We examined the association of antibiotic type with adjusted outcomes including length of stay (LOS), costs, and 7- and 30-day emergency department (ED) revisits and hospital readmissions.

RESULTS

We identified 10,740 hospitalizations for UTI across 39 hospitals. Approximately 5% of encounters demonstrated initial narrow-spectrum antibiotics, with hospital-level narrow-spectrum use ranging from <1% to 25%. Approximately 80% of hospital antibiograms demonstrated >80% Escherichia coli susceptibility to cefazolin. In adjusted models, those who received initial narrow-spectrum antibiotics had shorter LOS (narrow-spectrum: 33.1 (95% confidence interval [CI]: 30.8-35.4) h versus broad-spectrum: 46.1 (95% CI: 44.1-48.2) h) and reduced costs [narrow-spectrum: $4570 ($3751-5568) versus broad-spectrum: $5699 ($5005-$6491)]. There were no differences in ED revisits or hospital readmissions. In summary, children's hospitals have low rates of narrow-spectrum antibiotic use for UTIs despite many reporting high rates of cefazolin-susceptible E. coli. These findings, coupled with the observed decreased LOS and costs among those receiving narrow-spectrum antibiotics, highlight potential antibiotic stewardship opportunities.

Infant gastroesophageal reflux disease management consensus

AIM

Infant gastroesophageal reflux is mostly benign; however, when associated with complications like failure to thrive, it may be indicative of gastroesophageal reflux disease. There are currently several unmet needs pertaining to the management of infant gastroesophageal reflux (disease). Reflux in infants is mostly composed of breast milk or formula, so this population is significantly different to older children and adults. The objective of this Delphi consensus was to establish recommendations based on published literature and the experience of clinical experts in paediatric gastroenterology in the context of infant gastroesophageal reflux (disease).

METHODS

The Delphi methodology was used to obtain a consensus on 18 statements relating to clinical aspects of infant gastroesophageal reflux (disease).

RESULTS

The expert panel comprising paediatric gastroenterology clinical specialists reached a consensus for all statements by means of an online, anonymised voting system.

CONCLUSION

It was highlighted that there is generally low awareness of or adherence to guidelines in clinical practice and that acid suppression therapy should not be indicated for non-acid reflux, which constitutes a significant proportion of total gastroesophageal reflux episodes among infants. Furthermore, it was emphasised that there is an unmet medical need for therapy for some symptomatic infants with non-acid reflux disease.

Clostridium difficile infection in pediatric patients (Review)

Clostridium difficile (C. difficile) infection (CDI) is the most common cause of healthcare-associated diarrhea and among adults, the worldwide incidence rate of the infection is increasing. There is a small amount of data in the literature for pediatric patients, but most indicate an increasing trend. C. difficile is a constituent of the normal microbiota; however, under specific conditions that cause a disruption of the normal bacterial flora, colonization of C. difficile and the released toxins that cause inflammation and mucosal damage occurs. Risk factors for CDI at any age include hospitalization, exposure to antibiotics, administration of proton pump inhibitors, invasive mechanical ventilation, immunosuppression and presence of associated comorbidities. Clinical manifestations range from asymptomatic colonization to fulminant disease characterized by toxic megacolon, intestinal perforation and, rarely, death. The aim of the present review was to outline the features of CDI in pediatric patients.

Clostridioides difficile Infections: Prevention and Treatment Strategies

Clostridioides difficile is the most common causative agent of antibiotic-associated diarrhea. This spore forming, obligate anaerobic, gram-positive bacillus is becoming responsible for an increasing number of infections worldwide, both in community and in hospital settings, whose severity can vary widely from an asymptomatic infection to a lethal disease. While discontinuation of antimicrobial agents and antibiotic treatment of the infection remain the cornerstone of therapy, more recent fecal microbiota transplantation has also been valid as a therapy. The use of probiotics, especially Saccharomyces boulardii CNCM I-745 have become valid forms of prevention therapy. Although there are studies in adults with microbiota-targeted new generation therapies and Clostridium difficile vaccines, there are no data in the paediatric age group yet.

Clostridioides difficile Infection in Children: Recent Updates on Epidemiology, Diagnosis, Therapy

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.

An insight into Clostridioides difficile-associated diarrhea in Saudi children: diagnosis and treatment

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.

Impact of Penicillin Allergy Label on Clinical Outcomes of Pneumonia in Children

BACKGROUND

Penicillin (PCN) allergy label, reported in approximately 5% of children, influences antibiotic choice and prolongs hospital stay. To our knowledge, the impact of PCN allergy label on clinical outcomes of pneumonia in children is not well characterized.

OBJECTIVES

To investigate the impact of PCN allergy label on clinical outcomes of pneumonia in children.

METHODS

In this propensity score-matched cohort study, we used the TriNetX research network, a population-based database, to compare the 30-day risk of hospitalization, need for intensive level of care, and acute respiratory failure from pneumonia between pediatric patients (aged 1-17 years) with and without a PCN allergy label after matching the 2 cohorts for demographic and medical comorbidities. Antibiotic prescription patterns were also contrasted.

RESULTS

When comparing 3793 pediatric patients with pneumonia labeled with a PCN allergy with matched children without a PCN allergy label, PCN allergy label was associated with a higher risk of hospitalization (relative risk [RR], 1.15; 95% confidence interval [CI], 1.07-1.23), acute respiratory failure (RR, 1.27; 95% CI, 1.17-1.39), and need for intensive level of care (RR, 1.46; 95% CI, 1.15-1.84). PCN allergy label resulted in overutilization of broader-spectrum antibiotics and increased complications including cutaneous drug reactions (RR, 2.43; 95% CI, 1.31-4.52) and Clostridioides difficile infection (RR, 2.25; 95% CI, 1.14-4.44).

CONCLUSION

Children with a PCN allergy label are more likely to be hospitalized, receive broader-spectrum antibiotics, and develop acute respiratory failure from pneumonia. Delabeling may offer a way to lessen morbidity from pneumonia in children.

