1. In a very large retrospective cohort of hospitalized pediatric patients, the incidence of C. difficile infection decreased from 7.09 to 4.89 cases per 10,000 patient days between 2013 and 2019.

2. Specific testing for C. difficile also decreased over the same period.

Evidence Rating Level: 2 (Good)

Study Rundown: Infection with Clostrioides difficile (C. difficile) is a complication of hospitalization that causes significant morbidity in adult and pediatric populations alike. This study used a large national database to explore trends in C. difficile infection between 2013 and 2019. Across about 23,000 admissions including a C. difficile infection for about 17,000 patients, the adjusted yearly incidence decreased from 7.09 cases per 10,000 patient days in 2013 to 4.89 in 2019. Diagnosis was made using C. difficile-specific testing, most commonly nucleic acid amplification testing, as opposed to gastrointestinal panels in 74.8% of cases. The annual rate of C. difficile-specific testing decreased from 52.7 per 10,000 patient days in 2013 to 33.7 in 2019, while rates of panel testing increased. Chronic gastrointestinal conditions were comorbid in 41% of C. difficile hospitalizations, malignancy in 36%, and immunodeficiency in 24%. This study provides reassuring information on trends in C. difficile infection, which rapidly increased in incidence in the pediatric population in the early 2000s. A role for undertesting and underdiagnosis cannot be ruled out based on these data, but the increase in panel testing over the study period could explain part of the decrease in use of C. difficile-specific testing codes. Just as clinical suspicion for C. difficile must remain high in at-risk pediatric patients, surveillance of epidemiologic data will be important as C. difficile antibiotic therapies evolve.

Click to read the study in the Journal of Pediatrics

Relevant Reading: Clostridium difficile infection in children

In-Depth [retrospective cohort]: Data were drawn from the Pediatric Health Information System database. C. difficile infection was defined based on both an international classification of disease (ICD) diagnosis code and a billing code for C. difficile antibiotic therapy. Children aged 17 and younger admitted to 42 hospitals were included. Adjusted incidence rates were calculated using Poisson generalized linear models. The p-value for the difference between C. difficile incidences in 2013 and 2019 was <0.001. Yearly incidence decreased significantly in all age groups, including children less than 1 year old, over the study period. Based on Spearman correlation testing, changes in C. difficile incidence and C. difficile-specific testing were highly correlated in patients 1 year old or younger (p<0.001) but not correlated in other age groups. Oral metronidazole was used in 68.5% of cases but decreased concurrently with increased use of oral vancomycin in 2018-2019.

Image: PD

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