Clostridium difficile Infection and Treatment in the Pediatric Inflammatory Bowel Disease Population

Abstract

Objective Recent changes in the epidemiology of C. difficile infection include an increase in the incidence of C. difficile-associated disease (CDAD), and the identification of patients with inflammatory bowel disease (IBD) as a group-at-risk. In addition, effectiveness of antimicrobial therapies has been questioned. Our aim was to estimate the incidence of CDAD in a pediatric IBD population, and review treatment efficacy. Methods We identified patients aged ≤18 years from our center’s IBD database who tested positive for C. difficile toxin A and/or B between 8/1/07 and 12/31/08. Demographic information and treatment details were recorded. Chi-square and Fisher’s exact test were used to compare categorical variables and student’s t-test was used for continuous variables. Results From 372 pediatric IBD patients, we identified 29 patients who experienced a total of 40 cases of CDAD. The annualized incidence rate of CDAD was 7.2%. Initial treatment was successful in 17 cases (43%). Eventual success was documented with metronidazole in 15 cases (41%), with vancomycin in 16 cases (43%), and with other agents or a combination of agents in 6 cases (16%). Age, sex, and IBD type were not associated with initial treatment outcome or recurrence. The choice of initial antimicrobial treatment was not associated with treatment outcome. The type of IBD therapy medication was not associated with likelihood of CDAD recurrence although use of anti-inflammatory therapy was positively associated with initial antimicrobial treatment success. Conclusions CDAD occurred frequently in our cohort of pediatric IBD patients. Antimicrobial treatment success was achieved equally with either metronidazole or vancomycin. Initial treatment failed more than half the time, regardless of medication choice. Apparent lack of antimicrobial efficacy in resolving symptoms may reflect resistant C. difficile infection or increased IBD severity in a subset of patients who are C. difficile carriers. Awareness of the potential for a high incidence of CDAD and frequent failure rate of initial therapy is important in the management of children with IBD.

Incidence of Clostridium difficile Infection in Children with Inflammatory Bowel Disease Compared to Oncology and Immunocompetent Patients

“…Tissue injury and inflammation are mediated by exotoxins A and B generated by the bacteria [1,2]. Clinical presentation varies in severity, ranging from asymptomatic colonization of the colon to severe pseudomembranous colitis, toxic megacolon, bowel perforation, and death.…”

Clostridium difficile Infection in Pediatric Inflammatory Bowel Disease Patients in the Era of Molecular Diagnostics and Advanced Therapeutics

“…An increased prevalence of Clostridium difficile infection (CDI) in pediatric Inflammatory Bowel Disease (IBD) has been reported in various studies (1)(2)(3), primarily diagnosed by stool toxin assay (1,4). Although some risk factors for CDI have been reported consistently in adult IBD study including recent antibiotic use and recurrent hospitalizations (5), there are no consistent risk factors reported in pediatric studies.…”

Diarrea asociada a Clostridium difficile en niños

“…La tasa anual de DACD en una cohorte de niños con EII hospitalizados fue de 7,4%; pacientes que además presentaban una mayor tasa de recurrencia y de fracaso de tratamiento 26 . Se observó la asociación de DACD con una mayor gravedad en la evolución de EII, mayor necesidad de hospitalización y escalada en terapia inmunosupresora post-infección 27 .…”

“…De éstos, Infectología al Día 20 (91%) tenían patología gastrointestinal de base, cinco (23%) fueron sometidos a resección de intestino delgado y cinco (23%) fueron diagnosticados con colitis. Cuatro (18%) requirieron colostomía o colectomía y 11 (50%) tuvieron sospecha o certeza de enterocolitis necrosante 26 . Por todo lo anterior, hay que mantener la atención en la evolución epidemiológica de esta enfermedad, dado la mayor complejidad de los pacientes que tienen un riesgo potencial mayor, sumado al aumento de la incidencia, no sólo en neonatos, sino también en otros grupos etarios.…”