Clostridium difficile: What is the risk?

INTRODUCTION

Clostridium difficile infections (CDIs) are rising among pediatric patients in the community and hospital setting. Children undergoing transplants and bowel surgery are at a higher risk, while renal surgery has a lower risk. We hypothesize children undergoing pediatric urologic procedures are uncommonly diagnosed with postoperative CDI.

OBJECTIVE

To study CDI in pediatric patients undergoing urologic surgery and identify associated perioperative factors.

STUDY DESIGN

The American College of Surgeons National Surgical Quality Improvement Program Pediatric data file was queried for children undergoing surgery with pediatric urology or urology between 2015 and 2017. Data points included patient demographics (age, gender, race, ASA classification), surgery performed, and perioperative outcomes (operative time, admission status, length of stay, complications, readmission, and reoperation). Students T-test and Chi-square analyses were applied to detect differences between those with CDI and those without CDI.

RESULTS

Of the 27,193 patients undergoing urologic surgery, 36 (0.13%) were diagnosed with CDI. The surgeries are presented in the Summary Figure. Patients with CDI were more likely to be female (50% vs 28%, p = 0.003) than those without. There was no difference in mean age or race. Children with CDI had higher ASA classifications (p < 0.001). Their mean operative times were longer (156.1 ± 19.6 vs 105.2 ± 0.6 min, p < 0.001), as were their mean lengths of stay (4.6 ± 0.8 vs 1.3 ± 0.0 days, p < 0.001). CDI patients were more likely to have other complications (29% vs 6%, p < 0.001). Among patients with CDI, 19.4% experienced concomitant infectious complications. There was no difference in reoperation rate, but more patients with CDI required readmission (56% vs 4%, p < 0.001). A third of children with CDI had undergone vesicoureteral reflux correction, comprising 0.3% of the included procedures. Over 11% of children with CDI had undergone nephrectomy, comprising 1.1% of the included procedures for the highest rate.

DISCUSSION

CDI are uncommon following pediatric urologic procedures. No patients undergoing inguinal or scrotal cases developed CDI, while only one patient developed CDI after penile surgery. Our study does have several important limitations: we are unable to provide clinical information about the exact diagnoses, CDI risk factors such as antibiotic usage or comorbid conditions, and the number of patients who were tested for CDI.

CONCLUSION

While pediatric urologists are unlikely to encounter postoperative CDI, when they occur, they are associated with longer lengths of stay, increased readmission rates, and an increased rate of non-CDI complications.

Risk factors for Clostridioides difficile infection in children: A systematic review and meta-analysis

BACKGROUND

Clostridioides difficile infection (CDI) is considered an urgent threat to human health by the US Centers for Disease Control and Prevention. In recent years, C. difficile is increasingly being reported as a cause of gastrointestinal diseases in children, and the prevalence of hospital-acquired CDI (HA-CDI) and community-acquired CDI (CA-CDI) in children is increasing.

AIM

To perform a systematic review and meta-analysis of risk factors for Clostridioides difficile infection (CDI) in children.

METHODS

MEDLINE/PubMed, EMBASE, Web of Science, Scopus, OVID, China National Knowledge Infrastructure, Wanfang (Chinese), SinoMed (Chinese), and Weipu (Chinese) databases were searched from inception through January 12, 2022. Observational studies (cohort, case-control, and cross-sectional) on CDI in children were included in the analysis. Data were pooled using a fixed or random-effects model, and odds ratios (ORs) were calculated.

FINDINGS

A total of 25 observational studies were included in the analysis. Prior antibiotic exposure (OR, 1.93; 95% confidence interval (CI), 1.25-2.97), prolonged hospitalization (OR, 14.68; 95% CI, 13.24-16.28), hospitalization history (OR, 3.67; 95% CI, 1.91-7.06), gastric acid suppressants (OR, 1.96; 95% CI, 1.41-2.73), male gender (OR, 1.18; 95% CI, 1.05-1.32), neoplastic disease (OR, 3.40; 95% CI, 2.85-4.07), immunodeficiency (OR, 4.18; 95% CI, 3.25-5.37), solid organ transplantation (OR, 4.56; 95% CI, 3.95-5.27) and enteral feeding (OR, 2.21; 95% CI, 1.15-4.62) were associated with an increased risk of CDI.

CONCLUSION

This systematic review and meta-analysis provides further evidence for the susceptibility factors of CDI to improve clinicians' awareness of CDI and effectively prevent C. difficile associated diarrhoea in children.

Pharmacological Management of Pediatric Clostridioides difficile Infection: Clarifying the Controversies

Clostridioides difficile infection (CDI) is a major public health concern for pediatric and adult patients. The management of pediatric CDI poses a challenge to healthcare providers due to lack of strong randomized controlled trials to guide pharmacological management. Additionally, recent updates to CDI guidelines recommend oral vancomycin over metronidazole for the management of CDI in adults, leaving questions regarding how to best manage pediatric patients. This continuing education pharmacotherapy review describes available evidence for the safety and efficacy of medications used in the treatment and management of pediatric CDI and aims to clarify discrepancies between pediatric and adult recommendations.

Clostridioides difficile Infection in Children: A 5-Year Multicenter Retrospective Study

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.

Community-Associated Clostridioides difficile Infection in Children: A Review of Recent Literature

Clostridioides difficile infection (CDI) in children is more often acquired in the community than in the hospital. Community-associated Clostridioides difficile infection (CA-CDI) cases seem to be rising, although this is confounded by the unclear role of C. difficile in children 1 and 3 years of age and overreliance on nucleic acid amplification tests for diagnosis. Exposure to antibiotics, acid suppression medications, health care settings, and close contacts with CDI are associated with CA-CDI in children. These infections are more common in children with chronic medical conditions, especially those involving the gastrointestinal tract and immune suppression. Most CA-CDI in children are mild and managed in the outpatient setting, but a small subset requires hospitalization and can be quite severe. Approximately 10% of children with CA-CDI experience a recurrence. Infection control guidance focuses on the hospital setting and future studies on the best methods for preventing community spread of C. difficile are needed.

