title: Five years experience of Clostridium difficile infection in children at a UK tertiary hospital: proposed criteria for diagnosis and management.
abstract: BACKGROUND
  Clostridium difficile infection (CDI) is associated with significant morbidity and mortality in adults. There is increasing evidence of the pathogenic role of C. difficile in the paediatric population. We sought to ascertain the clinical presentation and severity of CDI in children at our institution and develop criteria to aid management.
  
  
  METHODS
  Clinical data was retrospectively collected from all children (0-16 yrs) with a positive C. difficile toxin result over a 5-year period. National adult guidelines were used to assess the severity and management of CDI.
  
  
  RESULTS
  Seventy-five patients were included with a mean age of 2.97 years. Forty-nine were hospital onset, 22 community onset and 4 healthcare-associated. The most common co-morbidity among the hospital onset infections was malignancy. Gastrointestinal conditions were most common among community onset infections. Fifty-five cases (73.3%) had received antibiotics in the preceding month, 7 (9.3%) had cow's milk intolerance and 9 (12%) had co-infection with another gut pathogen. According to national adult guidelines 57 cases (76%) were categorised as severe. Thirty cases received oral metronidazole, two patients required intensive care and one patient had a sub-total colectomy for pseudomembranous colitis. No mortality was observed.
  
  
  CONCLUSIONS
  We confirm the association of paediatric CDI with co-morbidities such as haematological and solid organ malignancies, recent antibiotic use and hospitalisation. We observed an association between cows milk protein intolerance and C. difficile. The use of adult criteria overestimated severity of disease in this cohort, as most cases experienced a mild course of illness with low morbidity and no mortality. This indicates that adult scoring criteria are not useful in guiding management and we propose specific criteria for children.
authors.affiliation: Clinical Microbiology & Public Health Laboratory, Health Protection Agency, Addenbrookes Hospital, Cambridge, United Kingdom.
authors.forename: Sumita
authors.initials: S
authors.lastname: Pai
authors.forename: Sani Hussaini
authors.initials: SH
authors.lastname: Aliyu
authors.forename: David Andrew
authors.initials: DA
authors.lastname: Enoch
authors.forename: Johannis Andreas
authors.initials: JA
authors.lastname: Karas
mesh_terms: D000293:Adolescent; D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D016360:Clostridioides difficile / Q000472:pathogenicity*; D003015:Clostridium Infections / Q000175:diagnosis / Q000382:microbiology / Q000517:prevention & control*; D015897:Comorbidity; D003428:Cross Infection / Q000175:diagnosis / Q000382:microbiology / Q000517:prevention & control*; D005260:Female; D006760:Hospitalization; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D011379:Prognosis; D012107:Research Design; D012189:Retrospective Studies; D012307:Risk Factors; D062606:Tertiary Care Centers; D013997:Time Factors; D006113:United Kingdom; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents