title: Investigation of a cluster of Clostridium difficile infections in a pediatric oncology setting.
abstract: BACKGROUND
  We investigated an increase in Clostridium difficile infection (CDI) among pediatric oncology patients.
  
  
  METHODS
  CDI cases were defined as first C difficile positive stool tests between December 1, 2010, and September 6, 2012, in pediatric oncology patients receiving inpatient or outpatient care at a single hospital. A case-control study was performed to identify CDI risk factors, infection prevention and antimicrobial prescribing practices were assessed, and environmental sampling was conducted. Available isolates were strain-typed by pulsed-field gel electrophoresis.
  
  
  RESULTS
  An increase in hospital-onset CDI cases was observed from June-August 2012. Independent risk factors for CDI included hospitalization in the bone marrow transplant ward and exposure to computerized tomography scanning or cefepime in the prior 12 weeks. Cefepime use increased beginning in late 2011, reflecting a practice change for patients with neutropenic fever. There were 13 distinct strain types among 22 available isolates. Hospital-onset CDI rates decreased to near-baseline levels with enhanced infection prevention measures, including environmental cleaning and prolonged contact isolation.
  
  
  CONCLUSIONS
  C difficile strain diversity associated with a cluster of CDI among pediatric oncology patients suggests a need for greater understanding of modes and sources of transmission and strategies to reduce patient susceptibility to CDI. Further research is needed on the risk of CDI with cefepime and its use as primary empirical treatment for neutropenic fever.
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA; Epidemic Intelligence Service, Scientific Education and Professional Development Program Office, Centers for Disease Control and Prevention, Atlanta, GA. Electronic address: vic5@cdc.gov.
authors.forename: Raymund
authors.initials: R
authors.lastname: Dantes
authors.affiliation: Epidemic Intelligence Service, Scientific Education and Professional Development Program Office, Centers for Disease Control and Prevention, Atlanta, GA; Communicable Disease Epidemiology Section, Colorado Department of Public Health and Environment, Denver, CO.
authors.forename: Erin E
authors.initials: EE
authors.lastname: Epson
authors.affiliation: Children's Hospital Colorado, Aurora, CO; University of Colorado School of Medicine, Aurora, CO.
authors.forename: Samuel R
authors.initials: SR
authors.lastname: Dominguez
authors.affiliation: Children's Hospital Colorado, Aurora, CO.
authors.forename: Susan
authors.initials: S
authors.lastname: Dolan
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
authors.forename: Frank
authors.initials: F
authors.lastname: Wang
authors.affiliation: Children's Hospital Colorado, Aurora, CO.
authors.forename: Amanda
authors.initials: A
authors.lastname: Hurst
authors.affiliation: Children's Hospital Colorado, Aurora, CO; University of Colorado School of Medicine, Aurora, CO.
authors.forename: Sarah K
authors.initials: SK
authors.lastname: Parker
authors.affiliation: Communicable Disease Epidemiology Section, Colorado Department of Public Health and Environment, Denver, CO.
authors.forename: Helen
authors.initials: H
authors.lastname: Johnston
authors.affiliation: Children's Hospital Colorado, Aurora, CO.
authors.forename: Kelly
authors.initials: K
authors.lastname: West
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
authors.forename: Lydia
authors.initials: L
authors.lastname: Anderson
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
authors.forename: James K
authors.initials: JK
authors.lastname: Rasheed
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
authors.forename: Heather
authors.initials: H
authors.lastname: Moulton-Meissner
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
authors.forename: Judith
authors.initials: J
authors.lastname: Noble-Wang
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
authors.forename: Brandi
authors.initials: B
authors.lastname: Limbago
authors.affiliation: Children's Hospital Colorado, Aurora, CO.
authors.forename: Elaine
authors.initials: E
authors.lastname: Dowell
authors.affiliation: Children's Hospital Colorado, Aurora, CO; University of Colorado School of Medicine, Aurora, CO.
authors.forename: Joanne M
authors.initials: JM
authors.lastname: Hilden
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
authors.forename: Alice
authors.initials: A
authors.lastname: Guh
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
authors.forename: Lori A
authors.initials: LA
authors.lastname: Pollack
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
authors.forename: Carolyn V
authors.initials: CV
authors.lastname: Gould
mesh_terms: D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016022:Case-Control Studies; D000077723:Cefepime; D002511:Cephalosporins / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D016360:Clostridioides difficile / Q000145:classification / Q000187:drug effects / Q000302:isolation & purification*; D003015:Clostridium Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D003428:Cross Infection / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D005243:Feces / Q000382:microbiology; D005260:Female; D006760:Hospitalization; D006761:Hospitals; D006801:Humans; D007223:Infant; D017053:Infection Control; D008297:Male; D008495:Medical Oncology; D010372:Pediatrics; D012307:Risk Factors; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents; D002511:Cephalosporins; D000077723:Cefepime
keywords: Clostridium difficile; Epidemiology; Hematology; Oncology