Clostridioides difficile Infection in Children: The Role of Infection Prevention and Antimicrobial Stewardship

There are 2 primary approaches to prevent Clostridioides difficile infection (CDI) in children: prevent transmission and acquisition of the organism and prevent the progression from colonization to disease. The most important interventions to reduce the risk of transmission include contact precautions, hand hygiene, and environmental disinfection. Glove use minimizes contamination of the hands by spores and is associated with reductions in CDI incidence. Hand hygiene with soap and water and disinfection with a sporicidal agent are recommended as the best approaches in hyperendemic settings. Because antibiotic exposure is the most important modifiable risk factor for CDI, antimicrobial stewardship focused on identified high-risk antibiotic classes (including clindamycin, fluoroquinolones, and third- and fourth-generation cephalosporins) is critical to preventing progression from colonization to infection. Despite clear evidence that antimicrobial stewardship programs (ASPs) are associated with reduced CDI rates in adults, data demonstrating the ASP impact on pediatric CDI are lacking.

Epidemiology, Diagnosis, and Treatment of Clostridioides difficile Infection in Immunocompromised Children

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.

Recent advances in Clostridioides difficile infection epidemiology, diagnosis and treatment in children

PURPOSE OF REVIEW

The US Centers for Disease Control and Prevention (CDC) classified Clostridioides difficile as an 'urgent' public health threat that requires 'urgent and aggressive action'. This call to action has led to new discoveries that have advanced C. difficile infection (CDI) epidemiology, diagnosis and treatment, albeit predominantly in adults. In 2017, the Infectious Diseases Society of America and Society for Healthcare Epidemiology of America published clinical practice guidelines for both adults and children. At that time, recommendations in children were generally limited to relatively low-quality evidence.

RECENT FINDINGS

Since publication of this guidance, there have been many advancements in the understanding of CDI in children. These include better understanding of healthcare settings as uncommon sources of C. difficile acquisition in children; risk factors for recurrent and community-associated CDI; performance of diagnostic tests in children and strategies for optimizing their use; and a more rigorous evidence base for CDI treatment in children, including the first-ever randomized controlled trial of CDI treatment in children and the largest study of fecal microbiota transplantation in children.

SUMMARY

This review highlights the most recent salient advancements in paediatric CDI knowledge and practice that supplement published clinical guidance provided prior to these advancements.

Impact of Antecedent Antibiotic Usage on Community-associated Clostridioides difficile Infection in Pediatrics

Children exposed to antibiotics develop community-associated Clostridioides difficile infections in the 12 weeks following exposure. This secondary analysis was a retrospective review of children with filled prescriptions for commonly prescribed antibiotics between January 1, 2012, and December 31, 2016. Compared with amoxicillin, incident rates of community-associated Clostridioides difficile infections were highest following clindamycin, cephalosporins, and amoxicillin-clavulanate.

A Simulated Client Exploration of Nonprescription Dispensing of Antibiotics at Drugstores for Pediatric Acute Diarrhea and Upper Respiratory Infection in Lahore, Pakistan

INTRODUCTION

The excessive consumption of antibiotics is a significant contributor to antimicrobial resistance, especially in children. Children are often advised antibiotics for viral infections. In developing countries, drugstores are a prime source of easy access to nonprescription antibiotics. Moreover, in Pakistan, their irrational use is an "everyday routine". The study, therefore, aimed to evaluate the dispensing of nonprescription antibiotics to children.

METHODS

Using pediatric acute diarrhea and acute upper respiratory infection as disease scenarios, a simulated client, cross-sectional study was conducted in Lahore, Pakistan, to explore the antibiotics' ease of availability at both categories of drugstores (pharmacies and medical stores) from November 1st, 2019 to January 31st, 2020. Chi-square (χ 2) test was used to compare the differences in practices of different categorical variables. Multivariable logistic regression was applied to analyze the association of various factors with antibiotics dispensing.

RESULTS

Antibiotics were dispensed without prescription in 456 (59%) of 773 simulated visits out of which 425 (93.2%) were dispensed on the advice of the drugstore staff. A qualified pharmacist was available in only 164 (21.2%) cases. Of the 386 visits for acute diarrhea and 387 for acute upper respiratory infection, nonprescription antibiotic dispensing occurred in 259 (67.1%) and 197 (50.9%) visits, respectively. There were considerable differences (p-value <0.05) in the practices and antibiotics dispensing between each disease scenario presented. Moreover, antibiotics were less commonly dispensed at pharmacist-supervised drugstores compared to unsupervised ones.

CONCLUSION

Overall, inappropriate dispensing practices were prevalent to a large extent at the drugstores, and antibiotics were effortlessly obtainable without prescription. The quality of the services provided, especially by the non-pharmacist staff, was also not satisfactory. Therefore, the Drug Regulating Authority of Pakistan must enforce strict implementation of drug laws at the drugstores without delay, especially in major cities to help curb the felonious use of antibiotics.

The Decline in Outpatient Antibiotic Use

BACKGROUND

A central component of the German antibiotic resistance strategy is to monitor the outpatient prescribing of systemic antibiotics nationwide, across all of the statutory health-insurance providers, in order to provide a basis for targeted quality-assurance measures.

METHODS

All outpatient drug prescription data from patients covered by the statutory health-insurance carriers in Germany in the age groups 0-14, 15-64, and ≥ 65 years were assessed. The chosen primary outcome measure under study was the prescription rate (number of antibiotic prescriptions per 1000 insurees per year) for the years 2010 to 2018.

RESULTS

Over the period of the study, a 21% decline was seen in the use of systemic antibiotics in outpatients, from 562 to 446 prescriptions per 1000 insurees per year in 2010 and 2018, respectively. The most marked reduction in the prescription rate-by 41%-was seen among child and adolescent insurees (in other age groups: -17% among those aged 15-64, -12% among those aged 65 and older). A downward trend was seen in all regions of Germany, and for most of the active substance groups for which data were obtained. In 2018, the prescription rate varied by a factor of 1.8 among regions, with the highest rate in the Saarland (572 per 1000 insurees per year) and the lowest in Brandenburg (318 per 1000 insurees per year).

