Association of <i>Clostridium difficile</i> with Antibiotic Associated Diarrhea among Hospitalized Children in Diyala-Iraq

Abstract

Background: Clostridium difficile infection (CDI) is an increasingly important cause of morbidity in hospitalized children. Absence of clinical suspicion and suboptimum laboratory diagnostic methods are behind the misdiagnosed infections. Objectives: To determine the association of Cl. difficle infection among hospitalized children suspected of having antibiotic associated diarrhea (AAD) plus detection of the bacterium’s toxins A and B and the enzyme glutamate dehydrogenase (GDH). Patients and methods: This cross-sectional study was conducted in Al-Batool Hospital for Maternity and Children in Baquba City for the period from March 2017 to April 2018. Sixty stool samples were collected from children inpatients. The age range was 15 days up to one year. 41 (68.3%) and 19 (31.7%) were males and females respectively. Additionally, 20 healthy children were enrolled as control group. The age range was 50 days up to one year, 12 (60%) and 8 (40%) were males and females respectively. Special questionnaire was preconstructed for collection of demographic information. Isolation of Cl. difficile was carried out on Colombia blood agar and tryptose sulfite cycloserine agar. Enzyme linked immunosorband assays were used for the detection of toxin A and B (CerTest-Biotec, Spain), and for the detection of glutamate dehydrogenase enzyme (CerTest-Biotec, Spain). Human privacy was respected by obtaining the parents’ oral consent. Statistical analyses were done using SPSS Version 18 and P values less than 0.05 were considered significant. Results: The isolation rate of Cl. difficile 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 toxin A, and 64.3% for toxin A and B together. Neither of the patients’ specimens was positive for toxin B alone, nor was healthy control positive for all toxins. The overall detection rate of GDH enzyme in study groups was 32.5%, with a significantly higher among patients as compared to control (28.8% vs. 3.8% , P = 0.045). The isolation and detection rate of Cl. difficile were increased as the time of the onset of diarrhea was increased. Other factors: age, sex, residence, and type of feeding were insignificantly affecting the isolation and detection rate of Cl. difficile by different techniques. The third generation cephalosporines either singly or in combinations with each other or with another antibiotic were mostly associated with the higher rates of diarrhea. Conclusion: Cl. difficile infection is associated with about one third of antibiotic associated diarrhea among hospitalized children one year of age in Diyala province. CDI should be included in the routine differential diagnoses for hospitalized children presenting with AAD.