Clostridioides (Clostridium) difficile carriage in asymptomatic children since 2010: a narrative review

Prevalence of Detection of Clostridioides difficile Among Asymptomatic Children: A Systematic Review and Meta-analysis

IMPORTANCE

Detection of Clostridioides difficile has frequently been described in asymptomatic infants and children, but accurate estimates across the age spectrum are unavailable.

OBJECTIVE

To assess the prevalence of C difficile detection among asymptomatic children across the age spectrum.

DATA SOURCES

This systematic review and meta-analysis included a search of the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, Scopus, and Web of Science for articles published from January 1, 1990, to December 31, 2020. Search terms included Clostridium difficile, Peptoclostridium difficile, Clostridioides difficile, CDF OR CDI OR c diff OR c difficile, Clostridium infections OR cd positive diarrhea OR cd positive diarrhea OR Clostridium difficile OR Peptoclostridium difficile OR pseudomembranous colitis OR pseudomembranous enterocolitis, enterocolitis, and pseudomembranous. These were combined with the following terms: bacterial colonization and colonization OR colonized OR colonizing OR epidemiology OR prevalence OR seroprevalence.

STUDY SELECTION

Studies were screened independently by 2 authors. Studies were included if they reported testing for C difficile among asymptomatic children (ie, children without diarrhea) younger than 18 years.

DATA EXTRACTION AND SYNTHESIS

Data were extracted independently and in duplicate by 2 reviewers. Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines were used. Data were pooled using a random-effects model.

MAIN OUTCOMES AND MEASURES

The primary outcome was prevalence of C difficile detection among asymptomatic children. Secondary outcomes included prevalence of toxigenic vs nontoxigenic strains of C difficile and prevalence of C difficile detection stratified by geographic region, income status, testing method, and year of testing.

RESULTS

A total of 95 studies with 19 186 participants were included. Rates of detection of toxigenic or nontoxigenic C difficile were greatest among infants aged 6 to 12 months (41%; 95% CI, 32%-50%) and decreased to 12% (95% CI, 7%-18%) among children aged 5 to 18 years. The prevalence of toxigenic C difficile colonization was lower, peaking at 14% (95% CI, 8%-21%) among infants aged 6 to 12 months and decreasing to 6% (95% CI, 2%-11%) among children older than 5 years. Although prevalence differed by geographic region (ie, North and South America vs Europe: β, -0.151, P = .001; North and South America vs Western Pacific: β, 0.136, P = .007), there was no difference by testing method (ie, culture vs polymerase chain reaction: β, 0.069, P = .052; culture vs enzyme immunoassay: β, -0.178, P = .051), income class (low-middle income vs high income: β, -0.144, P = .23; upper-middle vs high income: β, -0.020, P = .64), or period (before 1990 vs 2010-2020: β, -0.125, P = .19; 1990-1999 vs 2010-2020: β, -0.037, P = .42; 2000-2009 vs 2010-2020: β, -0.006, P = .86).

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis, C difficile colonization rates among children were greatest at 6 to 12 months of age and decreased thereafter. These estimates may provide context for interpreting C difficile test results among young children.

Diagnosis and management of paediatric Clostridioides difficile infection in a tertiary centre: A prospective audit

AIM

The optimisation of diagnosis and management of paediatric Clostridioides (formerly Clostridium) difficile (C. difficile) infection (CDI) has importance on multiple levels, from individual patient to population disease management and infection control. This study aimed to evaluate current practice at a paediatric tertiary hospital against Australasian Society for Infectious Diseases 2016 guidelines.

METHODS

Prospective audit was undertaken. All positive C. difficile tests (by two step immunoassay then polymerase chain reaction) over 6 month period were reviewed for appropriateness of testing, including review of clinical characteristics and treatment of appropriately requested positive tests (CDI cases). Consecutive test requests for C. difficile over 2 month period were reviewed for appropriateness of testing.

RESULTS

Of 70 consecutive test requests, 64 met laboratory criteria for processing. Of these, 31 (48%) out of 64 were asymptomatic or had clinically insignificant or laxative-associated diarrhoea. Overall, 44 (63%) out of 70 were deemed inappropriate requests. Of 45 positive tests, 17 (38%) were appropriately requested. Amongst inappropriate requests, 13 (46%) out of 28 were treated; those aged >2 years were significantly more likely to be treated (P < 0.05). Thirteen children were treated unnecessarily. Only one out of seven positive tests in infants (<1 year) was appropriately requested. Haematology/oncology patients accounted for 41% of cases. Treatment was in accordance with guidelines in 58% of cases.

CONCLUSIONS

Inappropriate testing for C. difficile and variable clinical response to positive tests have sequelae including unnecessary antibiotics for hospitalised children. Areas for improvement have been identified and this study confirms the need for establishment of national paediatric CDI guidelines with increased awareness of these by clinicians.

Bacteria producing antimicrobials against Clostridium difficile isolated from human stool

Clostridium difficile infection (CDI) is a common cause of morbidity and mortality in hospitalized patients worldwide. The major problem facing current treatment is multiple recurrences, prompting the need for alternative therapies. In this study we isolated bacterial species, from Egyptian individuals' stool, with antimicrobial activity against clinical isolates of C. difficile and tried to examine the nature of the produced antimicrobials. In vitro antibacterial activity against C. difficile was initially screened in 123 fecal samples cultures using an agar overlay method. The isolates with antimicrobial activity against C. difficile in addition to Clostridium isolates were identified using partial 16S rDNA gene sequencing analysis. The isolates acting against C. difficile belonged to Lactobacillus, Enterococcus and Clostridium genera. The concentrated cell-free supernatants (CFSs) from these bacterial isolates were examined for antimicrobial activity against C. difficile growth by broth dilution method. 10 x concentrated CFSs of five isolates showed inhibition for C. difficile growth which was significantly different (p < 0.001) from control. Lactobacillus agilis T99A and Clostridium butyricum T58A isolates were selected for further evaluation of the produced antimicrobials. The antimicrobial activity of 10x CFSs of the two isolates was stable after enzymatic treatment with proteinase K or heating treatments up to 90 °C or neutralizing pH. The spectrum of activity of the two isolates was evaluated using different gram-positive and gram-negative bacterial species and did not show antimicrobial activity against these species. Our results showed two unconventional bacterial isolates: L. agilis T99A and C. butyricum T58A producing extracellular thermo stable antimicrobial agents against C. difficile clinical isolates.