Association of Clostridium difficile with Antibiotic Associated Diarrhea among Hospitalized Children in Diyala-Iraq

Abstract

Background: Clostridium difficile infection (CDI) is an \nincreasingly important cause of morbidity in hospitalized children. Absence of clinical \nsuspicion and suboptimum laboratory diagnostic methods are behind the \nmisdiagnosed infections. Objectives: To determine the association of Cl. \ndifficle infection among hospitalized children suspected of having \nantibiotic associated diarrhea (AAD) plus detection of the bacterium’s toxins A \nand B and the enzyme glutamate dehydrogenase \n(GDH). Patients and methods: This cross-sectional study was \nconducted in Al-Batool Hospital for Maternity and Children in Baquba City for \nthe period from March 2017 to April 2018. Sixty stool samples were collected \nfrom children inpatients. The age range was 15 days up to one year. 41 (68.3%) \nand 19 (31.7%) were males and females respectively. Additionally, 20 healthy \nchildren were enrolled as control group. The age range was 50 days up to one \nyear, 12 (60%) and 8 (40%) were males and females respectively. Special \nquestionnaire was preconstructed for collection of demographic information. \nIsolation of Cl. difficile was carried out on Colombia blood agar and \ntryptose sulfite cycloserine agar. Enzyme linked immunosorband assays were used \nfor the detection of toxin A and B (CerTest-Biotec, Spain), and for the \ndetection of glutamate dehydrogenase enzyme (CerTest-Biotec, Spain). Human \nprivacy was respected by obtaining the parents’ oral consent. \nStatistical analyses were done using SPSS Version 18 and P values less than \n0.05 were considered significant. Results: The isolation rate of Cl. \ndifficile form patients and healthy children was 11.7% and 5% respectively. The toxins detection rate among patients was 23.3%, of these 35.7% for \ntoxin A, and 64.3% for toxin A and B together. Neither of the patients’ \nspecimens was positive for toxin B alone, nor was healthy control positive for \nall toxins. The overall detection rate of GDH enzyme in study groups was 32.5%, \nwith a significantly higher among patients as compared to control (28.8% vs. 3.8% , P = 0.045). \nThe isolation and detection rate of Cl. difficile were increased as the \ntime of the onset of diarrhea was increased. Other factors: age, sex, residence, \nand type of feeding were insignificantly affecting the isolation and \ndetection rate of Cl. difficile by different techniques. The third \ngeneration cephalosporines either singly or in combinations with each other or \nwith another antibiotic were mostly associated with the higher rates of \ndiarrhea. Conclusion: Cl. difficile infection is \nassociated with about one third of antibiotic associated diarrhea among \nhospitalized children one year of age in Diyala province. CDI should be \nincluded in the routine differential diagnoses for hospitalized children \npresenting with AAD.