CONCLUSION

The observed nationwide decline in the prescription of antibiotics to outpatients in all age groups may be a result of the numerous initiatives that have been put into action to reinforce the appropriate use of antibiotics in Germany. A change in pediatric prescribing practices is demonstrated by the marked reduction in this age group. The remaining major differences across German regions underscore the importance of regionally tailored programs for the promotion of rational antibiotic use.

Marked reductions in outpatient antibiotic prescriptions for children and adolescents - a population-based study covering 83% of the paediatric population, Germany, 2010 to 2018

BackgroundPrescribing of systemic antibiotics in general and of cephalosporins in particular in German paediatric outpatients has previously been reported to be higher than in other European countries.AimOur objective was to assess recent trends in antibiotic prescribing in German children.MethodsThis study was conducted as consecutive annual cross-sectional analyses and included all children aged 0-14 years (n = 9,389,183 in 2018) covered by statutory health insurance in Germany. Annual antibiotic prescription rates from 2010 to 2018 were calculated for the age groups 0-1, 2-5, 6-9 and 10-14 years. Poisson regression was used to estimate trends of prescription rates by age group and antibiotic subgroup.ResultsOverall, the age-standardised antibiotic prescription rate decreased significantly by 43% from 746 prescriptions per 1,000 persons in 2010 to 428 per 1,000 in 2018 (p < 0.001). Reductions were most pronounced in the age groups 0-1 year (-50%) and 2-5 years (-44%). The age group 2-5 years exhibited the highest prescription rate with 683 per 1,000 in 2018 (0-1 year: 320/1,000; 6-9 years: 417/1,000; 10-14 years: 273/1,000). Cephalosporins (second and third generation) accounted for 32% of prescribed antibiotics.ConclusionsMarked reductions in antibiotic prescribing during the last decade indicate a change towards more judicious paediatric prescribing habits. Compared with other European countries, however, prescribing of second- and third-generation cephalosporins remains high in Germany, suggesting frequent first-line use of these substances for common respiratory infections. Considerable regional variations underline the need for regionally targeted interventions.

Acute Hematogenous Osteomyelitis in Children: Clinical Presentation and Management

Acute hematogenous osteomyelitis (AHO) is a common invasive infection encountered in the pediatric population. In addition to the acute illness, AHO has the potential to create long-term morbidity and functional limitations. While a number of pathogens may cause AHO, Staphylococcus aureus is the most common organism identified. Despite the frequency of this illness, little high-quality data exist to guide providers in the care of these patients. The literature is reviewed regarding the epidemiology, microbiology and management of AHO in children. A framework for empiric therapy is provided drawing from the available literature and published guidelines.

The effects of proton pump inhibitors on the microbiome in young children

AIM

The use of proton pump inhibitor (PPI) treatments are increasing among paediatric patients worldwide. We aimed to review the effects of PPIs on the microbiome and its associated effect on the gastrointestinal, respiratory and metabolic systems. The role of probiotics is discussed.

METHODS

We searched for relevant articles published in English language in PubMed and Google Scholar. Articles were extracted using subject heading and key words of interest to the topic.

RESULTS

There is evidence that PPIs modify the microbiome of the mouth, gut and lungs. The specific adverse effects associated with PPIs were necrotising enterocolitis, late onset sepsis in premature infants, Clostridium difficile infection, asthma, obesity and small intestine bacterial overgrowth in young children. Studies on the use of probiotics to counteract adverse effects of PPIs were limited.

CONCLUSION

PPIs create dysbiosis of the microbiome in the mouth, gut and lungs in the paediatric population. Probiotics could restore dysbiosis but it has very poorly been studied if probiotics can counteract or prevent PPI induced adverse effects.

Epidemiology and Risk Factors for Community Associated Clostridioides difficile in Children

OBJECTIVE

To assess which risk factors are associated with community-associated Clostridioides difficile infection (CDI) in children.

STUDY DESIGN

This case control study was a retrospective review of all children 1-17 years of age with stool specimens sent for C difficile testing from January 1, 2012, to December 31, 2016. Cases and controls were children who had C difficile testing performed in the community or first 48 hours of hospital admission and >12 weeks after hospital discharge, with no prior positive C difficile testing in last 8 weeks, without other identified causes of diarrhea, and with clinical symptoms. Cases had positive confirmatory testing for C difficile. Controls had negative testing for C difficile and were matched to cases 1:1 by age and year of specimen collection.

RESULTS

The overall incidence rate of community-acquired CDI in this cohort was 13.7 per 100 000 children per year. There was a substantial increase in community-acquired CDI from 9.6 per 100 000 children per year in 2012 to a peak of 16.9 per 100 000 children per year in 2015 (Cochran-Armitage test for trend P = .002). The risk factors for community-acquired CDI included non-Hispanic ethnicity; amoxicillin-clavulanate, cephalosporin, and clindamycin use within the previous 12 weeks; a previous positive C difficile test within 6 months; and increased health care visits in the last year.

CONCLUSIONS

As rates of community-acquired CDI are increasing, enhanced antibiotic stewardship and recognition of health care disparities may ease the burden of community-acquired CDI.

Molecular characteristics of Clostridium difficile in children with acute gastroenteritis from Zhejiang

Background

Clostridium difficile infection (CDI) has an increasing pediatric prevalence worldwide. However, molecular characteristics of C. difficile in Chinese children with acute gastroenteritis have not been reported.

Methods

A five-year cross-sectional study was conducted in a tertiary children’s hospital in Zhejiang. Consecutive stool specimens from outpatient children with acute gastroenteritis were cultured for C. difficile, and isolates then were analyzed for toxin genes, multi-locus sequence type and antimicrobial resistance. Diarrhea-related viruses were detected, and demographic data were collected.

