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Patel P, Robinson PD, Fisher BT, Phillips R, Morgan JE, Lehrnbecher T, Kuczynski S, Koenig C, Haeusler GM, Esbenshade A, Elgarten C, Duong N, Diorio C, Castagnola E, Beauchemin MP, Ammann RA, Dupuis LL, Sung L. Guideline for the management of Clostridioides difficile infection in pediatric patients with cancer and hematopoietic cell transplantation recipients: 2024 update. EClinicalMedicine 2024; 72:102604. [PMID: 38680517 PMCID: PMC11046252 DOI: 10.1016/j.eclinm.2024.102604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/28/2024] [Accepted: 04/03/2024] [Indexed: 05/01/2024] Open
Abstract
Our objective was to update a clinical practice guideline for the prevention and treatment of Clostridioides difficile infection (CDI) in pediatric patients with cancer and hematopoietic cell transplantation recipients. We reconvened an international multi-disciplinary panel. A systematic review of randomized controlled trials (RCTs) for the prevention or treatment of CDI in any population was updated and identified 31 new RCTs. Strong recommendations were made to use either oral metronidazole or oral vancomycin for non-severe CDI treatment, and to use either oral vancomycin or oral fidaxomicin for severe CDI. A strong recommendation that fecal microbiota transplantation should not be routinely used to treat CDI was also made. The panel made two new good practice statements to follow infection control practices including isolation in patients experiencing CDI, and to minimize systemic antibacterial administration where feasible, especially in patients who have experienced CDI.
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Affiliation(s)
- Priya Patel
- Pediatric Oncology Group of Ontario, 480 University Ave, Suite 1014, Toronto, ON, M5G 1V2, Canada
- Department of Pharmacy, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Paula D. Robinson
- Pediatric Oncology Group of Ontario, 480 University Ave, Suite 1014, Toronto, ON, M5G 1V2, Canada
| | - Brian T. Fisher
- Division of Infectious Diseases, Children's Hospital of Philadelphia, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Robert Phillips
- Centre for Reviews and Dissemination, University of York, York, YO10 5DD, UK
- Department of Paediatric Haematology and Oncology, Leeds Children's Hospital, Leeds, LS1 3EX, UK
| | - Jessica E. Morgan
- Centre for Reviews and Dissemination, University of York, York, YO10 5DD, UK
- Department of Paediatric Haematology and Oncology, Leeds Children's Hospital, Leeds, LS1 3EX, UK
| | - Thomas Lehrnbecher
- Department of Pediatrics, Division of Hematology, Oncology and Hemostaseology, Goethe University Frankfurt, Theodor-W.-Adorno-Platz 1, 60629, Frankfurt am Main, Germany
| | | | - Christa Koenig
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 20, 3010, Bern, Switzerland
| | - Gabrielle M. Haeusler
- Infectious Diseases Unit, Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria, 3052, Australia
| | - Adam Esbenshade
- Vanderbilt-Ingram Cancer Centre, 2220 Pierce Ave, Nashville, TN, 37232, USA
| | - Caitlin Elgarten
- Division of Oncology, Children's Hospital of Philadelphia, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | | | - Caroline Diorio
- Division of Oncology, Children's Hospital of Philadelphia, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Elio Castagnola
- Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, 16147, Genova, Italy
| | - Melissa P. Beauchemin
- Columbia University Irving Medical Center/Herbert Irving Comprehensive Cancer Center, Columbia University School of Nursing, 1130 St Nicholas Ave, 2nd Floor, New York, NY, 10032, USA
| | - Roland A. Ammann
- StatConsult Ammann, Pleerweg 92, 3400, Burgdorf, Switzerland
- Kinderarztpraxis KurWerk, Poststrasse 9, 3400, Burgdorf, Switzerland
| | - L. Lee Dupuis
- Department of Pharmacy, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON, M5S 3M2, Canada
| | - Lillian Sung
- Child Health Evaluative Sciences, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
