title: The impact of Clostridium difficile on paediatric surgical practice: a systematic review.
abstract: OBJECTIVE
  The pathogenic potential of Clostridium difficile in children remains a controversial subject as healthy infants can be colonised by this organism. However recent analyses have clarified that C. difficile is an important enteropath in paediatric populations, particularly in antibiotic-associated diarrhoea. Paediatric surgical patients including those with Hirschsprung's disease (HD) may be especially vulnerable to C. difficile infection (CDI) and complicated C. difficile enterocolitis such as pseudomembranous colitis may require surgical management if refractory to medical therapy. Reports of increasing prevalence and emergence of hyper-virulent strains of C. difficile worldwide prompted an examination of the literature to assess the impact of CDI on current paediatric surgical practise.
  
  
  METHODS
  The literature was searched using a combination of the MESH terms "hirschsprung's disease", "enterocolitis", "clostridium difficile", and "children". Cases of Hirschsprung's associated enterocolitis (HAEC) investigated for C. difficile and complicated CDI in non HD patients were identified and analysed for clinical parameters, diagnostic evaluations, surgical interventions and outcome.
  
  
  RESULTS
  Pathogen isolation in HAEC was infrequently described. Only 98 children have been reported with C. difficile during an episode of HAEC over the last 40 years and aetiology remains unclear as asymptomatic carriage of C. difficile in HD occurs. Nonetheless 34 confirmed cases of pseudomembranous colitis complicating HD are reported in the literature with an associated 50 % mortality rate. Over 20 % of non Hirschsprung's patients with reported severe or complicated CDI required operative intervention. The need for surgery was associated with the presence of co-morbidity and high mortality occurred in this group.
  
  
  CONCLUSIONS
  Severe or complicated CDI in both HD and non HD paediatric patients is associated with high mortality and often requires surgical intervention. Although these patient cohorts represent a small number of cases, CDI should be suspected in children presenting with enterocolitis to enable early diagnosis and timely surgical intervention, particularly in patients with co-morbid conditions or preceding antibiotic use.
authors.affiliation: National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland.
authors.forename: D
authors.initials: D
authors.lastname: Mc Laughlin
authors.forename: F
authors.initials: F
authors.lastname: Friedmacher
authors.forename: P
authors.initials: P
authors.lastname: Puri
mesh_terms: D002648:Child; D016360:Clostridioides difficile / Q000302:isolation & purification*; D003082:Colectomy; D004761:Enterocolitis, Pseudomembranous / Q000150:complications / Q000175:diagnosis / Q000453:epidemiology; D014943:Global Health; D006627:Hirschsprung Disease / Q000150:complications / Q000453:epidemiology / Q000601:surgery; D006801:Humans; D015994:Incidence