Results

A total of 115 CDI cases (14.3%), and 69 co-infected cases with both viruses and toxigenic C. difficile, were found in the 804 stool samples. The 186 C. difficile isolates included 6 of toxin A-positive/toxin B-positive/binary toxin-positive (A⁺B⁺CDT⁺), 139 of A⁺B⁺CDT⁻, 3 of A⁻B⁺CDT⁺, 36 of A⁻B⁺CDT⁻ and 2 of A⁻B⁻CDT⁻. Sequence types 26 (17.7%), 35 (11.3%), 39 (12.4%), 54 (16.7%), and 152 (11.3%) were major genotypes with significant differences among different antimicrobial resistances (Fisher's exact test, P < 0.001). The A⁻B⁺ isolates had significantly higher resistance, compared to erythromycin, rifampin, moxifloxacin, and gatifloxacin, than that of the A⁺B⁺ (χ² = 7.78 to 29.26, P < 0.01). The positive CDI rate in infants (16.2%) was significantly higher than that of children over 1 year old (10.8%) (χ² = 4.39, P = 0.036).

Conclusions

CDI has been revealed as a major cause of acute gastroenteritis in children with various genotypes. The role of toxigenic C. difficile and risk factors of CDI should be emphatically considered in subsequent diarrhea surveillance in children from China.

Updated Management Guidelines for Clostridioides difficile in Paediatrics

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.

Differences in Gut Microbiome in Hospitalized Immunocompetent vs. Immunocompromised Children, Including Those With Sickle Cell Disease

Background: Gut microbial diversity and composition play important roles in health. This cross-sectional study was designed to test the hypothesis that hospitalized children who may be relatively immunocompromised (IC), defined as those with cancer, sickle cell disease (SCD), transplantation, or receiving immunosuppressive therapy) would have decreased microbial diversity, increased Clostridioides difficile colonization and different species composition compared to non-immunocompromised (Non-IC) children admitted to the same pediatric unit. Methods: A stool sample was obtained within 72 h of admission to a single unit at The Children's Hospital at Montefiore, Bronx, NY from March 2016 to February 2017 and the microbiome assessed by 16S rRNA sequencing. C. difficile colonization was assessed by glutamate dehydrogenase antigen and toxin polymerase chain reaction assays. Results: Stool samples were obtained from 69 IC (32 SCD, 19 cancer, 9 transplantation and 9 other) and 37 Non-IC patients. There were no significant differences in microbial alpha diversity and C. difficile colonization comparing IC vs. non-IC patients. Lower alpha diversity, however, was independently associated with the use of proton pump inhibitors or antibiotics, including prophylactic penicillin in patients with SCD. Differences in specific species abundances were observed when comparing IC vs. non-IC patients, particularly children with SCD. Non-IC patients had increased abundance of commensals associated with health including Alistipes putredinis, Alistipes ihumii, Roseburia inulinivorans, Roseburia intestinalis, and Ruminococcus albus (p < 0.005). Conclusions: Antibiotics and proton pump inhibitors, which were more commonly used in IC children, were identified as risk factors for lower microbial diversity. Non-IC patients had higher abundance of several bacterial species associated with health. Longitudinal studies are needed to determine the clinical significance of these differences in gut microbiome.

Clostridium difficile Infection in Children: Epidemiology and Trend in a Swedish Tertiary Care Hospital

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.

Recurrent community-acquired Clostridium(Clostridioides)difficile infection in Serbianchildren

Information on recurrent Clostridium difficile infections (rCDI) in children is rare and limited, especially community acquired (CA-CDI).This study was designed to identify risk factors for rCA-CDI in Serbian pediatric population. The study group included 71 children (aged from 1 to 14 years) with a first episode of CDI. Data were collected from 56 (78.87%) children with only one episode of CA-CDI and from 15 (21.13%) children with rCA-CDI were mutually compared. The following parameters were found to be statistically significantly more frequent in the children with rCA-CDI group (p < 0.05); leukemia as underlying disease, treatment with immunosuppressive and-or cytostatic drugs, and treatment with antibiotics. Similarly, previously visits to outpatient facilities, daycare hospitals and hospitals were also associated with rCDI. Analysis of clinical symptoms and laboratory parameters, revealed a statistically significant association of the severity of the first episode of CDI (determined by an increase in body temperature, higher maximum WBC and higher CRP) with development of a rCDI. Ribotype (RT) 027 was more common in children with rCA-CDI (66.7%, p = 0.006). During the seven-year research period, we found a rate of rCA-CDI rate in children of 21.13%. Our study identified several parameters statistically significantly more frequently in children with rCA-CDI. The obtained results will serve as a basis for future larger studies, but new prospective, studies are necessary to build a prediction model of rCDI in children that can be used to guide the treatment to prevent rCDI.

Risk factors for Clostridioides (Clostridium) difficile infection following solid organ transplantation in children

BACKGROUND

Clostridioides (Clostridium) difficile infection (CDI) in pediatric solid organ transplant (SOT) recipients is a growing problem, though CDI risk factors in this population are poorly understood. Our objective was to characterize CDI risk factors in pediatric SOT recipients.

METHODS

This retrospective case-control study, performed at a single freestanding academic children's hospital, included all SOT recipients age 1-22 years who were tested for C. difficile by toxin B gene PCR between August 2009 and August 2017. CDI risk factors were assessed by comparing PCR-positive and PCR-negative cases by generalized linear mixed models.

RESULTS

Between August 2009 and August 2017, 409 SOTs were performed of which 138 (33.7%), 134 (32.8%), 131 (32.0%), and 6 (1.5%) were kidney, liver, heart, and small intestine transplants, respectively. Of 205 SOT recipients were tested for CDI, with 723 C. difficile PCR tests performed among these patients. 68/205 (33%) patients developed CDI at least once during the study period. Median (interquartile range) time to diagnosis of first CDI following SOT was 8.9 (1.2, 19.6) months. CDI was independently associated with calcineurin inhibitor use at time of C. difficile testing (odds ratio [OR] 2.38, 95% confidence interval [CI] 1.08, 5.24, P = 0.03) and systemic antibiotic exposure within 30 days of C. difficile testing (OR 1.74, 95% CI 1.08, 2.79, P = 0.02).

