Risk of Pediatric C Difficile Increases with Proton Pump Inhibitor Use

Older age among children and the use of proton pump inhibitors are linked to severe C difficile infection in pediatric patients, according to new findings.

Investigators retrospectively reviewed 124 children in order to identify the risk factors for severe cases of C difficile infection in this population. The study authors wrote that C difficile infection is increasing among children and because of this, they wanted to study the clinical characteristics between C difficile infection and colonization. Diagnosing pediatric C difficile infection is particularly challenging, they added, because there is no strict disease definition and unclear epidemiology.

The children were observed between 2011 and 2018 and were between the ages of 1 and 18 years. The study authors defined C difficile infection as 3 or more loose stool in the previous 24 hours. The investigators reviewed more than 1200 stool samples sent for testing and discovered 323 positive samples, which were then isolated.

There were 49 children who fulfilled the definition of C difficile infection and 75 had C difficile colonization, the researchers reported. Compared to the children with colonization, infected children were more likely to present with watery and mucoid stool, plus occult blood in the stool, the researchers said.

Of the 49 children with C difficile infection, 36 patients presented with mild to moderate forms of the disease, the researchers said. The remaining 13 patients were categorized as severe or complicated C difficile infection. The investigators also found elevated creatinine levels and hyponatremia in the children with C difficile infection.

The average age in both groups was about 4.5 years old and half of the patients were male, the investigators said.

The investigators categorized patients into groups by severity in order to understand the independent risk factors. Increasing age was significantly linked to severe disease in previous reports, but these study authors learned that it was no longer a significant association after they excluded infants younger than age 1 from their analysis. In their study, instead, they highlight 4 years of age or older as the critical age for C difficile infection. They said that older children or adolescents tend to develop more severe diseases, which can be explained by microbial diversity increasing with age.

Proton pump inhibitor use within 1 month seemed to be the other risk factor, the researchers said. They said that their cohort “reminds clinical physicians that proton pump inhibitors should be prescribed with caution, especially in those with risks for C difficile infection.”

“Stool characters and typical presentations such as profuse watery or mucoid diarrhea could help us differentiate C difficile infection from colonization, especially in institutions where two steps algorism cannot be performed,” the study authors concluded. “Our study highlights increased age and prior use of proton pump inhibitors as two independent factors for severe or complicated C difficile infection. Further carefully designed studies are necessary to clarify the relationships between microbiota transition and increased severity of C difficile infection in childhood.”

The paper, “Increased age and proton pump inhibitors are associated with severe Clostridium difficile infections in children,” was published in the Journal of Microbiology, Immunology and Infection.