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

Jonathan D. Crews, MD


January 24, 2014

Diagnosis of Pediatric CDI

The diagnosis of CDI requires a positive C difficile test in a symptomatic individual. Only children with symptoms consistent with CDI should be tested because current diagnostic modalities cannot distinguish between colonization and toxin-induced disease.

Not every child with diarrhea, however, should be tested for C difficile. Children younger than 12 months have high rates of colonization and develop clinical disease only in unique circumstances. Thus, for infants, the AAP recommends that testing be limited to those with Hirschsprung disease or severe motility disorders.[1]

For children 1-2 years of age, the interpretation of a positive test result can be difficult. Asymptomatic carriage of C difficile is still common in this age group, and viruses (eg, norovirus, rotavirus) are more common causes of diarrhea. Therefore, the AAP suggests pursuing alternative infectious etiologies in a child 1-2 years of age who tests positive for C difficile.[1]

Several strategies are available for the detection of C difficile or its toxins (toxin A and toxin B). In most institutions, the cell cytotoxicity assay has been replaced by more rapid and sensitive tests. Testing for toxins can be done with an enzyme immunoassay (EIA), which is an appropriate and commonly used diagnostic method for C difficile. However, although the C difficile toxin EIA offers a rapid turnaround time, it is less sensitive than the other testing strategies.[18,19]

Molecular-based assays (eg, nucleic acid amplification tests) detect the toxin-producing genes tcdA and tcdB. These tests provide high sensitivity and specificity with a rapid result.[20] Commercially available versions are being increasingly used.

Another option used at some children's hospitals is the algorithmic approach. The first step is generally a highly sensitive EIA for glutamate dehydrogenase, an antigen present on all strains of C difficile. Because even nontoxigenic strains contain glutamate dehydrogenase, a subsequent test is performed using the toxin EIA; molecular-based assay; or, less often, the cell cytotoxicity assay.[21]

Testing of multiple stool specimens is not recommended because this strategy is low yield, increases the likelihood of false-positive results, and is not cost-effective. A standard stool culture and trichrome stain will not detect C difficile but can be used to investigate for alternative enteropathogens.


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