1
|
Rodig NM, Weatherly M, Kaplan AL, Ballal SA, Elisofon SA, Daly KP, Kahn SA. Fecal Microbiota Transplant in Pediatric Solid Organ Transplant Recipients. Transplantation 2023; 107:2073-2077. [PMID: 37211643 DOI: 10.1097/tp.0000000000004656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND Fecal microbiota transplant (FMT) is an effective treatment for recurrent Clostridioides difficile infection (CDI). Safety concerns around FMT are increased in immunocompromised populations, such as solid organ transplant (SOT) recipients. Outcomes among adult SOT recipients suggest FMT is efficacious and safe; however, pediatric SOT data are lacking. METHODS We describe the efficacy and safety of FMT among pediatric SOT recipients in a single-center retrospective study from March 2016 to December 2019. Successful FMT was defined as no recurrence of CDI within 2 mo of FMT. We identified 6 SOT recipients ages 4-18 y who received FMT a median of 5.3 y post-SOT. RESULTS Success after a single FMT was 83.3%. One liver recipient did not achieve cure after 3 FMTs and remains on low-dose vancomycin. One serious adverse event (SAE) occurred; cecal perforation and bacterial peritonitis occurred following colonoscopic FMT coordinated with intestinal biopsy in a kidney transplant recipient. He achieved full recovery and CDI cure. There were no other SAEs. There were no adverse events related to immunosuppression or transplantation status including: bacteremia, cytomegalovirus activation or reactivation, allograft rejection, or allograft loss. CONCLUSIONS In this limited series, efficacy of FMT in pediatric SOT is comparable to efficacy in the general pediatric recurrent CDI population. There may be an increased risk of procedure-related SAE in SOT patients and larger cohort studies are needed.
Collapse
Affiliation(s)
- Nancy M Rodig
- Division of Nephrology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Madison Weatherly
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA
| | - Abby L Kaplan
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA
| | - Sonia Arora Ballal
- Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA
| | - Scott A Elisofon
- Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA
| | - Kevin P Daly
- Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Division of Advanced Cardiac Therapies, Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Stacy A Kahn
- Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA
| |
Collapse
|
2
|
Gerzina EA, Brewer ED, Guhan M, Geha JD, Huynh AP, O'Conor D, Thorsen AC, Tan GC, Bhakta K, Hosek K, Malik TH, O'Mahony CA, Faraone ME, Fuller K, Rana A, Swartz SJ, Srivaths PR, Galván NTN. Good outcomes after pediatric intraperitoneal kidney transplant. Pediatr Transplant 2022; 26:e14294. [PMID: 35470524 DOI: 10.1111/petr.14294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 03/31/2022] [Accepted: 04/06/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Kidney transplantation in small children is technically challenging. Consideration of whether to use intraperitoneal versus extraperitoneal placement of the graft depends on patient size, clinical history, anatomy, and surgical preference. We report a large single-center experience of intraperitoneal kidney transplantation and their outcomes. METHODS We conducted a retrospective review of pediatric patients who underwent kidney transplantation from April 2011 to March 2018 at a single large volume center. We identified those with intraperitoneal placement and assessed their outcomes, including graft and patient survival, rejection episodes, and surgical or non-surgical complications. RESULTS Forty-six of 168 pediatric kidney transplants (27%) were placed intraperitoneally in children mean age 5.5 ± 2.3 years (range 1.6-10 years) with median body weight 18.2 ± 5 kg (range 11.4-28.6 kg) during the study period. Two patients (4%) had vascular complications; 10 (22%) had urologic complications requiring intervention; all retained graft function. Thirteen patients (28%) had prolonged post-operative ileus. Eight (17%) patients had rejection episodes ≤6 months post-transplant. Only one case resulted in graft loss and was associated with recurrent focal segmental glomerular sclerosis (FSGS). Two patients (4%) had chronic rejection and subsequent graft loss by 5-year follow-up. At 7-year follow-up, graft survival was 93% and patient survival was 98%. CONCLUSIONS The intraperitoneal approach offers access to the great vessels, which allows greater inflow and outflow and more abdominal capacity for an adult donor kidney, which is beneficial in very small patients. Risk of graft failure and surgical complications were not increased when compared to other published data on pediatric kidney transplants.