CONCLUSIONS

CDI is a common, relatively late post-transplant complication and independently associated with calcineurin inhibitor and systemic antibiotic exposure. The potential impact of specific immunosuppressive drug and antibiotic selection on CDI risk reduction requires further investigation.

A population-based study of prescribing trends in a potentially vulnerable paediatric population from 1999 to 2012

OBJECTIVES

There is a limited understanding of paediatric medication prescribing trends and patterns, thus poorly positioning decision-makers to identify quality and safety concerns related to medication use. The objective of this study was to determine overall medication prescribing trends and patterns among children receiving Ontario Drug Benefits over a thirteen-year period in the province of Ontario, Canada.

METHODS

Administrative health databases housed within the Institute for Clinical Evaluative Sciences (ICES), Ontario, Canada, were used to identify outpatient prescriptions dispensed from 1999 to 2012 through a publicly funded programme to children ≤18 years of age. Medications were classified according to the American Hospital Formulary Service Pharmacologic-Therapeutic Classification system. Descriptive statistics were used to summarize prescribing patterns.

KEY FINDINGS

This study identified 457 037 children who were dispensed a new prescription between 1999 and 2012. About 56% received their first prescription before 6.5 years of age, and 85% of the children in this study were from families who received social assistance. The most commonly prescribed drugs were antiinfectives (56.1%). Prescriptions for several central nervous system agents, including antipsychotics and agents for attention-deficit/hyperactivity disorder, increased across the study period. Changes in prescribing patterns within opioids, hormones and autonomic agents were noted. The results suggest that historically, prescribing trends have shifted with public policy, pharmaceutical marketing and diagnostic patterns, thus identifying them as a possible tool to measure the impact of policydriven practice changes. Anti-infective prescribing increased markedly with the global H1N1 pandemic. Pharmaceutical marketing, formulary decisions and diagnostic trends may affect the prescribing of ADHD medications globally. The prescribing of codeine-containing products and medroxyprogesterone appeared to fluctuate in response to important publications in the medical literature, and the use of epinephrine syringes increased after public policy changes in the province of Ontario. The steady rise in the use of medications whose long-term effects in children are unknown, such as antipsychotics and proton pump inhibitors, identifies areas in need of future research.

CONCLUSIONS

This study presents the first overview of Canadian prescribing trends for children, the majority of which are of low socioeconomic status and represent a potentially vulnerable population. Our analysis suggests that future research is required to determine whether prescribing trends could be used as indicators of policy effectiveness, pharmacovigilance and diagnostic trends.

Gastroesophageal reflux in children: an updated review

Background

Gastroesophageal reflux is a common disorder in pediatrics. Clinicians should be familiar with the proper evaluation and management of this condition.

Objective

To provide an update on the current understanding, evaluation, and management of gastroesophageal reflux in children.

Methods

A PubMed search was performed with Clinical Queries using the key term ‘gastroesophageal reflux’. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to the English literature and the pediatric age group.

Results

Regurgitation is the most frequent symptom of gastroesophageal reflux and is present in nearly all cases. Gastroesophageal reflux occurs normally in infants, is often physiological, peaks at 4 months of age, and tends to resolve with time. Gastroesophageal reflux disease occurs when gastric contents reflux into the esophagus or oropharynx and produce troublesome symptom(s) and/or complication(s). A thorough clinical history and a thorough physical examination are usually adequate for diagnosis. When the diagnosis is ambiguous, diagnostic studies may be warranted. A combined esophageal pH monitoring and multichannel intraluminal esophageal electrical impedance device is the gold standard for the diagnosis of gastroesophageal reflux disease if the diagnosis is in doubt. In the majority of cases, no treatment is necessary for gastroesophageal reflux apart from reassurance of the benign nature of the condition. Treatment options for gastroesophageal reflux disease are discussed.

Conclusion

In most cases, no treatment is necessary for gastroesophageal reflux apart from reassurance because the condition is benign and self-limiting. Thickened feedings, postural therapy, and lifestyle changes should be considered if the regurgitation is frequent and problematic. Pharmacotherapy should be considered in the treatment of more severe gastroesophageal reflux disease for patients who do not respond to conservative measures. Proton pump inhibitors are favored over H₂-receptor antagonists because of their superior efficacy. Antireflux surgery is indicated for patients with significant gastroesophageal reflux disease who are resistant to medical therapy.

Risk factors for community-associated Clostridioides difficile infection in young children

The majority of paediatric Clostridioides difficile infections (CDI) are community-associated (CA), but few data exist regarding associated risk factors. We conducted a case–control study to evaluate CA-CDI risk factors in young children. Participants were enrolled from eight US sites during October 2014–February 2016. Case-patients were defined as children aged 1–5 years with a positive C. difficile specimen collected as an outpatient or ⩽3 days of hospital admission, who had no healthcare facility admission in the prior 12 weeks and no history of CDI. Each case-patient was matched to one control. Caregivers were interviewed regarding relevant exposures. Multivariable conditional logistic regression was performed. Of 68 pairs, 44.1% were female. More case-patients than controls had a comorbidity (33.3% vs. 12.1%; P = 0.01); recent higher-risk outpatient exposures (34.9% vs. 17.7%; P = 0.03); recent antibiotic use (54.4% vs. 19.4%; P < 0.0001); or recent exposure to a household member with diarrhoea (41.3% vs. 21.5%; P = 0.04). In multivariable analysis, antibiotic exposure in the preceding 12 weeks was significantly associated with CA-CDI (adjusted matched odds ratio, 6.25; 95% CI 2.18–17.96). Improved antibiotic prescribing might reduce CA-CDI in this population. Further evaluation of the potential role of outpatient healthcare and household exposures in C. difficile transmission is needed.

