Clostridium difficile Diarrhea in Children: Diagnosis, Management, and Prevention

Jonathan D. Crews, MD


January 24, 2014

Pediatric Clostridium difficile Infection

The incidence of Clostridium difficile infection (CDI) is increasing in the pediatric population. Over the past decade, there has been much interest in pediatric CDI. During this time, several important studies were conducted that clarify the epidemiology of CDI in children. Moreover, in 2013, the American Academy of Pediatrics (AAP) published guidelines on pediatric CDI.[1]

This article will update the clinician on the diagnosis, management, and prevention of CDI in children.

Changing Epidemiology

The past decade has seen a significant change in the epidemiology of C difficile in North America and Europe. An increase in disease incidence and severity has been accompanied by an extension of the disease into the community and into low-risk populations.[2,3] Parallel with such trends has been the emergence of a hypervirulent strain, NAP1.[4] Although most studies have predominantly focused on adults, evidence that children are also being affected by the recent changes in C difficile epidemiology is growing.

The incidence of CDI in hospitalized children is increasing.[5,6,7] For example, in a retrospective study involving 22 US children's hospitals, cases of pediatric CDI increased by 53% from 2001 to 2006 (2.6-4.0 cases per 1000 admissions; P = .04).[5] Subsequent studies have confirmed the increases in CDI in children.[6,7]

Furthermore, children with CDI experience substantial morbidity and mortality. A recent study demonstrated that CDI in hospitalized children was associated with increased mortality, longer hospital stays, and higher hospital costs compared with hospitalized children who did not have CDI.[8] The accumulating evidence points to the importance of pediatric CDI in the hospital setting.

Recognition that children can acquire C difficile in community settings is also growing.[9,10,11,12] In a recent population-based study from Olmsted County, Minnesota, the rate of community-associated CDI increased 10.5-fold from 1991 to 2007.[9] Single-center studies from children's hospitals show that 18%-35% of pediatric CDI cases were deemed community-associated.[9,10,11,12]

Risk Factors for Pediatric CDI

The most important risk factor for CDI in children remains recent antibiotic use. Any antibiotic can predispose to the development of CDI; however, fluoroquinolones, clindamycin, and cephalosporins are most highly associated with CDI.[10,11,12,13] Exposure to gastric acid suppressants (either proton pump inhibitors or H2-receptor antagonists) and the presence of gastrostomy tubes have also been associated with pediatric CDI.[10,14,15]

Although there are descriptions of healthy children acquiring CDI, most cases involve children with underlying medical conditions. The conditions most often associated with pediatric CDI include cancer, inflammatory bowel disease, cystic fibrosis, and solid organ transplantation.[5,6]


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