CAP TODAY Pathology/Laboratory Medicine/Laboratory Management
Policy statement on Clostridium difficile infection in infants and children
Clostridium difficile is the most common cause of antimicrobial-associated diarrhea and infection in hospitalized children, and its incidence is increasing. C. difficile is a spore-forming, anaerobic, gram-positive bacillus that produces toxins A and B, which are responsible for the intestinal disease associated with infection. The emergence of an epidemic strain of toxin-producing C. difficile, NAP1, may be the cause of the increased number of infections in children. Recent guidelines developed for adult C. difficile infections (CDIs) do not address pediatric-specific issues. The American Academy of Pediatrics recently published a policy statement for CDIs in infants and children. The purpose of the policy statement is to provide pediatricians with updated information and recommendations about CDIs in pediatric patients. The challenge of determining the rate of CDIs is whether the presence of the microbe represents true disease or asymptomatic carriage. In infants, testing for C. difficile is not recommended in a setting where there is a high prevalence of asymptomatic carriage. Testing should be limited to infants with Hirschsprung disease or other severe motility disorders, or to instances of C. difficile outbreak. In addition, C. difficile toxin cannot be assumed to be the causative agent for diarrhea in children who have not reached adolescence. For example, in two studies of hospital inpatients who were newborn to two years of age, 11 to 59 percent of patients with diarrhea and 24 to 33 percent of controls were colonized with C. difficile. Transmission is via the fecal-oral route, and controlling contact with the patient or the patient’s contaminated environment is critical. A test of cure after treatment of CDI is not recommended due to the microbe and its toxins and genome shedding for a long period of time after the resolution of diarrheal symptoms. In conclusion, the American Academy of Pediatrics Committee on Infectious Diseases recommends that alternative etiologies be sought in pediatric patients younger than three years old, even with a positive test result for C. difficile. A positive test result after the third year of life indicates probable CDI. Endoscopic or histological test results positive for pseudomembranous colitis would indicate a definite infection. The policy also recommends precautions specific to antimicrobial treatment, decontamination, and patient contact.
American Academy of Pediatrics Committee on Infectious Diseases. Policy statement: Clostridium difficile infection in infants and children. Pediatrics. 2013;131:196–200.
Online version of article and updated information available at http://pediatrics.aappublications.org/content/131/1/196.full.html