Risk factors for Clostridium difficile infection in pediatric inpatients: A meta-analysis and systematic review

Objective:

To summarize risk factors for Clostridioides (formerly Clostridium) difficile infection (CDI) in hospitalized pediatric patients as determined by previous observational studies.

Design:

Meta-analysis and systematic review.

Patients:

Studies evaluating risk factors for CDI in pediatric inpatients were eligible for inclusion.

Method:

We systematically searched MEDLINE, Web of Science, Scopus, and EMBASE for subject headings and text words related to CDI and pediatrics from 1975 to 2017. Two of the investigators independently screened studies, extracted and compiled data, assessed study quality, and performed the meta-analysis.

Results:

Of the 2,033 articles screened, 14 studies reporting 10,531,669 children met the inclusion criteria. Prior antibiotic exposure (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.31–3.52) and proton pump inhibitor (PPI) use (OR, 1.33; 95% CI, 1.07–1.64) were associated with an increased risk of CDI in children. Subgroup analyses using studies reporting only adjusted results suggested that prior antibiotic exposure is not a significant risk factor for CDI. H2 receptor antagonist (H2RA) use (OR, 1.36; 95% CI, 0.31–5.98) and that female gender (OR, 0.87; 95% CI, 0.74–1.03) did not play a significant role as a risk factor for developing CDI.

Conclusion:

Prior antibiotic exposure appears to be an important risk factor for CDI based on the combined analysis but not significant using adjusted studies. PPI use was associated with an increased risk of CDI. Judicious and appropriate use of antibiotics and PPIs may help reduce the risk of CDI in this vulnerable population.

Efficacy and safety of intravenous ceftriaxone at home versus intravenous flucloxacillin in hospital for children with cellulitis (CHOICE): a single-centre, open-label, randomised, controlled, non-inferiority trial

BACKGROUND

Outpatient parenteral antimicrobial therapy in children is common despite no evidence of its efficacy or safety from clinical trials. We aimed to compare the efficacy and safety of intravenous antibiotic therapy at home with that of standard treatment in hospital for children with moderate to severe cellulitis.

METHODS

The Cellulitis at Home or Inpatient in Children from the Emergency Department (CHOICE) trial was a randomised, controlled, non-inferiority trial in children aged 6 months to 18 years who presented to the emergency department at The Royal Children's Hospital (Melbourne, VIC, Australia) with uncomplicated moderate to severe cellulitis. Participants were randomly assigned to receive either intravenous ceftriaxone (50 mg/kg once daily) at home or intravenous flucloxacillin (50 mg/kg every 6 h) in hospital with web-based randomisation, stratified by age and periorbital cellulitis. The primary outcome was treatment failure, which was defined as no clinical improvement or occurrence of an adverse event, resulting in a change in empiric antibiotics within 48 h of the first dose. Secondary outcomes included adverse events and acquisition of antibiotic-resistant bacteria. Outcomes were assessed in all randomised participants with outcome data (intention-to-treat population) and in all individuals who received treatment as allocated and did not have any major protocol violations (per-protocol population). For home treatment to be non-inferior to hospital treatment, the difference between groups in the proportion of children with treatment failure in the intention-to-treat population had to be less than 15%. This trial is registered with ClinicalTrials.gov, number NCT02334124.

FINDINGS

Between Jan 9, 2015, and June 15, 2017, we screened 1135 children for eligibility, of whom 190 were randomly assigned to receive ceftriaxone at home (n=95) or flucloxacillin in hospital (n=95). The intention-to-treat analysis comprised 188 children (93 in the home group and 95 in the hospital group) because two children in the home group were found to be ineligible after randomisation and were excluded. Treatment failure occurred in two (2%) children in the home group and in seven (7%) children in the hospital group (risk difference -5·2%, 95% CI -11·3 to 0·8, p=0·088). In the per-protocol analysis, treatment failure occurred in one (1%) of 89 children in the home group and in seven (8%) of 91 children in the hospital group (-6·5%, -12·4 to -0·7). Fewer children treated at home than in hospital had an adverse event (two [2%] vs ten [11%]; p=0·048). There was no difference between groups in rates of nasal acquisition of meticillin-resistant Staphylococcus aureus or gastrointestinal acquisition of extended-spectrum β-lactamase-producing bacteria or Clostridium difficile after 3 months.

INTERPRETATION

Home treatment with intravenous ceftriaxone is not inferior to treatment in hospital with intravenous flucloxacillin for children with cellulitis. The standard of care for the intravenous treatment of uncomplicated cellulitis in children should be home or outpatient care when feasible.

FUNDING

The Royal Children's Hospital Foundation and Murdoch Children's Research Institute.

An Updated Review of Clostridium difficile Treatment in Pediatrics

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.

Fecal Microbiota Transplantation for Recurrent Clostridium difficile Infection and Other Conditions in Children: A Joint Position Paper From the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition

Fecal microbiota transplantation (FMT) is becoming part of the treatment algorithms against recurrent Clostridium difficile infection (rCDI) both in adult and pediatric gastroenterology practice. With our increasing recognition of the critical role the microbiome plays in human health and disease, FMT is also being considered as a potential therapy for other disorders, including inflammatory bowel disease (Crohn disease, ulcerative colitis), graft versus host disease, neuropsychiatric diseases, and metabolic syndrome. Controlled trials with FMT for rCDI have not been performed in children, and numerous clinical and regulatory considerations have to be considered when using this untraditional therapy. This report is intended to provide guidance for FMT in the treatment of rCDI in pediatric patients.

