The purpose of this article is to present an exemplar related to diagnostic testing whereby reasoned decisions can assist the pediatric surgical clinician in the expeditious screening, diagnosis, and management of Clostridioides difficile infection (CDI). In 2017, the Emerging Infections Program for CDI reported that the incidence of healthcare-associated CDI was 9.03 in 100,000 and 26.70 for community-associated CDI in the 1- to 17-year age group. Multistate prevalence data looking at healthcare-associated infections (HCAIs) in acute care hospitals showed that C. difficile was the most common pathogen, causing 12.1% of HCAIs. Given the current trends, defining the pediatric epidemiological characteristics of CDI, which is less common than in adults, is vital. Consequently, clinicians need to know when to suspect CDI; however, classic risks associated with this HCAI are considered to be a moving target leading to challenges in the diagnosis, management, and ability to control the disease. Because the diagnosis of CDI is based on clinical and laboratory findings and precludes management, a sensitive and specific diagnostic test with rapid turnaround time is imperative. The use of probabilities is discussed in the context of the threshold approach in clinical decision making.
AntonaraS., LeberA. (2016). Diagnosis of Clostridium difficile infections in children. Journal of Clinical Microbiology, 54, 1425–1433.
4.
AxelradJ., FreedbergD., WhittierS., GreendykeW., LebwohlB., GreenD. (2019). Impact of gastrointestinal panel implementation on health care utilization and outcomes. Journal of Clinical Microbiology, 57, e01775–e01783.
5.
BarbutF., BraunM., BurghofferB., LalandeV., EckertC. (2009). Rapid detection of toxigenic strains of Clostridium difficile in diarrheal stools by real-time PCR. Journal of Clinical Microbiology, 47, 1276–1277.
6.
BartlettJ., ChangT., FurwithM., GorbachS., OnderdonkA. (1978). Antibiotic-associated pseudomembranous colitis due to toxin-producing Clostridia. The New England Journal of Medicine, 298, 531–534.
7.
BealS., TremblayE., ToffelS., VelezL., RandK. (2018). A gastrointestinal PCR panel improves clinical management and lowers health care costs. Journal of Clinical Microbiology, 56, e01457–e01467.
8.
BinnickerM. (2015). Multiplex molecular panels for diagnosis of gastrointestinal infection: Performance, result interpretation, and cost-effectiveness. Journal of Clinical Microbiology, 53, 3723–3728.
9.
BurhamC., CarrollK. (2013). Diagnosis of Clostridium difficile infection: An ongoing conundrum for clinicians and clinical laboratories. Clinical Microbiology Reviews, 26, 604–630.
10.
BussS., LeberA., ChapinD., FeyP., BankowskiM., JonesM., RogatchevaM., KanackK., BourzacK. (2015). Multicenter evaluation of the BioFire FilmArray gastrointestinal panel for etiologic diagnosis of infectious gastroenteritis. Journal of Clinical Microbiology, 53, 915–925.
11.
CarrollK., MizusawaM. (2020). Laboratory tests for the diagnosis of Clostridium difficile. Clinics in Colon and Rectal Surgery, 33, 73–81.
ChenK., StephensD., AndersonE., ActonR., SaltzmanD., HessD. (2012). Clostridium difficile infection in the pediatric surgery population. Journal of Pediatric Surgery, 47, 1385–1389.
14.
ChuA., MichailS. (2019). Pediatric recurrent Clostridium difficile infections in immunocompetent children: Lessons learned from case reports of the first twelve consecutive patients. World Journal of Meta-Analysis, 7, 350–357.
15.
CohenS. H., GerdingD. N., JohnsonS., KellyC. P., LooV. G., McDonaldC. L., PepinJ., WilcoxM. H., Society for Healthcare Epidemiology of America & Infectious Diseases Society of America (2010). Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control and Hospital Epidemiology, 31(5), 431–455.
de GraafH., PaiS., BurnsD., KarasJ., EnochD., FaustS. (2015). Co-infection as a confounder for the role of Clostridium difficile infection in children with diarrhoea: A summary of the literature. European Journal of Clinical Microbiology & Infectious Diseases, 34, 1281–1287.
