Fulminant Clostridium difficile toxic megacolon in a pediatric heart transplant recipient

The impact of Clostridium difficile on paediatric surgical practice: a systematic review

PURPOSE

The pathogenic potential of Clostridium difficile in children remains a controversial subject as healthy infants can be colonised by this organism. However recent analyses have clarified that C. difficile is an important enteropath in paediatric populations, particularly in antibiotic-associated diarrhoea. Paediatric surgical patients including those with Hirschsprung's disease (HD) may be especially vulnerable to C. difficile infection (CDI) and complicated C. difficile enterocolitis such as pseudomembranous colitis may require surgical management if refractory to medical therapy. Reports of increasing prevalence and emergence of hyper-virulent strains of C. difficile worldwide prompted an examination of the literature to assess the impact of CDI on current paediatric surgical practise.

METHODS

The literature was searched using a combination of the MESH terms "hirschsprung's disease", "enterocolitis", "clostridium difficile", and "children". Cases of Hirschsprung's associated enterocolitis (HAEC) investigated for C. difficile and complicated CDI in non HD patients were identified and analysed for clinical parameters, diagnostic evaluations, surgical interventions and outcome.

RESULTS

Pathogen isolation in HAEC was infrequently described. Only 98 children have been reported with C. difficile during an episode of HAEC over the last 40 years and aetiology remains unclear as asymptomatic carriage of C. difficile in HD occurs. Nonetheless 34 confirmed cases of pseudomembranous colitis complicating HD are reported in the literature with an associated 50 % mortality rate. Over 20 % of non Hirschsprung's patients with reported severe or complicated CDI required operative intervention. The need for surgery was associated with the presence of co-morbidity and high mortality occurred in this group.

CONCLUSION

Severe or complicated CDI in both HD and non HD paediatric patients is associated with high mortality and often requires surgical intervention. Although these patient cohorts represent a small number of cases, CDI should be suspected in children presenting with enterocolitis to enable early diagnosis and timely surgical intervention, particularly in patients with co-morbid conditions or preceding antibiotic use.

Recent trends in the epidemiology and treatment of C. difficile infection in children

PURPOSE OF REVIEW

Clostridium difficile is the most common cause of healthcare-associated diarrhea among adults in Western countries, and is increasingly recognized as an important pathogen in children. This review provides an update on the changing epidemiology of C. difficile infection (CDI) for pediatric providers and summarizes current knowledge regarding available therapies.

RECENT FINDINGS

The incidence of CDI has more than doubled among adults over the past decade, with a particular rise in incidence among patients presenting from the community. CDI has also increased among children in both inpatient and outpatient settings and there is growing evidence that specific populations of children may be at highest risk. Antibiotic-based therapies remain the mainstay of treatment for CDI, but new therapies have been developed with potential future applications in children. Use of nonantibiotic-based therapies is limited in children, but their use has been studied among adults with intractable or recurrent disease.

SUMMARY

The rise in incidence of CDI over the past decade warrants increased recognition by pediatric providers. Knowledge of the pediatric populations at highest risk for infection as well as the options for therapy will improve understanding of this changing disease.

Conservative surgical treatment for toxic megacolon due to Clostridium difficile infection in a transplanted pediatric patient

Severe disease caused by Clostridium difficile is frequently encountered in transplant recipients and carries a high mortality. Numerous studies have been published on this subject in the adult population, but few in the pediatric setting. A 4-year-old boy who had undergone heart transplant 20 months earlier was admitted to the pediatric intensive care unit after humoral rejection. Seven days after admission, he developed septic shock, abdominal distension, and paralytic ileus without diarrhea. Pseudomembranous colitis due to C. difficile was confirmed by microbiological and radiological studies. Despite treatment with rectal vancomycin and intravenous metronidazole, the patient did not improve and required decompressive laparotomy; because of the poor subsequent clinical course, terminal ileostomy and cecostomy were performed in a second operation. Recovery was satisfactory, and surgical reconstruction of intestinal tract was performed 3 months later without complications. Although early surgery with total colectomy is indicated, when there is a poor response to medical treatment in cases of C. difficile toxic megacolon, the case we present responded favorably to a conservative surgical approach that enabled intestinal integrity to be restored 3 months later. In the pediatric population, less aggressive therapeutic options should be considered, as they have benefits on the subsequent quality of life of the patient.