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Clostridium difficile testing should only be performed in children with diarrhea and prioritized to those with known risk factors for C difficile infection (CDI).
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C difficile testing is most appropriate in children older than 2 years; for children younger than 2, C difficile testing should be pursued only if symptoms persist in the absence of alternative diagnoses or if the clinical presentation is severe or CDI-consistent.
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For otherwise healthy children with diarrhea in the community and no
Pitfalls in Diagnosis of Pediatric Clostridium difficile Infection
Section snippets
Key points
Increased Incidence of C difficile Infection
The epidemiology of CDI has changed dramatically in recent years. Between 2000 and 2010, the incidence of CDI more than doubled in adults and CDI-related hospitalizations increased by nearly 300%.10 The changing epidemiology of CDI is likely multifactorial, owing in part to the emergence of an epidemic strain of C difficile, the North American pulsed-field gel electrophoresis type 1 (NAP1) strain, which has been associated with increased morbidity and mortality11, 12 and linked with outbreaks
Available C difficile diagnostic tests and their characteristics in adults and children
For both children and adults, several laboratory tests are available to diagnose CDI. The 2 tests frequently used as “gold standards” are not readily available outside of research settings because they are technically complicated; however, it is against these standards that the performance of the other tests usually is compared. Still, even the gold standard tests are imperfect, because neither unequivocally identifies the patient whose symptoms are owing to C difficile; indeed, these 2 tests
Challenges to accurate diagnosis of pediatric C difficile infection
Although the application of different C difficile testing methods can lead to diagnostic difficulties by yielding discordant results, there are additional challenges to the evaluation of CDI in pediatric populations. These issues can be classified into 2 major categories: the issue of low PPV resulting from true false positives in low-prevalence populations, and the concern for “biological false positives,” in which the test accurately identifies the presence of C difficile or its toxins in
Summary
The epidemiology of CDI has changed dramatically over the past decade and C difficile remains a growing public health concern across North America and Europe. Likewise, the incidence of CDI has increased among children and C difficile is increasingly recognized as an important cause of health care–associated diarrhea among pediatric patients. Still, the increased identification of CDI in healthy children in the community and increased testing among infants requires cautious interpretation,
References (79)
- et al.
Differences in outcome according to Clostridium difficile testing method: a prospective multicentre diagnostic validation study of C difficile infection
Lancet Infect Dis
(2013) - et al.
Clinical relevance of a positive molecular test in the diagnosis of Clostridium difficile infection
J Hosp Infect
(2013) - et al.
Asymptomatic carriage of toxigenic Clostridium difficile by hospitalized patients
J Hosp Infect
(2013) - et al.
European Society of Clinical Microbiology and Infectious Diseases (ESCMID): data review and recommendations for diagnosing Clostridium difficile-infection (CDI)
Clin Microbiol Infect
(2009) - et al.
Diagnosis of Clostridium difficile infection by toxin detection kits: a systematic review
Lancet Infect Dis
(2008) - et al.
Molecular techniques for diagnosis of Clostridium difficile infection: systematic review and meta-analysis
Mayo Clin Proc
(2012) - et al.
Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe
Lancet
(2005) - et al.
The role of glutamate dehydrogenase for the detection of Clostridium difficile in faecal samples: a meta-analysis
J Hosp Infect
(2011) - et al.
Detection of toxigenic Clostridium difficile in pediatric stool samples: an evaluation of Quik Check Complete Antigen assay, BD GeneOhm Cdiff PCR, and ProGastro Cd PCR assays
Diagn Microbiol Infect Dis
(2011) - et al.
