The Pediatric Infectious Disease Journal:

Clostridium difficile is an important cause of antibiotic-associated diarrhea and the most widely recognized diarrheal pathogen acquired in healthcare settings.

Antibiotic or gastric acid suppressant exposure, gastrointestinal feeding devices, and certain medical conditions, such as malignancy and inflammatory bowel disease, are recognized to be associated with CDAD in children.

However, the risk factors specific to community-associated CDAD in children remain unclear. Herein, we describe the clinical characteristics and risk factors of pediatric community-associated CDAD (CA-CDAD) at a free-standing children’s hospital.

Risk Factors: 30 Days Before Illness

The use of antibiotics within 30 days of illness was more common among CA-CDAD cases 40.6% than controls 27.5%.

When assessed according to antibiotic class, CA-CDAD cases were more likely to have received cephalosporins and clindamycin. The use of gastric acid suppressants was frequent among CA-CDAD cases, yet there was no difference in the proportion of case and control subjects that used them.

In the final multivariate model of exposures within 30 days of illness, when controlling for age, cephalosporin use and the presence of a gastrointestinal feeding device were found to be significantly associated with CDAD.

Risk Factors: 90 Days Before Illness

The use of antibiotics within 90 days was more common among CA-CDAD cases 49.3% than controls 34.1%.

When examined according to antibiotic class, CA-CDAD cases were more likely to have received cephalosporins and clindamycin. In addition, CA-CDAD cases were more likely to have received 2 or more antibiotic classes within 90 days, compared with controls. No difference was noted in the proportion of cases and controls that used gastric acid suppressants in the 90 days before illness.

In the final multivariate model for exposures within 90 days of illness, when controlling for age, authors observed that exposure to cephalosporins, exposure to clindamycin and the presence of a gastrointestinal feeding device were more common among CA-CDAD cases than controls, however none of these associations were statistically significant.

Conclusions:

Antibiotics are the most important risk factor for CDAD since they disrupt the intestinal flora, thereby permitting toxin-producing C. difficile to establish and proliferate.

In the adult population, antibiotics are also an established risk factor for CA-CDAD, and differences in the strength of the association have been described between classes of antibiotic.

Study found that recent cephalosporin use posed the greatest risk for CA-CDAD in children. Gastrointestinal feeding devices were also associated with pediatric CA-CDAD, although the mechanism for their relationship with CDAD between remains unclear.

This study also found that a substantial proportion of CA-CDAD cases had recent exposure to outpatient healthcare settings is consistent with previous studies in children and adults. A higher proportion of pediatric CA-CDAD cases had an outpatient healthcare encounter within 30 days of illness than control subjects.

Outpatient healthcare settings may be a source of CDAD for children through contact with contaminated environmental surfaces or through receipt of medical interventions that alter the intestinal microbiota.

This study suggests that programs focused on decreasing outpatient antibiotic use may decrease the burden of CA-CDAD in children.

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