To test or not to test? Optimizing pediatric Clostridium difficile management

Background: The burden of disease attributable to C. difficile infection in infants and children is incompletely described. C. difficile toxin testing is frequently performed in an attempt to identify infectious etiologies of gastroenteritis. Differentiating between colonization and infection confounds interpretation of toxin testing results and may result in inappropriate management.

 

Objective: In this local and comparative national analysis, we assessed testing practices for C. difficile infections in infants and children.

 

Methods: We performed a retrospective cohort study of infants and children with positive C. difficile toxin assays who presented to two local pediatric facilities between July 1 and November 30, 2007.  We compared rates of toxin testing, clinical symptoms, antibiotic use, and management from our local facilities with that from information submitted by 40 member pediatric inpatient facilities to the Pediatric Health Information System (PHIS).

 

Results:   C. difficile toxin was noted in 42 of 796 (5%) stool specimens from children from two metropolitan-area pediatric hospitals and from 784 (10.9%) of 7163 samples submitted nationally during the period July 1 to November 30, 2007. The mean age of local subjects was 8.4 years (range 0-19) and 5.7 years (range 0-18) for national subjects. Diarrhea (71%), the presence of gross or occult blood in stool (53%) and abdominal cramps (50%) were the most common symptoms in local subjects who had a mean hospitalization of 9.6 days. PHIS subjects had an average hospitalization of 19.9 days with outliers (>2 S.D.) removed. Four (0.5%) locally submitted stool samples also had growth of a bacterial organism. Concomitant gastrointestinal illnesses, including inflammatory bowel disease (23%), gastritis or GERD (17%) dysphagia (14%), gastroenteritis (14%) and nutritional intolerance (14%) were noted in local subjects who underwent toxin testing. In both local and national subjects in whom C. difficile toxin was detected, cephalosporins, vancomycin, aminoglycosides and trimethoprim-sulfamethoxazole were frequently administered prior to specimen acquisition. At the time of testing, 2.6% of the local cohort and 26.8% of the national cohort had received metronidazole; following diagnosis, metronidazole was initiated in 60.5% of the local cohort and 63.8% of the national cohort. Probiotic administration was noted in 5.3% of local subjects before testing and 28.9% of local subjects after testing compared to 7.4% before and 9.8% after testing, nationally.

 

Conclusions: Low rates of toxin detection in symptomatic children both locally and nationally suggest more judicious use of these assays. Targeted use of C. difficile toxin testing based on risk factors gleamed from local and national analyses could result in optimization of resource expenditure in pediatric facilities.