18.
DebastS., BauerM., KuijperE. (2014). European Society of Clinical Microbiology and Infectious Diseases: Update of the treatment guidance document for Clostridium difficile infection. Clinical Microbiology and Infection, 20(Suppl. 2), 1–26.
19.
DePestelD., AronoffD. (2013). Epidemiology of Clostridium difficile infection. Journal of Pharmacy Practice, 26, 464–475.
20.
DeshpandeA., PantC., AndersonM., DonskeyC., SferraT. (2013). Clostridium difficile infection in the hospitalized pediatric population: Increasing trend in disease incidence. The Pediatric Infectious Disease Journal, 32, 1138–1140.
21.
EastwoodK., ElseP., CharlettA., WilcoxM. (2009). Comparison of nine commercially available Clostridium difficile toxin detection assays, a real-time PCR Assay for C. difficile tcdB, and a glutamate dehydrogenase detection assay to cytotoxin testing and cytotoxigenic culture methods. Journal of Clinical Microbiology, 47, 3211–3217.
22.
FinneyJ. (1893). Gastroenterostomy for cicatrizing ulcer of the pylorus. Bulletin of the John Hopkins Hospital, 4, 53–55.
23.
GnocchiM., GagliardiM., GismondiP., GaianiF., AngelisG., EspositoS. (2020). Updated management guidelines for Clostridioides difficile in paediatrics. Pathogens, 9, 291–303.
24.
GueryB., GalperineT., BarbutF. (2019). Clostridioides difficile: Diagnosis and treatment. The British Medical Journal, 366, I4609–I4628.
25.
GuhA., MuY., WinstonL., JohnstonH., OlsonD., FarleyM., WilsonL., HolzbauerS., PhippsE., CumyatiG., VeldavsZ., KainerM., KarlssonM., GerdingD., McDonaldL. (2020). Trends in U.S. burden of Clostridioides difficile infection and outcomes. New England Journal of Medicine, 382, 1320–1330.
26.
GuptaA., PardiD., BaddourL., KhannaS. (2016). Outcomes in children with Clostridium difficile infection: Results from a nationwide survey. Gastroenterology Report, 4, 293–298.
27.
HallI., O'TooleE. (1935). Intestinal flora in new-born infants: With a description of a new pathogenic anaerobe, Bacillys difficilis. American Journal of Diseases in Children, 49, 390–402.
28.
KociolekL., PalacH., PatelS., ShulmanS., GerdingD. (2015). Risk factors for recurrent Clostridium difficile in children: A nested case-control study. The Journal of Pediatrics, 167, 384–389.
29.
KulaylatA., RocourtD., PodanyA., EngbrechtB., TwilleyM., SantosM., CilleyR., HollenbeakC., DillonP. (2016). Costs of Clostridium difficile infection in pediatric operations: A propensity score-matching analysis. Surgery, 161, 1376–1386.
30.
LawsonP., CitronD., TyrellK., FinegoldS. (2016). Reclassification of Clostridium difficile as Clostridioides difficile (Hall and O'Toole 1935) Prévot 1938. Anaerobe, 40, 95–99.
31.
LeesE., MiyajimaE., PirmohamedM., CarrolE. (2016). The role of Clostridium difficile in the paediatric and neonatal gut—A narrative review. European Journal of Microbiology & Infectious Diseases, 35, 1047–1057.
MagillS., EdwardsJ., BambergW., BeldavsZ., DumyatiG., KainerM., LynfieldR., MaloneyM., McAllister-HollodL., NadleJ., RayS., ThompsonD., WilsonL., FridkinS., Emerging Infections Program Healthcare-Associated Infections and Antimicrobial Use Prevalence Survey Team (2014). Multistate point-prevalence survey of health care–associated infections. The New England Journal of Medicine, 370, 1198–1208.
