Clinical Guideline Highlights for the Hospitalist: Clostridium difficile Infections in Children

Clostridium difficile (name changed to Clostridioides difficile [CDI]) are a major public health problem, with 500,000 infections annually in the United States, 15,000-30,000 associated deaths, and acute care costs exceeding $4.8 billion. The recent clinical practice guideline for CDI provides recommendations about the epidemiology, diagnosis, treatment, prevention, and environmental management. A total of 52 recommendations are included, and we will review 11 with pertinence to pediatrics in this highlight.

Recommendation 1. In infants ≤12 months of age, testing for CDI should never be routinely recommended because of the high prevalence of asymptomatic carriage of toxigenic C. difficile in infants (strong recommendation, moderate quality of evidence).

Recommendation 2. In children 1-2 years of age, testing should not be routinely performed unless other causes have been excluded (weak recommendation, low quality of evidence).Recommendation 3. In children ≥2 years of age, testing is recommended for patients with prolonged or worsening diarrhea and risk factors (eg, underlying inflammatory bowel disease) or immunocompromising conditions) or relevant exposures (eg, contact with the healthcare system or recent antibiotics) (weak recommendation, moderate quality of evidence).

The rate of C. difficile colonization among asymptomatic infants can exceed 40%. This rate declines over the first year but remains 15% at 12 months of age.¹ Therefore, the guideline recommends against routinely testing infants ≤12 months of age as a positive test probably reflects colonization rather than disease. Testing in infants is recommended only when other causes have been excluded and a concern for pseudomembranous colitis, toxic megacolon, or clinically significant diarrhea exists.

The rate of asymptomatic colonization remains elevated in the second year of life. By 2-3 years, the rate is 1%-3% which is similar to that in healthy adults. However, the role of C. difficile in community-onset diarrhea in otherwise healthy children is controversial. In a study of 100 hospitalized children aged <2 years with CDI and diarrhea, all had resolution of diarrhea regardless of whether therapy was administered.² Another study found an alternative pathogen in >50% of hospitalized children with CDI.³ Therefore, the guideline recommends against testing in children aged 1-2 years unless other causes have been excluded and in children aged >2 years only when they have prolonged or worsening diarrhea along with risk factors or exposures.

Recommendation 4. In institutions without specific required criteria for stool submissions, use a stool toxin test as part of a multistep algorithm (ie, glutamate dehydrogenase [GDH] plus toxin, GDH plus toxin arbitrated by nucleic-acid amplification tests [NAAT], or NAAT plus toxin) rather than a NAAT alone (weak recommendation, low quality of evidence).

Recommendation 5. In institutions with specific required criteria for stool submissions, use a NAAT alone or a multistep algorithm for testing (ie, GDH plus toxin, GDH plus toxin arbitrated by NAAT, or NAAT plus toxin) rather than a toxin test alone (weak recommendation, low quality of evidence).

There are a variety of testing approaches for CDI and recommendations vary based on local practice. If laboratories accept all stools, a more specific approach is recommended, including a toxin test as part of a multistep algorithm to limit false positives. If laboratories first screen for symptoms and antibiotic exposure before accepting stool samples, a more sensitive approach is recommended including NAAT alone or a multistep algorithm rather than toxin alone.