The clinical significance of Clostridium difficile infections in infants and children

Abstract

In neonates, and in infants below the age of 6 months, the pathogenicity of C. difficile remains controversial. Cases of pseudomembranous colitis (PMC) due to C. difficile are rare before the age of two years, and some 60% of asymptomatic neonates excrete C. difficile in the stools because of natural nosocomial colonisation of the digestive tract during the first few days of life. After the age of one year, the asymptomatic carrier rate diminishes, with respect to the adult incidence, but remains at 5-10% until the age of two. Furthermore, many small infants who are asymptomatic excrete toxins A and B in their stools, in concentrations equal to or even higher than those seen in adults with PMC. The relative insensitivity of the infantile alimentary tract to toxins A and B may be the result of absent or immature intestinal receptors, or of the presence of maternal milk antibodies which neutralise the binding of toxin A to the receptor. Nonetheless, some toxin producing strains of C. difficile can be pathogenic in the young age group, as witnessed by the description of seven cases of fatal fulminant PMC in neonates, probably linked to direct invasion of the tissues by C. difficile with massive endotoxaemia. We should also mention one case of PMC with perforation of the colon in a neonate whose breast feeding mother was taking ciprofloxacin.