Optimizing the Use of Medications and Other Therapies in Infant Gastroesophageal Reflux

Gastroesophageal reflux (GER) is the retrograde movement of gastric (and sometimes duodenal) contents into the esophagus. While the majority of GER is physiologic, for patients, it can be associated with symptoms. While some symptoms are merely bothersome (crying), others can be life threatening (cough, gagging, choking). The main driver of GER in infants is the frequent feedings that produce increased intra-abdominal pressure, which is known to trigger transient relaxations of the lower esophageal sphincter. The recent 2018 clinical practice guidelines reported by the North American and European Societies for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN/ESPGHAN) have recommended non-pharmacologic management initially with subsequent consideration of brief trials with acid suppressants. The main target for these acid suppressants is the gastric parietal cells. Our review of the literature has revealed a paucity of data regarding the use of histamine-2 receptor antagonists and proton pump inhibitors in infants. Despite the absence of well-controlled clinical studies, the prescription rate of these medications has increased internationally. Risks to patients of all ages have become increasingly recognized, with new associations being reported all too often. Here we report our review of all pharmacologic modalities as well as some non-surgical options.

Outpatient Antibiotic Use and the Need for Increased Antibiotic Stewardship Efforts

Antibiotic-resistant infections pose a growing threat to public health. Antibiotic use, regardless of whether it is warranted, is a primary factor in the development of resistance. In the United States, the majority of antibiotic health care expenditures are due to prescribing in outpatient settings. Much of this prescribing is inappropriate, with research showing that at least 30% of antibiotic use in outpatient settings is unnecessary. In this State of the Art Review article, we provide an overview of the latest research on outpatient antibiotic prescribing practices in the United States. Although many of the researchers in these studies describe antibiotic prescribing across all patient age groups, we highlight prescribing in pediatric populations when data are available. We then describe the various factors that can influence a physician's prescribing decisions and drive inappropriate antibiotic use and the potential role of behavioral science in enhancing stewardship interventions to address these drivers. Finally, we highlight the role that a wide range of health care stakeholders can play in aiding the expansion of outpatient stewardship efforts that are needed to fully address the threat of antibiotic resistance.

Long-term, low-dose of clarithromycin as a cause of community-acquired Clostridium difficile infection in a 5-year-old boy

Clostridium difficile is one of the most common causes of antibiotic-associated diarrhoea. Despite C. difficile infection (CDI) has increased in all ages worldwide, episodes of CDI are often misdiagnosed due to the lack of clinical suspicion. Macrolides are also associated with CDI. Additionally, exposure to macrolides in the 12 weeks preceding infection is reported to be a significant risk factor of CDI in a child. We report here a 5-year-old Japanese boy who presented with acute onset of watery diarrhoea. He was diagnosed with community-acquired CDI induced by long-term (20 weeks), low-dose, oral clarithromycin for otitis media with effusion, and he recovered by conservative treatment. Physicians should be more cautious of community-acquired CDI in children who take long-term, low-dose macrolides, not to misdiagnose as diarrhoea by its side effect, and avoid unnecessary use of systemic antibiotics.

Community-acquired Clostridium difficile infection in Serbian pediatric population

Carriage of Clostridium (C.) difficile in the intestinum of children, as well as its role in the disease (diarrhea) onset, is still controversial. The aim of this study is to investigate the community-acquired Clostridium difficile infection (CA-CDI) in Serbian pediatric population and to describe the basic clinical characteristics and risk factors for CA-CDI occurrence in Serbian pediatric population. The data obtained from 63 Serbian pediatric patients with CA-CDI and from control group of 126 children with community-acquired diarrhea, whose stool specimens were negative for C. difficile and toxins A/B, were mutually compared. In the current work, we found that children with CA-CDI display a significantly less severe disease clinical presentation than children with diarrheas of other origin. Lethal outcome was noted in two cases, but in children with severe underlying diseases (Crohn's disease and leukemia). By using the multivariate statistical regression model, the following statistically significant risk factors for community-acquired C. difficile-associated diarrhea development were determined: previous application of laxatives (OR = 0.199, CI 0.55-0.79, p = 0.015), general antibiotic use during the previous 2 months (OR = 0.05, CI 0.02-0.17, p < 0.001), and specifically the use of penicillins (OR = 0.112, CI 0.04-0.31, p < 0.0001) and cephalosporins (OR = 0.16, CI 40.06-0.44, p < 0.0001). Antibiotics from the groups of cephalosporins and penicillins were found to be the most important independent risk factors. Laxative application plays a significant role in the community-acquired Clostridium difficile infections in children, with mechanisms that are not completely understood.

Impact of a mixed educational and semi-restrictive antimicrobial stewardship project in a large teaching hospital in Northern Italy

BACKGROUND

The overuse of antimicrobials favors the dissemination of antimicrobial resistance, as well as invasive fungal diseases and Clostridium difficile infections (CDI). In this study, we assessed the impact of a mixed educational and semi-restrictive antimicrobial stewardship (AMS) project in a large teaching hospital in Italy.

METHODS

The AMS project was conducted from May 2014 to April 2016. It consisted of two initiatives in two consecutive periods: (1) educational activities; (2) semi-restrictive control of antimicrobial prescribing through a computerized software. The primary endpoint was consumption of antibacterials and antifungals. Secondary endpoints were incidence of CDI, methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSI), carbapenem-resistant Klebsiella pneumoniae (CRKP) BSI, and Candida BSI.

RESULTS

During the study period, a statistically significant reduction in consumption was observed for antibacterials (-1.45 defined daily doses (DDD)/1000 patient-days monthly, 95% confidence intervals [CI] -2.38 to -0.52, p 0.004), mainly driven by reductions in the use of fluoroquinolones, third/fourth generation cephalosporins, and carbapenems. No decrease in consumption of antifungals was observed (-0.04 DDD/1000 patient-days monthly, 95% CI -0.34 to +0.25, p 0.750). A statistically significant trend towards reduction was observed for incidence of CRKP BSI (incidence rate ratio 0.96, 95% CI 0.92-0.99, p 0.013). No statistically significant variations in trends were observed for CDI, MRSA BSI, and Candida BSI.

CONCLUSIONS

The mixed AMS project was effective in reducing the use of major antibacterials and the incidence of CRKP BSI. Further research is needed to assess the extent of long-term benefits of semi-restrictive approaches.