Collapse
Affiliation(s)
| | - Eileen D Brewer
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, Texas, USA
| | - Maya Guhan
- Baylor College of Medicine, Houston, Texas, USA
| | - Joseph D Geha
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Anh P Huynh
- Baylor College of Medicine, Houston, Texas, USA
| | | | | | - Gail C Tan
- Baylor College of Medicine, Houston, Texas, USA
| | - Kirti Bhakta
- Transplant Services, Texas Children's Hospital, Houston, Texas, USA
| | - Kat Hosek
- Outcomes and Impact Service, Texas Children's Hospital, Houston, Texas, USA
| | | | - Christine A O'Mahony
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | | | - Kelby Fuller
- Transplant Services, Texas Children's Hospital, Houston, Texas, USA
| | - Abbas Rana
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Sarah J Swartz
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, Texas, USA
| | - Poyyapakkam R Srivaths
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, Texas, USA
| | - N Thao N Galván
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
3
|
Bernard R, Hourigan SK, Nicholson MR. Fecal Microbiota Transplantation and Microbial Therapeutics for the Treatment of Clostridioides difficile Infection in Pediatric Patients. J Pediatric Infect Dis Soc 2021; 10:S58-S63. [PMID: 34791396 PMCID: PMC8600035 DOI: 10.1093/jpids/piab056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Clostridioides difficile infection (CDI) is the most common cause of antibiotic-associated diarrhea and has high rates of recurrent disease. As a disease associated with intestinal dysbiosis, gastrointestinal microbiome manipulation and fecal microbiota transplantation (FMT) have evolved as effective, although relatively unregulated therapeutics and not without safety concerns. FMT for the treatment of CDI has been well studied in adults with increasing data reported in children. In this review, we discuss the current body of literature on the use of FMT in children including effectiveness, safety, risk factors for a failed FMT, and the role of FMT in children with comorbidities. We also review emerging microbial therapeutics for the treatment of rCDI.
Collapse
Affiliation(s)
- Rachel Bernard
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr. Vanderbilt Children’s Hospital, Nashville, Tennessee, USA,Corresponding Author: Rachel Bernard, DO MS, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr. Vanderbilt Children’s Hospital, 2200 Children’s Way, Suite 11226 Doctors’ Office Tower, Nashville, TN 38201, USA. E-mail:
| | - Suchitra K Hourigan
- Division of Pediatric Gastroenterology, Pediatric Specialists of Virginia, Fairfax, Virginia, USA
| | - Maribeth R Nicholson
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr. Vanderbilt Children’s Hospital, Nashville, Tennessee, USA
| |
Collapse
|
4
|
Stone JM, Savage A, Hudspeth M, Twombley K, Kasi N, Quiros JA, Arbizu RA, Curry S. Multi-organism gastrointestinal polymerase chain reaction positivity among pediatric transplant vs non-transplant populations: A single-center experience. Pediatr Transplant 2020; 24:e13771. [PMID: 32639105 PMCID: PMC8103891 DOI: 10.1111/petr.13771] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 05/01/2020] [Accepted: 05/26/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Diarrhea is a common problem in the pediatric post-solid organ transplant and post-hematopoietic stem cell transplant populations. Infectious etiology incidences are poorly defined, and the possibility of multi-organism positivity is often uninvestigated. The aim of this study is to utilize stool multiplex GIP assays to compare the PTP and NTP regarding the incidence and profiles of single-organism and multi-organism infectious diarrhea. METHODS A single-center retrospective review was conducted, investigating stool multiplex GIP panel results over a more than 3-year period, for pediatric patients. Assays test for 23 viral, bacterial, and protozoal organisms. RESULTS Positive assays in the PTP and NTP were 70/101 (69.3%) and 962/1716 (56.1%), respectively (P = .009). Thirty-two percent (32/101) of assays within the PTP were multi-organism positive, significantly more than 14.8% (254/1716) in the NTP (P < .00001). There was no significant difference in the incidence of single-organism positives, 37.6% (38/101) in PTP and 41.3% (708/1716) in the NTP. The PTP demonstrated a statistically significantly higher incidence of the following organisms within multi-agent positive GIPs (P < .05 for each): Clostridioides difficile, Cryptosporidium, EPEC, norovirus, and sapovirus. CONCLUSIONS The pediatric PTP demonstrates higher incidence of positive GIPs, higher rate of multi-organism positivity, and unique infectious organism incidence profiles. These data can provide a framework for understanding organism-specific pathogenicity factors, assessing the clinical impact of enteric co-infection, and understanding the utility of this testing modality in this unique population.
