title: Clostridium difficile infection is associated with increased risk of death and prolonged hospitalization in children.
abstract: BACKGROUND
  Clostridium difficile infection (CDI) is associated with significant morbidity and mortality among adults. However, outcomes are poorly defined among children.
  
  
  METHODS
  A retrospective cohort study was performed among hospitalized children at 41 children's hospitals between January 2006 and August 2011. Patients with CDI (exposed) were matched 1:2 to patients without CDI (unexposed) based on the probability of developing CDI (propensity score derived from patient characteristics). Exposed subjects were stratified by C. difficile test date, suggestive of community-onset (CO) versus hospital-onset (HO) CDI. Outcomes were analyzed for matched subjects.
  
  
  RESULTS
  We identified 5107 exposed and 693 409 unexposed subjects. Median age was 6 years (interquartile range [IQR], 2-13 years) for exposed and 8 years (IQR, 3-14 years) for unexposed subjects. Of these, 4474 exposed were successfully matched to 8821 unexposed by propensity score. In-hospital mortality differed significantly (CDI, 1.43% vs matched unexposed, 0.66%; P < .001). Mortality rates were similar between CO-CDI and matched subjects. However, mortality rates were significantly greater among HO-CDI compared with matched unexposed (odds ratio, 6.73 [95% confidence interval {CI}, 3.77-12.02]). Mean differences in length of stay (LOS) and total cost were significant: 5.55 days (95% CI, 4.54-6.56 days) and $18 900 (95% CI, $15 100-$22 700) for CO-CDI, and 21.60 days (95% CI, 19.29-23.90 days) and $93 600 (95% CI, $80 000-$107 200) for HO-CDI.
  
  
  CONCLUSIONS
  Pediatric CDI is associated with increased mortality, longer LOS, and higher costs. These findings underscore the importance of antibiotic stewardship and infection control programs to prevent this disease in children.
authors.affiliation: Division of Infectious Diseases, and Department of Perelman School of Medicine, University of Pennsylvania, Pennsylvania, USA.
authors.forename: Julia Shaklee
authors.initials: JS
authors.lastname: Sammons
authors.forename: Russell
authors.initials: R
authors.lastname: Localio
authors.forename: Rui
authors.initials: R
authors.lastname: Xiao
authors.forename: Susan E
authors.initials: SE
authors.lastname: Coffin
authors.forename: Theoklis
authors.initials: T
authors.lastname: Zaoutis
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D016360:Clostridioides difficile / Q000302:isolation & purification*; D003015:Clostridium Infections / Q000191:economics / Q000453:epidemiology* / Q000382:microbiology / Q000401:mortality*; D015331:Cohort Studies; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay; D008297:Male; D012189:Retrospective Studies; D016019:Survival Analysis
keywords: C. difficile infection; epidemiology; outcomes; pediatrics