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Chien MM, Chang MH, Chang KC, Ni YH, Wu JF. The incidence of Clostridium difficile infection in children with and without inflammatory bowel diseases: A single-center study in Taiwan from 2006 to 2019. J Formos Med Assoc 2024:S0929-6646(24)00206-7. [PMID: 38631957 DOI: 10.1016/j.jfma.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 03/18/2024] [Accepted: 04/07/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND The incidence of Clostridium difficile infection (CDI) is increasing around the world, and patients with inflammatory bowel disease (IBD) have a higher risk of obtaining CDI. The data on the incidence rate of CDI in the Asian pediatric IBD population was lacking. METHODS We retrospectively collected data from a tertiary medical center in Taipei, Taiwan. All patients aged 1-18 years old who visited the outpatient department or were admitted to our hospital between 2006 and 2019 were included. CDI was defined as positive stool C. difficile toxin or C. difficile culture results with appropriate antibiotic use within the range of 7 days prior or 14 days after the result. RESULTS We compared the average annual incidence of CDI before and after 2013. The average incidence of community-acquired CDI (CA-CDI) increased from 0.063 to 0.564 cases per 1,000 visits, with a rate ratio (RR) of 8.82 (95% CI 5.74-14.38). In patients with IBD, the rate increased from 26.738 to 278.873 cases per 1,000 visits (RR=10.12, 95% CI: 4.57-29.02). The average incidence rate increased from 0.685 to 1.874 cases per 1,000 admissions in pediatric general patients (RR = 2.72, 95% CI 1.82-4.20) and from 14.706 to 62.500 cases per 1,000 admissions in pediatric IBD patients (RR = 3.77, 95% CI 0.71-93.53). CONCLUSIONS Both CA-CDI and healthcare facility-onset CDI (HO-CDI) were increasing substantially in the pediatric population over the past decade in Taiwan. Compared to the general pediatric population, pediatric IBD patients had a much higher incidence of CDI.
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Affiliation(s)
- Mu-Ming Chien
- Department of Pediatrics, Taipei Medical University Hospital, Taipei City, Taiwan; Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei City, Taiwan; Taipei Medical University Research Center for Digestive Medicine, Taipei Medical University, Taipei City, Taiwan; Department of Pediatrics, National Taiwan University Hospital, Taipei City, Taiwan
| | - Mei-Hwei Chang
- Department of Pediatrics, National Taiwan University Hospital, Taipei City, Taiwan; College of Medicine, National Taiwan University Hospital, Taipei City, Taiwan
| | - Kai-Chi Chang
- Department of Pediatrics, National Taiwan University Hospital, Taipei City, Taiwan
| | - Yen-Hsuan Ni
- Department of Pediatrics, National Taiwan University Hospital, Taipei City, Taiwan; College of Medicine, National Taiwan University Hospital, Taipei City, Taiwan
| | - Jia-Feng Wu
- Department of Pediatrics, National Taiwan University Hospital, Taipei City, Taiwan; College of Medicine, National Taiwan University Hospital, Taipei City, Taiwan.
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Mpakaniye P, Boven A, Callens S, Engstrand L, Vlieghe E, Brusselaers N. Clostridioides difficile recurrence in individuals with and without cancer: a Swedish population-based cohort study. Infection 2024; 52:649-660. [PMID: 38407777 PMCID: PMC10954957 DOI: 10.1007/s15010-024-02193-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 01/19/2024] [Indexed: 02/27/2024]
Abstract
PURPOSE Patients with cancer are vulnerable to Clostridioides difficile infection (CDI) due to their disease, treatment and regular hospital contact, yet if CDI-recurrence is more common remains unclear, and differences among cancer types remain unexplored. METHODS This Swedish nationwide population-based cohort included all 43,150 individuals with recorded CDI (2006-2019) to assess CDI-recurrence in individuals with and without cancer, with binary multivariable logistic regression, stratified by anatomical location, and survival status. RESULTS Compared to those without cancer (N = 29,543), ongoing cancer (diagnosis < 12 months; N = 3,882) was associated with reduced recurrence (OR = 0.81, 95% CI 0.73-0.89), while there was no association with cancer history (diagnosis ≥ 12 months; N = 9,725). There was an increased 8-week all-cause mortality (Ongoing cancer: OR = 1.58, 95% CI 1.43-1.74; Cancer history: OR = 1.45, 95% CI 1.36-1.55) compared to those without cancer. Among CDI-survivors, those with ongoing cancer presented with a decreased odds of recurrence (OR = 0.84, 95% CI 0.76-0.94), compared to those without cancer history, with no association for those with cancer history (OR = 1.04, 95% CI 0.97-1.1). Large variations were seen across cancer types, with the highest observed proportion of recurrence in oral and mesothelial cancer, and the lowest for esophageal cancer, although no statistically significant OR were found. CONCLUSION The population-based study indicates that individuals with cancer may have fewerrecurrences than expected, yet variations by cancer type were large, and mortality was high.