35.
Martinez-MeléndezA., Camacho-OrtizA., Morfin-OteroR., Maldonado-GarzaJ., Villareal-TreviñoL., Garza-GonzálezE. (2017). Current knowledge on the laboratory diagnosis of Clostridium difficile infection. World Journal of Gastroenterology, 23, 1552–1567.
36.
McDonaldL., GerdingD., JohnsonS., BakkenJ., CarrollK., CoffinS., DubberkeE., GareyK., GouldC., KellyC., LooV., SammonsJ., SandoraT., WilcoxM. (2018). Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases, 66, 987–994.
37.
MehrotraP., JangJ., GidengilC., SandoraT. (2017). Attributable cost to Clostridium difficile infection in pediatric patients. Infection Control & Hospital Epidemiology, 38, 1472–1477.
38.
Miranda-KatzM., ParmarD., DangR., AlabasterA., GreenhowT. (2020). Epidemiology and risk factors for community associated Clostridioides difficile in children. The Journal of Pediatrics, 221, 99–106.
39.
NicholsonM., CrewsJ., StarkeJ., JiangZ., DuPontH., EdwardsK. (2017). Recurrent Clostridium difficile infection in children: Patient risk factors and markers of intestinal inflammation. Pediatric Infectious Disease Journal, 36, 379–383.
40.
PantC., DeshpandeA., AltafM., MinochaA., SferraT. (2013). Clostridium difficile infection in children: A comprehensive review. Current Medical Research & Opinion, 29, 967–984.
41.
PantC., DeshpandeA., GilroyR., OlyaeeM., DonskeyC. (2016). Rising incidence of Clostridium difficile related discharges among hospitalized children in the United States. Infection Control & Hospital Epidemiology, 37, 104–106.
42.
PasarónR. (2012). Clostridium difficile: A pediatric surgical experience. Sutureline: American Pediatric Surgical Nurses Association, 19(3), 12–18.
43.
PechalA., LinK., AllenS., RevelesK. (2016). National age group trends in Clostridium difficile infection incidence and health outcomes in United States community hospitals. BMC Infectious Diseases, 16, 682–688.
44.
PengZ., LingL., StrattonC., LiC., PolageC., WuB., TanY. (2018). Advances in the diagnosis and treatment of Clostridium difficile infections. Emerging Microbes & Infection, 7, 15–29.
45.
PlancheT., WilcoxM. (2015). Diagnostic pitfalls in Clostridium difficile infection. Infectious Disease Clinics of North America, 29, 63–82.
46.
ReaganJ., HerzigC., Pogorzelska-MaziarzM., DickA., StoneP., SrinathD. (2015). State law mandates for reporting of healthcare-associated Clostridium difficile Infections in hospitals. Infection Control & Hospital Epidemiology, 36, 350–252.
47.
SamadyW., BushR., PongA., AndrewsA., Stucky FisherE. (2014). Predictors of Clostridium difficile infections in hospitalized children. Journal of Hospital Medicine, 9, 94–98.
48.
SamadyW., PongA., FisherE. (2014). Risk factors for the development of Clostridium difficile for in hospitalized children. Current Opinions in Pediatrics, 26, 568–572.
49.
SandlundJ., DaviesK., WilcoxM. (2020). Ultrasensitive Clostridioides difficile toxin testing for higher diagnostic accuracy. Journal of Clinical Microbiology, 58, e01913–e01919.
50.
SandoraT., FungM., FlahertyK., HelsingL., ScanlonP., Potter-BynoeG., GidengilC., LeeG. (2011). Epidemiology and risk factors for Clostridium difficile infection in children. The Pediatric Infectious Disease Journal, 30, 580–584.
SurawiczC., BrandtL., BinionD., AnanthatkrishnanA., CurryS., GilliganP., McFarlandL., MellowM., ZuckerbraunB. (2013). Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. The American Journal of Gastroenterology, 108, 479–498.
