Pitfalls in Diagnosis of Pediatric Clostridium difficile Infection

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Key points

  • Clostridium difficile testing should only be performed in children with diarrhea and prioritized to those with known risk factors for C difficile infection (CDI).

  • 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.

  • For otherwise healthy children with diarrhea in the community and no

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,

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      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.

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