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Affiliation(s)
- Peace Mpakaniye
- Centre for Translational Microbiome Research, Department Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
- Global Health Institute, Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Annelies Boven
- Centre for Translational Microbiome Research, Department Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
- Global Health Institute, Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
- The Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Steven Callens
- General Internal Medicine and Infectious Diseases, Ghent University, Ghent University Hospital, Ghent, Belgium
| | - Lars Engstrand
- Centre for Translational Microbiome Research, Department Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Erika Vlieghe
- Global Health Institute, Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
- Infectious Diseases, Department of General Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Nele Brusselaers
- Centre for Translational Microbiome Research, Department Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden.
- Global Health Institute, Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium.
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.
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Dop D, Marcu IR, Padureanu V, Caragea DC, Padureanu R, Niculescu SA, Niculescu CE. Clostridium difficile infection in pediatric patients (Review). Biomed Rep 2024; 20:18. [PMID: 38169799 PMCID: PMC10758920 DOI: 10.3892/br.2023.1706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 11/27/2023] [Indexed: 01/05/2024] Open
Abstract
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.
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Affiliation(s)
- Dalia Dop
- Department of Pediatrics, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Iulia Rahela Marcu
- Department of Physical and Rehabilitation Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Vlad Padureanu
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Daniel Cosmin Caragea
- Department of Nephrology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Rodica Padureanu
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Stefan-Adrian Niculescu
- Department of Orthopedics, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Carmen Elena Niculescu
- Department of Pediatrics, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
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Reasoner SA, Nicholson MR. Clostridioides difficile Infection in Pediatric Inflammatory Bowel Disease. Curr Gastroenterol Rep 2023; 25:316-322. [PMID: 37646895 PMCID: PMC10843265 DOI: 10.1007/s11894-023-00890-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE OF REVIEW Children with inflammatory bowel disease (IBD) are at increased risk of C. difficile infection (CDI) and experience worse outcomes associated with an infection. In this article, we review recent research on the incidence, diagnosis, complications, and treatment options for CDI in children with IBD. RECENT FINDINGS Children with IBD have an elevated incidence of CDI, but their CDI risk does not associate with established risk factors in adults with IBD. Existing testing methodologies are inadequate at differentiating CDI from C. difficile colonization in children with IBD. Fecal microbiota transplantation offers a durable cure for recurrent CDI. CDI remains a frequent occurrence in children with IBD. Careful clinical monitoring should be used to diagnose CDI and patients with co-occurring IBD and CDI require careful surveillance for worse outcomes. Future research should explore the optimal diagnosis and treatment modalities in this unique patient population.
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Affiliation(s)
- Seth A Reasoner
- Division of Molecular Pathogenesis, Department of Pathology, Microbiology & Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Maribeth R Nicholson
- Immunology & Inflammation (VI4), Vanderbilt Institute for Infection, Vanderbilt University Medical Center, Nashville, TN, USA.
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Monroe Carrell Junior Children's Hospital at Vanderbilt, Nashville, TN, USA.