Collapse
Affiliation(s)
- John M. Stone
- Department of Pediatric Gastroenterology Hepatology and Nutrition, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Andrew Savage
- Department of Pediatric Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michelle Hudspeth
- Department of Pediatric Hematology and Oncology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Katherine Twombley
- Department of Pediatric Nephrology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nagraj Kasi
- Department of Pediatric Gastroenterology Hepatology and Nutrition, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jose Antonio Quiros
- Department of Pediatric Gastroenterology Hepatology and Nutrition, Mount Sinai Kravis Children’s Hospital, New York, New York, USA
| | - Ricardo A. Arbizu
- Department of Pediatric Gastroenterology Hepatology and Nutrition, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Scott Curry
- Department of Infectious Disease, Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
5
|
Spinner JA, Bocchini CE, Luna RA, Thapa S, Balderas MA, Denfield SW, Dreyer WJ, Nagy-Szakal D, Ihekweazu FD, Versalovic J, Savidge T, Kellermayer R. Fecal microbiota transplantation in a toddler after heart transplant was a safe and effective treatment for recurrent Clostridiodes difficile infection: A case report. Pediatr Transplant 2020; 24:e13598. [PMID: 31617299 PMCID: PMC6982574 DOI: 10.1111/petr.13598] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/19/2019] [Accepted: 09/01/2019] [Indexed: 12/17/2022]
Abstract
Pediatric recipients of SOT have a significantly increased risk of Clostridiodes (formerly Clostridium) difficile infection (CDI), which is associated with adverse outcomes after SOT. Alterations to the intestinal microbiota community structure increase the risk of CDI. FMT is a safe and effective treatment for recurrent CDI in immunocompetent children and adults. While there are increasing data that FMT in immunosuppressed patients is safe and effective without increased risk of infection, data regarding safety and efficacy of FMT in children after SOT are limited. To our knowledge, we report the youngest immunocompromised patient to undergo FMT and the third overall case of FMT in a child after HTx. Our patient presented with five episodes of rCDI in 6 months, and 16S rRNA genetic analysis revealed significant loss of overall microbiota community structure and diversity prior to FMT compared with a donor and a healthy, age-matched control. After FMT, marked and prolonged (at least 16 months) shifts in the recipient microbiota community structure and diversity were evident, approaching that of donor and healthy, age-matched control. FMT was well tolerated, restored microbial diversity without any graft or transplant complications, and prevented further rCDI episodes after more than 4 years of follow-up.
