Published online Jul 31, 2019. doi: 10.13105/wjma.v7.i7.350
Peer-review started: April 22, 2019
First decision: June 10, 2019
Revised: June 13, 2019
Accepted: July 26, 2019
Article in press: July 26, 2019
Published online: July 31, 2019
Processing time: 102 Days and 19.1 Hours
Childhood recurrent Clostridium difficile infections (CDI) may be difficult to control and may represent an unknown underlying pathology. Recurrence often occurs in immunodeficiency disorders and inflammatory bowel disease (IBD).
There have been multiple studies showing correlation between certain risk factors predisposing to the development of CDI. Risk factors such as acid suppressing agents, especially H2 receptor antagonists, exposure to antibiotics and immunosuppressants, comorbidities such as cancer, cystic fibrosis and IBD, and hospitalization have been known to increase the incidence of CDI for some time. These studies are charged with the task of understanding the risk for developing the infection in general, however, there is a paucity of studies that describe a select population of children that have recurrence of this infection. While community acquired CDI is more common in pediatrics than adults, recurrent CDI is not common in children.
The main objectives of this report are understanding CDI in a very unique population of children who are not immunocompromised and do not have any identified IBD. This study describes important discoveries of unidentified underlying gastrointestinal conditions which may not be recognized unless the child is adequately evaluated by a specialist in the field. The study also describes the success, and the durable gut microbial changes after fecal microbial transplant in this population. These discoveries contribute to the successful outcome in management of these subjects by identifying and addressing the underlying disease.
Pediatric patients with recurrent CDI, defined as two or more distinct episodes of CDI associated with diarrhea or bloody diarrhea who were referred for evaluation to pediatric gastro-enterology service were identified. Subjects younger than one year and older than twenty-one years of age were excluded. All subjects with known immunosuppression or IBD prior to referral were excluded. Subjects had been followed up for at least one year.
We have observed 12 children in succession. All patients received CDI antibiotics prior to referral. Five of the 12 patients had previously undiscovered potential pathologies, including eosinophilic colitis and IBD. After the treatment of basal colitis, the symptoms of CDI disappear and there is no need for CDI treatment. Nine patients required fecal microbial transplantation for antibiotic CDI failure, which is safe and effective (100% efficacy) for preventing recurrence. Intestinal microbial changes following fecal transplantation are characterized by a significant and sustained increase in diversity and the abundance of Bacteroides.
Children with recurrent CDI deserve a through gastrointestinal workup as they may frequently have an underlying disease which can contribute to the management of the condition. When medical therapy fails in this population, fecal microbial transplant is a safe and durable therapy. Children with recurrent CDI may have unidentified gastrointestinal disease contributing to the recurrence of the infection. Children with recurrent clostridium difficile frequently have an unidentified gastrointestinal disorder, which when identified and addressed, can help with management of clostridium difficile recurrence.
Children with recurrent CDI need a thorough gastrointestinal workup to optimize their care and management. Future research should focus on individualized medicine and targeting underlying disease on a case by case basis.