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Lo Porto D, Mularoni A, Castagnola E, Saffioti C. Clostridioides difficile infection in the allogeneic hematopoietic cell transplant recipient. Transpl Infect Dis 2023; 25 Suppl 1:e14159. [PMID: 37787395 DOI: 10.1111/tid.14159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/09/2023] [Accepted: 09/14/2023] [Indexed: 10/04/2023]
Abstract
Clostridioides difficile (CD) is one of the most important causes of diarrhea in hospitalized patients, in particular those who undergo an allogeneic hematopoietic cell transplant (allo-HCT) and who are more at risk of developing a CD infection (CDI) due to frequent hospitalizations, iatrogenic immunosuppression, and prolonged antibiotic cycles. CDI may represent a severe condition in allo-HCT patients, increasing the length of hospitalization, influencing the intestinal microbiome with a bidirectional association with graft-versus-host disease, and leading to unfavorable outcomes, including death. The diagnosis of CDI requires the exclusion of other probable causes of diarrhea in HCT patients and is based on highly sensitive and highly specific tests to distinguish colonization from infection. In adult patients, fidaxomicin is recommended as first-line, with oral vancomycin as an alternative agent. Bezlotoxumab may be used to reduce the risk of recurrence. In pediatric patients, vancomycin and metronidazole are still suggested as first-line therapy, but fidaxomicin will probably become standard in pediatrics in the near future. Because of insufficient safety data, fecal microbiota transplantation is not routinely recommended in HCT in spite of promising results for the management of recurrences in other populations.
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Affiliation(s)
- Davide Lo Porto
- Unit of Infectious Diseases, IRCCS-ISMETT Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
| | - Alessandra Mularoni
- Unit of Infectious Diseases, IRCCS-ISMETT Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
| | - Elio Castagnola
- Pediatric Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Carolina Saffioti
- Pediatric Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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7
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Wu X, Ai RJ, Xu J, Wen Q, Pan HQ, Zhang ZH, Ning W, Fang Y, Ding DF, Wang Q, Han S, Liu X, Wu M, Jia ZY, Jia S, Lin T, Cui BT, Nie YZ, Wang X, Zhang FM. Washed microbiota transplantation for Clostridioides difficile infection: A national multicenter real-world study. J Dig Dis 2023; 24:540-549. [PMID: 37681235 DOI: 10.1111/1751-2980.13227] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/21/2023] [Accepted: 09/06/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVES Fecal microbiota transplantation (FMT) has been recommended for the treatment of recurrent Clostridioides difficile infection (CDI). We aimed to evaluate the therapeutic efficacy and safety of washed microbiota transplantation (WMT), a new method of FMT, for CDI across various medical settings. METHODS This multicenter real-world cohort study included CDI patients undergoing WMT. The primary outcome was the clinical cure rate of CDI within 8 weeks after WMT. Secondary outcomes included the CDI recurrence rate and reduction in total abdominal symptom score (TASS) during the follow-up period. Adverse events related to WMT were recorded. RESULTS Altogether 90.7% (49/54) of CDI patients achieved clinical cure after treated with WMT. The cure rate was 83.3% for cases with severe and complicated CDI (ScCDI) (n = 30) and 100% for non-ScCDI cases (n = 24) (P = 0.059). No difference was observed in the clinical cure rate between patients with first and recurrent CDI (91.9% vs 88.2%, P = 0.645). One week post-WMT, TASS showed a remarkable decrease compared to that at baseline (P < 0.001). Totally, 8.2% (4/49) of patients suffered CDI recurrence during the follow-up period. A WHO performance score of 4, age ≥65 years, higher TASS score, and higher Charlson comorbidity index score were potential risk factors for efficacy (P = 0.018, 0.03, 0.01, 0.034, respectively). Four (3.8%) transient adverse events related to WMT were observed. CONCLUSIONS This study emphasizes the attractive value of WMT for CDI. Early WMT may be recommended for CDI, especially for those in serious condition or with complex comorbidities. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT03895593 (registered on 27 March 2019).