Collapse
Affiliation(s)
- Joseph A Spinner
- Section of Pediatric Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX
| | - Claire E Bocchini
- Section of Pediatric Infectious Disease, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX
| | - Ruth A Luna
- Texas Children’s Microbiome Center and Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX
| | - Santosh Thapa
- Texas Children’s Microbiome Center and Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX
| | - Miriam A Balderas
- Texas Children’s Microbiome Center and Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX
| | - Susan W Denfield
- Section of Pediatric Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX
| | - William J Dreyer
- Section of Pediatric Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX
| | - Dorottya Nagy-Szakal
- Section of Pediatric Gastroenterology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX,USDA/ARS Children’s Nutrition Research Center, Houston, TX, USA
| | - Faith D Ihekweazu
- Section of Pediatric Gastroenterology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX
| | - James Versalovic
- Texas Children’s Microbiome Center and Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX
| | - Tor Savidge
- Texas Children’s Microbiome Center and Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX
| | - Richard Kellermayer
- Section of Pediatric Gastroenterology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX,USDA/ARS Children’s Nutrition Research Center, Houston, TX, USA
| |
Collapse
|
6
|
Cheung DA, Beduschi T, Tekin A, Selvaggi G, Ruiz P, Vianna RM, Garcia J. Clostridium difficile infection mimics intestinal acute cellular rejection in pediatric multivisceral transplant-A case series. Pediatr Transplant 2020; 24:e13621. [PMID: 31815352 DOI: 10.1111/petr.13621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/22/2019] [Accepted: 10/28/2019] [Indexed: 12/19/2022]
Abstract
Clostridium difficile infection (CDI) is the most common health care-associated infection in the United States. Thirty-nine percent of intestinal transplant recipients may develop CDI. Induction of rejection has been reported as a rare event. To our knowledge, this will be the second report of an association between CDI and rejection in the literature. We describe our experience with four pediatric MVT recipients, three of whom on treatment of their CDI alone had resolution of biopsy findings of intestinal ACR. Our patients were males aged 2-5 years old who had their first CDI post-MVT occurring from 2 months to 15 months post-transplant. All first episodes of CDI were treated with a 10-14 day course of metronidazole with one additionally receiving vancomycin. All four recipients had recurrent CDI, and two recipients had septic shock as a manifestation of their CDI. Three recipients had biopsies showing mild rejection during episodes of CDI, and treatment of the CDI resulted in resolution of biopsy findings of rejection. Our case series suggests CDI may mimic ACR on intestinal biopsy. Treatment of rejection during active CDI carries the risk of over-suppression and worsening of CDI. Our experience has taught us that surveillance endoscopy for rejection may be deceiving during an active CDI, and if mild acute rejection is noted during active CDI, treatment of rejection can be safely delayed and potentially avoided.
Collapse
Affiliation(s)
- Donna Ann Cheung
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Miami, Miami, FL, USA
| | - Thiago Beduschi
- Division of Liver/GI Transplant, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital/University of Miami, Miami, FL, USA
| | - Akin Tekin
- Division of Liver/GI Transplant, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital/University of Miami, Miami, FL, USA
| | - Gennaro Selvaggi
- Division of Liver/GI Transplant, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital/University of Miami, Miami, FL, USA
| | - Phillip Ruiz
- Division of Transplantation Laboratories and Immunopathology, Department of Surgery and Pathology, University of Miami, Miami, FL, USA
| | - Rodrigo M Vianna
- Division of Liver/GI Transplant, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital/University of Miami, Miami, FL, USA
| | - Jennifer Garcia
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Miami, Miami, FL, USA
| |
Collapse
|
7
|
Marra AR, Perencevich EN, Nelson RE, Samore M, Khader K, Chiang HY, Chorazy ML, Herwaldt LA, Diekema DJ, Kuxhausen MF, Blevins A, Ward MA, McDanel JS, Nair R, Balkenende E, Schweizer ML. Incidence and Outcomes Associated With Clostridium difficile Infections: A Systematic Review and Meta-analysis. JAMA Netw Open 2020; 3:e1917597. [PMID: 31913488 PMCID: PMC6991241 DOI: 10.1001/jamanetworkopen.2019.17597] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE An understanding of the incidence and outcomes of Clostridium difficile infection (CDI) in the United States can inform investments in prevention and treatment interventions. OBJECTIVE To quantify the incidence of CDI and its associated hospital length of stay (LOS) in the United States using a systematic literature review and meta-analysis. DATA SOURCES MEDLINE via Ovid, Cochrane