National variability in surveillance, testing, and infection prevention for Clostridium difficile infection in pediatric populations
Am J Infect Control
(2013)
Diagnosis and management of Clostridium difficile infection by pediatric infectious diseases physicians
J Pediatric Infect Dis Soc
A point prevalence survey of health care-associated infections in Canadian pediatric inpatients
Am J Infect Control
The prevalence of Clostridium difficile and toxin in a nursery population: a comparison between patients with necrotizing enterocolitis and an asymptomatic group
J Pediatr
Trends in Clostridium difficile infection and risk factors for hospital acquisition of Clostridium difficile among children with cancer
J Pediatr
Impact of Clostridium difficile infection on pediatric inflammatory bowel disease
J Pediatr
Limited clinical utility of Clostridium difficile toxin testing in infants in a pediatric hospital
Diagn Microbiol Infect Dis
How well does physician selection of microbiologic tests identify Clostridium difficile and other pathogens in paediatric diarrhoea? Insights using multiplex PCR-based detection
Clin Microbiol Infect
Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA)
Infect Control Hosp Epidemiol
Review of current literature on the economic burden of Clostridium difficile infection
Infect Control Hosp Epidemiol
Comparison of the burdens of hospital-onset, healthcare facility-associated Clostridium difficile infection and of healthcare-associated infection due to methicillin-resistant Staphylococcus aureus in community hospitals
Infect Control Hosp Epidemiol
Multistate point-prevalence survey of health care-associated infections
N Engl J Med
Clostridium difficile toxins: mechanism of action and role in disease
Clin Microbiol Rev
Acquisition of Clostridium difficile from the hospital environment
Am J Epidemiol
Evaluation of hospital room assignment and acquisition of Clostridium difficile infection
Infect Control Hosp Epidemiol
Antimicrobial-associated risk factors for Clostridium difficile infection
Clin Infect Dis
Clostridium difficile and the microbiota
J Clin Invest
HCUP projections: Clostridium difficile hospitalizations 2011 to 2012
Emergence of Clostridium difficile infection due to a new hypervirulent strain, polymerase chain reaction ribotype 078
Clin Infect Dis
A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality
N Engl J Med
Burden of Clostridium difficile infection in the United States
N Engl J Med
Burden of Clostridium difficile on the healthcare system
Clin Infect Dis
Epidemiological features of Clostridium difficile-associated disease among inpatients at children's hospitals in the United States, 2001–2006
Pediatrics
Clostridium difficile infections among hospitalized children, United States, 1997–2006
Emerg Infect Dis
Clostridium difficile infection in hospitalized children in the United States
Arch Pediatr Adolesc Med
Changing epidemiology of Clostridium difficile-associated disease in children
Infect Control Hosp Epidemiol
Increase in Clostridium difficile-related hospitalizations among infants in the United States, 2000–2005
Pediatr Infect Dis J
Clostridium difficile infection among children across diverse US geographic locations
Pediatrics
The epidemiology of Clostridium difficile infection in children: a population-based study
Clin Infect Dis
Clostridium difficile infection is associated with increased risk of death and prolonged hospitalization in children
Clin Infect Dis
Cited by (24)
Detection of potential enteric pathogens in children with severe acute gastroenteritis using the filmarray: Results from a three - years hospital-based survey in Northern Italy
2022, Diagnostic Microbiology and Infectious DiseaseCitation Excerpt :Clostridioides difficile was the second most common pathogen. This finding is difficult to interpret, given the high rate of asymptomatic carriage in young infants (<12 months) and frequent co-detection of other pathogens (Furuya-Kanamori et al., 2015, Sammons and Toltzis, 2015). Therefore, testing should be performed when specifically requested and consultation with the pediatrician is recommended (Sammons and Toltzis, 2015).
Impact of Multiplex Testing on the Identification of Pediatric Clostridiodes Difficile
2020, Journal of PediatricsRelationship between enteric pathogens and acute gastroenteritis disease severity: a prospective cohort study
2019, Clinical Microbiology and InfectionCitation Excerpt :The multivariable regression model included terms for all individual enteropathogens, as we considered each individual enteropathogen target as being a potentially important contributor to disease severity. In the regression models, we tested interaction effects for co-detected pathogen combinations that were identified in a minimum of ten participants, and the interaction effect between participant age (<6 months, 6–23 months, ≥24 months) and the presence of C. difficile [15]. Each interaction term was tested in the aforementioned models using a forward stepwise selection procedure.
Enteropathogen detection in children with diarrhoea, or vomiting, or both, comparing rectal flocked swabs with stool specimens: an outpatient cohort study
2017, The Lancet Gastroenterology and HepatologyCitation Excerpt :Pairwise interactions between specimen (swab or stool), location, and diarrhoea at presentation—all three pairings with all permutations—were included in the models. Calculations were repeated as an exploratory analysis with C difficile-positive specimens classified as negative in children younger than 2 years, and restricted to paired specimens obtained within 24 h of each other.19 Other exploratory analyses examined details from the follow-up survey about the ease of rectal swab use and the acceptability of collecting rectal swabs compared with collecting stool specimens.
Special situations in inflammatory bowel disease: First Latin American consensus of the Pan American Crohn's and Colitis Organisation (PANCCO) (Second part)
2017, Revista de Gastroenterologia de MexicoClostridium difficile presence in Spanish and Belgian hospitals
2016, Microbial PathogenesisCitation Excerpt :The mean age of all patients studied (62.5 years old) corroborates this observation. Recent reports warn that the incidence of CDI has increasingly risen among paediatric patients [24]. Collins et al. [23] reported in one survey conducted in Western Australia that undiagnosed CDI cases only occurred among paediatric patients, and 32.3% of all CDI cases were aged <20 years.