Clostridium difficile infectious diarrhea in children

The article was written by Specialist Doctor II Nguyen Thi Tam - Pediatric Center - Vinmec Times City International Hospital

Clostridium difficile is a Gram-positive, anaerobic, spore-forming (spore forming) bacterium that occurs in soil, water, air, intestines and feces of animals and humans. The bacterium, which is spread from person to person through oral faeces or direct contact with Clostridium difficile-contaminated environment, is a major cause of diarrhea associated with healthcare workers, in adults and children, in hospitals and in the community. .

Clostridium difficile carrier rate in neonates 25-30%, children 1-12 months: 10-25%, children > 1 year old: 5-10%, children 3 years old: 0-3% (similar to adults) Fort).

Pathogenic bacteria produce potent toxins, toxins that have both enterotoxin properties and cytotoxic activity. Bacterial toxins A and B disrupt the cellular structure of the intestinal epithelium, causing inflammation and cell death.
Toxin A (enterotoxin) causes inflammation leading to mucosal damage and intestinal secretions. Toxin B (cytotoxicity) plays an important role in creating virulence of bacteria, stronger than toxin A in causing damage to the colonic mucosa. Bacterial strains lacking toxin A can be as virulent as strains with both toxins. The concentration of toxins in the stool can be correlated with the severity of the disease. Disease occurs as a result of an overgrowth of existing internal microorganisms or from an infection from an external source. Normal bacteriological changes in the gastrointestinal tract following antibiotic administration are the most favorable factors for disease onset.
The disease usually occurs in patients who are currently or after taking antibiotics such as Ampicillin, Clindamycin, Cephalosporins and Amynoglucosides. Toxins produced by strains of Clostridium difficile in the gastrointestinal tract cause pseudomembranous colitis.
There are 3 degrees of illness:
* Acute diarrhea caused by Clostridium Difficile
Appears during or a few weeks after taking antibiotics (maybe as late as 10 weeks). Acute onset, mild to moderate severity. Fever, abdominal cramps, abdominal distension. Loose, watery stools, maybe 10 times a day. The stools are often strong and very foul-smelling, 15% of the cases are accompanied by visible blood.

* Pseudomembranous colitis
Severe inflammation of the inner lining of the intestines, uncommon in children Appears during or after 21 days of taking at least 1 antibiotic Fever Persistent loose stools Pain and bloating Leukocytosis blood smear stool smear with blood and white blood cells Severe condition: dehydration, hypoalbuminemia, sepsis, peritoneal effusion, pleural effusion Severe bowel manifestations: intestinal perforation, intussusception, gas in the intestinal wall. Rectal prolapse (rare) Definite diagnosis: pseudomembranous finding on enteroscopy or biopsy * fulminant presentation
Paralytic ileus, toxic megacolon, hypotension, or shock Manifestation: fever , diarrhea, lower abdominal pain or diffuse pain, abdominal distention, hypovolemia, increased blood neutrophils, hypoalbuminemia and acidosis. Diarrhea may not be present if paralytic ileus is present. Complications: toxic megacolon or intestinal perforation Requires urgent surgical intervention * Recurrent infection
12-30% of children with Clostridium difficile infection have recurrent disease. Appear 1-3 weeks after the first onset (in some cases late: 2 months) Recurrence symptoms are similar to the previous one. The mechanism is not clear (Hypothesis: bacterial spores persist in the intestine, low concentration of antitoxin antibodies, intestinal flora disorder). Antibiotic resistance has not been identified as a factor in relapse.

Pseudomembranous colitis should be considered in any patient who develops diarrhea 2 months after antibiotic use or 72 hours after admission. Diagnosis is confirmed by stool testing for Clostridium difficile toxins A and B (Elisa). If the test is negative, but there is clinical suspicion, repeat the test. Sometimes a colonoscopy or CT scan is needed to check the condition of the colon.

* Mild or moderate cases:
Metronidazole: 30 mg/kg/24 hours in 4 divided doses, up to 500 mg Or Vancomycin 10 mg/kg/1 time x 4 times/day orally for 10 days, up to 125mg/dose , in the absence of metronidazole response. * In severe cases:
Vancomycin oral dose as above * In case of fulminant disease:
Oral vancomycin, maximum dose 500 mg * Fulminant disease with intestinal obstruction:
Metronidazole 30 mg/kg/24 hours can be combined in 4 divided doses intravenous injection, maximum dose 500 mg and oral vancomycin, maximum dose 500 mg. * First mild and moderate relapse: repeat as first dose.
* Repeat recurrence:
Vancomycin 14 days and gradually reduce the dose New drug class: Fidaxomicin

Intestinal infections caused by Clostridium difficile can be controlled by the following measures:
Wash hands with soap and water Only use antibiotics when really needed, use as prescribed by the doctor and must be used until when cured. Drink plenty of water and diluted fruit juices to ensure nutrition Eat starchy foods, probiotic foods or yogurt containing healthy bacteria when you have diarrhea. Care for patients infected with Clostridium Bifficile in a separate room, protective clothing, gloves, cleaning utensils, and rooms carefully. Educate patients on health and guide visitors to implement contact isolation measures to avoid infection. The pediatric department at Vinmec International General Hospital is the address for receiving and examining diseases that infants and young children are susceptible to: viral fever, bacterial fever, otitis media, pneumonia in children ,....With modern equipment, sterile space, minimizing the impact as well as the risk of disease spread. Along with that is the dedication from the doctors with professional experience with pediatric patients, making the examination no longer a concern of the parents.