Library Databases via Wiley, Cumulative Index of Nursing and Allied Health Complete via EBSCO Information Services, Scopus, and Web of Science were searched for studies published in the United States between 2000 and 2019 that evaluated CDI and its associated LOS. STUDY SELECTION Incidence data were collected only from multicenter studies that had at least 5 sites. The LOS studies were included only if they assessed postinfection LOS or used methods accounting for time to infection using a multistate model or compared propensity score-matched patients with CDI with control patients without CDI. Long-term-care facility studies were excluded. Of the 119 full-text articles, 86 studies (72.3%) met the selection criteria. DATA EXTRACTION AND SYNTHESIS Two independent reviewers performed the data abstraction and quality assessment. Incidence data were pooled only when the denominators used the same units (eg, patient-days). These data were pooled by summing the number of hospital-onset CDI incident cases and the denominators across studies. Random-effects models were used to obtain pooled mean differences. Heterogeneity was assessed using the I2 value. Data analysis was performed in February 2019. MAIN OUTCOMES AND MEASURES Incidence of CDI and CDI-associated hospital LOS in the United States. RESULTS When the 13 studies that evaluated incidence data in patient-days due to hospital-onset CDI were pooled, the CDI incidence rate was 8.3 cases per 10 000 patient-days. Among propensity score-matched studies (16 of 20 studies), the CDI-associated mean difference in LOS (in days) between patients with and without CDI varied from 3.0 days (95% CI, 1.44-4.63 days) to 21.6 days (95% CI, 19.29-23.90 days). CONCLUSIONS AND RELEVANCE Pooled estimates from currently available literature suggest that CDI is associated with a large burden on the health care system. However, these estimates should be interpreted with caution because higher-quality studies should be completed to guide future evaluations of CDI prevention and treatment interventions.
Collapse
Affiliation(s)
- Alexandre R. Marra
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
- Division of Medical Practice, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
| | - Eli N. Perencevich
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
| | - Richard E. Nelson
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah, Salt Lake City
| | - Matthew Samore
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah, Salt Lake City
| | - Karim Khader
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah, Salt Lake City
| | - Hsiu-Yin Chiang
- Big Data Center, China Medical University Hospital, Taichung City, Taiwan
| | - Margaret L. Chorazy
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | - Loreen A. Herwaldt
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | - Daniel J. Diekema
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | | | - Amy Blevins
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis
| | - Melissa A. Ward
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | - Jennifer S. McDanel
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | - Rajeshwari Nair
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
| | - Erin Balkenende
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | - Marin L. Schweizer
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
| |
Collapse
|
8
|
Breuer C, Döring S, Rohde H, Rutkowski S, Müller I, Oh J. Clostridium difficile infection after pediatric solid organ transplantation: a practical single-center experience. Pediatr Nephrol 2019; 34:1269-1275. [PMID: 30843115 DOI: 10.1007/s00467-019-04219-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 02/06/2019] [Accepted: 02/14/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND During the last two decades, there has been a worldwide increase in frequency and severity of infections with Clostridium difficile (CDI). Solid organ transplant (SOT) recipients receiving immunosuppressing medications are especially at risk. METHODS We collected data from immunocompromised pediatric patients, including kidney and liver transplant recipients, at our tertiary pediatric care center in Germany. For this, we performed a retrospective review of institutional databases and analyzed data from all children who underwent diagnostic tests for CDI in a 3-year study period. RESULTS A total of 797 diagnostic tests in 343 patients were performed. We found 104 infection episodes in 69 patients (42% female, ages 12 days-20 years). Children after SOT accounted for 20% of all detected CDI patients in our series. Median time of CDI onset after transplantation was 588 days. Overall antibiotic exposure was identified as the major risk factor, particularly in immunocompromised children after SOT (exposure in > 95% of all cases). CONCLUSIONS The occurrence of CDI in the pediatric SOT population contributes to a greater length of stay and higher hospital charges. However, only very few severe complications from CDI were observed in our cohort. A potentially fulminant course of CDI can be prevented in most cases if timely diagnosis and treatment are carried out.