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Affiliation(s)
- Xia Wu
- Department of Microbiota Medicine & Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Ru Jun Ai
- Department of Microbiota Medicine & Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Jie Xu
- Department of Microbiota Medicine & Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Quan Wen
- Department of Microbiota Medicine & Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Hua Qin Pan
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Zhi Hua Zhang
- Department of Gastroenterology, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Wang Ning
- Department of Gastroenterology, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shaanxi Province, China
| | - Ying Fang
- Department of Gastroenterology, The Affiliated Children's Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Da Fa Ding
- Department of Endocrinology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Quan Wang
- Department of Geriatrics, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Shuang Han
- Department of Gastroenterology, Honghui Hospital, Xi'an, Shaanxi Province, China
| | - Xiao Liu
- Department of Gastroenterology, Xi'an International Medical Center Hospital, Xi'an, Shaanxi Province, China
| | - Mei Wu
- Department of Gastroenterology, The Second Affiliated Hospital of Guilin Medical University, Guilin, Guangxi Zhuang Autonomous Region, China
| | - Zhen Yu Jia
- Department of General Practice, The Affiliated Zhangjiagang Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Song Jia
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Tao Lin
- Department of Gastroenterology, Xi'an Daxing Hospital, Xi'an, Shaanxi Province, China
| | - Bo Ta Cui
- Department of Microbiota Medicine & Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Yong Zhan Nie
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi Province, China
- National Clinical Research Center for Digestive Diseases, Xi'an, Shaanxi Province, China
| | - Xin Wang
- Department of Gastroenterology, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shaanxi Province, China
- National Clinical Research Center for Digestive Diseases, Xi'an, Shaanxi Province, China
| | - Fa Ming Zhang
- Department of Microbiota Medicine & Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing, Jiangsu Province, China
- National Clinical Research Center for Digestive Diseases, Xi'an, Shaanxi Province, China
- Division of Microbiotherapy, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, China
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Shirley DA, Tornel W, Warren CA, Moonah S. Clostridioides difficile Infection in Children: Recent Updates on Epidemiology, Diagnosis, Therapy. Pediatrics 2023; 152:e2023062307. [PMID: 37560802 PMCID: PMC10471512 DOI: 10.1542/peds.2023-062307] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 08/11/2023] Open
Abstract
Clostridioides (formerly Clostridium) difficile is the most important infectious cause of antibiotic-associated diarrhea worldwide and a leading cause of healthcare-associated infection in the United States. The incidence of C. difficile infection (CDI) in children has increased, with 20 000 cases now reported annually, also posing indirect educational and economic consequences. In contrast to infection in adults, CDI in children is more commonly community-associated, accounting for three-quarters of all cases. A wide spectrum of disease severity ranging from asymptomatic carriage to severe diarrhea can occur, varying by age. Fulminant disease, although rare in children, is associated with high morbidity and even fatality. Diagnosis of CDI can be challenging as currently available tests detect either the presence of organism or disease-causing toxin but cannot distinguish colonization from infection. Since colonization can be high in specific pediatric groups, such as infants and young children, biomarkers to aid in accurate diagnosis are urgently needed. Similar to disease in adults, recurrence of CDI in children is common, affecting 20% to 30% of incident cases. Metronidazole has long been considered the mainstay therapy for CDI in children. However, new evidence supports the safety and efficacy of oral vancomycin and fidaxomicin as additional treatment options, whereas fecal microbiota transplantation is gaining popularity for recurrent infection. Recent advancements in our understanding of emerging epidemiologic trends and management of CDI unique to children are highlighted in this review. Despite encouraging therapeutic advancements, there remains a pressing need to optimize CDI therapy in children, particularly as it pertains to severe and recurrent disease.
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Affiliation(s)
| | | | - Cirle A. Warren
- Infectious Diseases and International Health, Department of Medicine
- Complicated C. difficile Clinic, UVA Health, University of Virginia, Charlottesville, Virginia
| | - Shannon Moonah
- Infectious Diseases and International Health, Department of Medicine
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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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