Objective To assess which risk factors are associated with community-associated Clostridioides difficile infection (CDI) in children. Study design This case control study was a retrospective review of all children 1-17 years of age with stool specimens sent for C difficile testing from January 1, 2012, to December 31, 2016. Cases and controls were children who had C difficile testing performed in the community or first 48 hours of hospital admission and >12 weeks after hospital discharge, with no prior positive C difficile testing in last 8 weeks, without other identified causes of diarrhea, and with clinical symptoms. Cases had positive confirmatory testing for C difficile. Controls had negative testing for C difficile and were matched to cases 1:1 by age and year of specimen collection. Results The overall incidence rate of community-acquired CDI in this cohort was 13.7 per 100 000 children per year. There was a substantial increase in community-acquired CDI from 9.6 per 100 000 children per year in 2012 to a peak of 16.9 per 100 000 children per year in 2015 (Cochran-Armitage test for trend P = .002). The risk factors for communityacquired CDI included non-Hispanic ethnicity; amoxicillin-clavulanate, cephalosporin, and clindamycin use within the previous 12 weeks; a previous positive C difficile test within 6 months; and increased health care visits in the last year. Conclusions As rates of community-acquired CDI are increasing, enhanced antibiotic stewardship and recognition of health care disparities may ease the burden of community-acquired CDI.

Background: The use of serious games as an educational tool may be an effective strategy to improve knowledge and skill among health care trainees. GridlockED is a serious board game designed to simulate a shift in the emergency department (ED) that incorporates concepts such as prioritization in a multipatient environment and stewardship of finite resources. Serious games can present concepts to learners that are not easily accessible through other teaching methods. GridlockED was designed to demonstrate the principles behind ED flow and how to prioritize in a complex multipatient environment. The objective of this study was to identify teaching points to which learners are exposed while playing the GridlockED game.Methods: We conducted a prospective, observational study from May to August 2017. Practicing emergency physicians, residents, and nurses were recruited as participants to play GridlockED. Participants were instructed on how to play the game and then engaged in playing GridlockED, during which their gameplay was video recorded. The videos of the play sessions were qualitatively analyzed using an interpretive description technique. All teaching points explicitly stated by players or implicitly observed by researchers were recorded.Results: Teaching points were identified in the GridlockED play sessions centered around the concepts of patient prioritization and staff placement. Major themes present in gameplay, as well as deviations from reality and frequent misconceptions about emergency care, were also identified. Conclusion:Observations of experienced ED practitioners reveal that the GridlockED board game creates opportunities for engaging medical learners in systems-level teaching. Our findings will help create the basis for future education modules, but further study is required to ensure that junior trainees actually learn when playing the game.

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Background: Recurrence of community-associated (CA) Clostridiodes difficile infection (CDI) approaches 30%. Studies on risk factors and treatment of choice for pediatric CA-CDI are scarce with variable recommendations. Methods: This was a retrospective cohort study of the electronic health records of children 1–17 years with stool specimens sent for C. difficile at Kaiser Permanente Northern California from January 01, 2012 to December 31, 2016. Children with (1) CA disease, (2) confirmatory C. difficile laboratory testing with no other identified causes of diarrhea and (3) clinical symptoms consistent with CDI were defined as cases. Recurrent CA-CDI was defined using the above-described case criteria and onset of diarrhea within 8 weeks of primary CA-CDI. Results: Of the 7350 children with stool samples sent for C. difficile testing, 408 had primary CA-CDI. Forty-five (11%) experienced a recurrence. Using multivariable logistic regression, inflammatory bowel disease [odds ratio (OR) 7.5; 95% confidence interval (CI): 2.6–21.1] and cancer (OR 6.3; 95% CI: 1.6–24.1) diagnoses were risk factors for recurrent disease. Compared with children of Caucasian race, those with multi/other/unknown race had an OR of 3.03 (95% CI: 1.04–8.82) of recurrence. There was no statistically significant difference in the type or duration of therapy as a predictor for recurrent CA CDI. Six percent of children who received metronidazole were switched to vancomycin due to subjective metronidazole allergy or intolerance or metronidazole treatment failure. Conclusions: Recurrent CA-CDI in children in our population is less common than previously reported. This study supports first-line treatment with the standard, short course metronidazole in most cases of primary CA-CDI.