Collapse
Affiliation(s)
- Christian Breuer
- University Children's Medical Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. .,Kinderärzte an der Rathausallee, Norderstedt, Germany.
| | - Sabrina Döring
- University Children's Medical Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Holger Rohde
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Rutkowski
- University Children's Medical Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ingo Müller
- University Children's Medical Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jun Oh
- University Children's Medical Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
9
|
Clostridium difficile: A Frequent Infection in Children After Intestinal Transplantation. Transplantation 2019; 104:197-200. [PMID: 31205257 DOI: 10.1097/tp.0000000000002795] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Organ transplantation (Tx) is a risk factor for Clostridium difficile infection (CDI). After intestinal transplantation (ITx), few data are available on the impact of this graft infection and the possible induction of rejection. METHODS We included retrospectively all children after ITx in our unit, with at least 1 year of graft survival. All samples positive for Clostridium difficile (CD) and its toxin were considered. RESULTS Among the 57 ITx recipients (60 Txs), 22 children (39%) developed culture-proven CDI, 12 after isolated small bowel Tx, 9 after liver-small bowel Tx, and 1 after multivisceral Tx. Twenty patients had diarrhea, 8 bloody stools, 4 fever, and 1 hypothermia. Nine were hospitalized for an average of 6.5 days (2-20) and 4 with severe dehydration. Nine (40%) had received antibiotics for an average of 19 days (7-60) before CDI. Two patients were asymptomatic. CDI was treated with metronidazole in 12 children, vancomycin in 6, and both in 3. Three children presented mild-to-severe rejections. Two patients presented concomitantly CDI and rejection. The third patient presented a rejection with severe complications 4 years after CDI. Recurrence of toxinogenic CD was observed in 9 children, in 7 associated with clinical symptoms. During the last follow-up, the stool number was the same as before CDI except for 1 patient with ongoing infection. CONCLUSIONS CDI is more prevalent in children after ITx compared with other organ Tx; it is most often symptomatic but mildly or moderately severe. Standard antibiotics efficiently control the symptoms. Induction of rejection is a rare event.
Collapse
|
10
|
Risk factors for Clostridium difficile infection in pediatric inpatients: A meta-analysis and systematic review. Infect Control Hosp Epidemiol 2019; 40:420-426. [DOI: 10.1017/ice.2019.23] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AbstractObjective: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.
Collapse
|
11
|
Guzman L, Qiu F, Kalil AC, Mercer DF, Langnas A, Florescu DF. Risk factors for Clostridium difficile infection in intestinal transplant recipients during the first year post-transplant. Transpl Infect Dis 2018; 20:e12858. [PMID: 29427406 DOI: 10.1111/tid.12858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 08/14/2017] [Accepted: 10/07/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Clostridium difficile is the most common cause of healthcare-associated infectious diarrhea. Risk factors for C. difficile infections (CDI) in intestinal transplant recipients (ITR) are not well-defined. The aim of our study was to assess specific risk factors for CDI in ITR. METHODS This is a 1:3 case-control study that included 29 ITR who developed CDI (cases) and 87 ITR without CDI (controls) observed during the first year post-transplantation. Wilcoxon rank sum and Fisher's exact tests were used to compare variables. Univariate and multivariable conditional logistic regressions analysis were performed to identify risk factors for CDI. RESULTS The multivariable conditional logistic regression analysis showed that proton pump inhibitors (PPI) administration (odds ratio [OR] = 0.06; 95% confidence interval [CI]: 0.007-0.52; P = .01) was the only factor associated with lower rates of CDI. Outcomes for cases vs controls: rejection episodes 24.14% vs 20.69% (P = .7), graft loss 0% vs 2.3% (P = .99), and survival rate 1 year post-transplantation 79.3% (59.6-90.1%) vs 87.2% (78.1-92.7%) (P = .38). CONCLUSIONS Proton pump inhibitor administration might be protective for CDI in ITR. Risks factors for CDI might be different in ITR compared to other populations; anatomical differences and medications administered in the post-transplantation period may affect intestinal microbiota.
