title: Clinical and Microbiologic Assessment of Cases of Pediatric Community-associated Clostridium difficile Infection Reveals Opportunities for Improved Testing Decisions.
abstract: BACKGROUND
  Most children with Clostridium difficile infection (CDI) experience community onset of CDI symptoms.
  
  
  METHODS
  We retrospectively compared hospital-onset healthcare facility-associated CDI cases to community-associated (CA) CDI cases diagnosed by Cepheid Xpert tcdB polymerase chain reaction (PCR) at an academic children's hospital over a 1-year period. Saved stools from CDI cases additionally underwent anaerobic stool culture and multiplex gastrointestinal pathogen PCR testing.
  
  
  RESULTS
  Compared with 25 hospital-onset healthcare facility-associated CDI cases, the 74 CA-CDI cases were more frequently <2 years old (18% vs. 0%, P = 0.034) and less frequently had antibiotic exposure in the past 30 days (26% vs. 88%, P < 0.0001), proton pump inhibitor exposure (16% vs. 36%, P = 0.036) or a gastrostomy tube (11% vs. 32%, P = 0.013). Among children diagnosed with CA-CDI, 19 (26%) had no identified CDI risk factors (immunocompromised; gastrostomy tube; recent antibiotic, proton pump inhibitor or inpatient/outpatient healthcare exposures). Clinical testing for viral pathogens was uncommon among children thought to have CA-CDI. Multiplex PCR testing of saved stool samples failed to identify C. difficile among 23% of cases diagnosed with CA-CDI by the Cepheid Xpert tcdB PCR assay. CDI antibiotic therapy was provided to nearly all patients testing positive by tcdB PCR irrespective of CDI risk factors.
  
  
  CONCLUSIONS
  Many children diagnosed with CA-CDI by PCR lack CDI risk factors and have discordant results when additional CDI testing methods are performed, suggesting overdiagnosis of CDI in children with community-onset diarrhea. More selective CDI testing of low-risk pediatric patients is needed to more accurately diagnose CDI and limit unnecessary CDI antibiotic treatment in children.
authors.affiliation: From the *Division of Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago; Departments of †Pediatrics and ‡Pathology, Northwestern University Feinberg School of Medicine; §Department of Pathology and Laboratory Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago; ¶Division of Infectious Diseases, Edward Hines, Jr. Veterans Affairs Hospital, Chicago, Illinois; ‖Department of Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois.
authors.forename: Larry K
authors.initials: LK
authors.lastname: Kociolek
authors.forename: Sameer J
authors.initials: SJ
authors.lastname: Patel
authors.forename: Xiaotian
authors.initials: X
authors.lastname: Zheng
authors.forename: Kathleen M
authors.initials: KM
authors.lastname: Todd
authors.forename: Stanford T
authors.initials: ST
authors.lastname: Shulman
authors.forename: Dale N
authors.initials: DN
authors.lastname: Gerding
mesh_terms: D000046:Academic Medical Centers; D000293:Adolescent; D001431:Bacteriological Techniques / Q000379:methods; D002648:Child; D002675:Child, Preschool; D016360:Clostridioides difficile / Q000302:isolation & purification*; D003015:Clostridium Infections / Q000175:diagnosis* / Q000473:pathology*; D017714:Community-Acquired Infections / Q000175:diagnosis* / Q000473:pathology*; D003955:Diagnostic Tests, Routine / Q000379:methods*; D005260:Female; D006776:Hospitals, Pediatric; D006801:Humans; D007223:Infant; D008297:Male; D016133:Polymerase Chain Reaction / Q000379:methods*; D012189:Retrospective Studies; D055815:Young Adult