Collapse
Affiliation(s)
- L Guzman
- Infectious Diseases Division, University of Nebraska Medical Center, Omaha, NE, USA
| | - F Qiu
- College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - A C Kalil
- Infectious Diseases Division, University of Nebraska Medical Center, Omaha, NE, USA
| | - D F Mercer
- Transplant Surgery Division, University of Nebraska Medical Center, Omaha, NE, USA
| | - A Langnas
- Transplant Surgery Division, University of Nebraska Medical Center, Omaha, NE, USA
| | - D F Florescu
- Infectious Diseases Division, University of Nebraska Medical Center, Omaha, NE, USA.,Transplant Surgery Division, University of Nebraska Medical Center, Omaha, NE, USA
| |
Collapse
|
12
|
Costs of Clostridium difficile infection in pediatric operations: A propensity score–matching analysis. Surgery 2017; 161:1376-1386. [DOI: 10.1016/j.surg.2016.10.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 09/12/2016] [Accepted: 10/07/2016] [Indexed: 12/17/2022]
|
13
|
Cózar-Llistó A, Ramos-Martinez A, Cobo J. Clostridium difficile Infection in Special High-Risk Populations. Infect Dis Ther 2016; 5:253-69. [PMID: 27515721 PMCID: PMC5019980 DOI: 10.1007/s40121-016-0124-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Indexed: 02/07/2023] Open
Abstract
Antibiotic use continues to be the most important risk factor for the development of Clostridium difficile infection (CDI) through disruption of the indigenous microbiota of the colon. This factor, together with environmental contamination, makes hospital and other healthcare facilities the perfect breeding ground for the infection. Several groups of patients are exposed to the hospital environment and, at the same time, affected by conditions that can make CDI more prevalent, more severe or make it present a different clinical picture. The list of such conditions appears too extensive to be reviewed in a single article. Nevertheless, several groups, including the critically ill, oncological patients, solid organ and hematopoietic transplant recipients, patients with inflammatory bowel disease, patients with kidney disease and pregnant women, have generated more attention and have been studied in more detail. On the other hand, pediatric patients constitute a controversial group because the large number of asymptomatic carriers makes interpretation of clinical findings and diagnostic tests difficult, as is the development of an appropriate approach to treatment. We present an in-depth discussion of CDI in these high-risk populations and we also review the issue of CDI in pediatric patients.
Collapse
Affiliation(s)
- Alberto Cózar-Llistó
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Antonio Ramos-Martinez
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Javier Cobo
- Infectious Diseases Service, Hospital Universitario Ramón y Cajal, IRYCIS, Carretera de Colmenar Viejo Km 9.1, 28034, Madrid, Spain.
| |
Collapse
|
14
|
Abstract
The detection and diagnosis of Clostridium difficile infection in pediatric populations have some unique considerations in comparison to testing in adults. The testing methodologies, including toxigenic culture, cell cytotoxicity, antigen detection, and, more recently, molecular testing, are the same in all age groups. However, limited data exist on the specific performance characteristics in children. In this review, we focus on the challenges of testing in pediatric populations and assess the available data on test performance in these populations. Additionally, a review of the existing guidance for testing is provided.
Collapse
|