Background
Clostridium difficile (
C. difficile) is a Gram-positive, anaerobic spore-forming bacillus, which can exist as both toxigenic and non-toxigenic forms [
1]. It has become a significant cause of nosocomial infection with high mortality rates, particularly in the elderly. There is increasing interest in the changing epidemiology of
C. difficile, as mortality rates have risen in association with emergence of hypervirulent strains such as the toxinotype group V, PCR ribotype 078 (NAP7/BK/078) and North American toxinotype III, PCR ribotype 027 (NAP1/BI/027), and there have been increasing rates of community-associated disease in recent years [
2]. Approximately 4–5 % of non-hospitalised healthy adults carry the organism in their intestinal flora [
3]. In hospitalised adults and those in long-term care facilities, the rate of asymptomatic carriage is estimated to be 20–50 % [
4,
5], and varying carriage rates of up to 70 % have been reported in healthy newborns [
6]. In children, there is a decreasing trend in carriage rate with increasing age; with colonisation falling to adult levels of around 5 % by the age of 2 years.
C. difficile colonisation results in a spectrum of clinical conditions ranging from asymptomatic carrier state to fulminant colitis. The pathophysiology of
C. difficile-associated diarrhoea requires alteration of the colonic microflora, colonisation by
C. difficile, and the release of enterotoxins from the toxigenic strains (typically toxin A and toxin B and in some instances a binary toxin) [
1]. The use of broad-spectrum antibiotics disturbs the indigenous intestinal microbiota, which eliminates competing microbes and allows
C. difficile overgrowth and toxin production in the colon.
Researchers have tried to identify the differences in host mechanism between adult and paediatric populations, as
C. difficile has traditionally been viewed as non-pathogenic in young infants, given that they may carry both toxigenic and non-toxigenic strains without overt clinical symptoms. One theory is that infants lack the mechanism for cellular internalization of the large clostridial toxins owing to their presumed lack of toxin receptors, which purportedly reach adult levels after weaning [
7]. Some studies have considered the protective mechanisms of breast milk in
C. difficile colonisation in comparison to artificial formula [
8,
9]. An in-vitro and in-vivo study showed that human colostrum contains neutralizing antibodies to toxins A and B [
6,
10]. A study examining the association between serum IgG antitoxin A levels and development of clinical symptoms found that adults with low or absent antibody levels were more likely to develop diarrhoea or colitis, whereas those with higher titres were more likely to exhibit asymptomatic carriage [
11]. Similarly, relapse/recurrence of CDI occurred more frequently in individuals with lower levels of IgG/IgM to Toxin A [
12], but there are no reported data on when infants develop seropositivity to
C. difficile antigens, and whether this correlates with the clearing of the organism from the bowel flora or with symptomatic
C. difficile infection.
Concern about
C. difficile disease in children has resurfaced due to the higher rates of infections and recurrence found in specific groups of children, such as children with haematological malignancies, inflammatory bowel disease (IBD), and cystic fibrosis following lung transplantation [
13]. Although there have been a number of epidemiological studies performed in the United States [
14] and Canada, large gaps in our knowledge remain as to the role of
C. difficile and its interaction with other bowel flora in neonates and children. There is also controversy over whom to test for
C. difficile, with the American Academy of Pediatrics releasing a policy statement in 2013 outlining when
C. difficile testing should be considered in children — recommending avoidance of routine testing in children under 1 year of age, due to their higher carriage rates. Between 1–3 years, testing may be considered, but testing for other pathogens (especially viral pathogens) should be prioritized. Over 3 years, it is advised that testing should be performed in the same circumstances as it would be in adults (i.e., acute diarrhoea and recent history of antibiotic use) [
14].
First-line treatments for
C. difficile disease are vancomycin or metronidazole, although in 22–38 % of cases (particularly in severe disease), failure of treatment has been reported with metronidazole. Disease relapse/recurrence is also a concern with both drugs [
15]. More recently, fidaxomicin, the first in a new class of macrocylic antimicrobials against
C. difficile, has been introduced with greater efficacy in patients with recurrent disease, though data is lacking in use for patients below 18 years of age [
16,
17]. Pharmacokinetic study of the drug in children 6 months–18 years is underway in the USA (Clinicaltrials.gov: NCT01591863), but expert panel has suggested that there is no unmet need for a new treatment in children under 2 years, given the lack of a clear case definition in this population [
18].
In recent years, with rapid advances in genetic sequencing techniques, there has been increasing interest in the human gut microbiome. The microbiome constitutes the many and varied microbes (including bacteria, viruses, archaea, and fungi) that colonize the skin, oral cavity, and gut shortly after birth in all humans [
19]. These microbes are generally thought to be commensals; however, their particular composition is thought to play a role in certain illnesses (e.g., IBD) [
20,
21]. There is an association between reduced diversity of the gut microbiome, intestinal dysbiosis,
C. difficile carriage [
22], and
C. difficile disease/recurrence in adults [
23]. Analysis of
C. difficile-infected mice found that the microbiota consistently contained (in addition to
C. difficile) opportunistic pathogens that have been identified within the microbiota of humans with CDI. These pathogens include:
Klebsiella pneumoniae,
Proteus mirabilis, and
Enterococcus faecalis [
22].
Klebsiella pneumoniae and
Ruminococcus gnavus were noted to be associated with
C. difficile carriage in an infant study, with
Bifidobacterium longum appearing to have a protective role [
24]. In addition, administration of targeted bacteriotherapy (with a mixture including
Lactobacillus reuteri and
Bacteroidetes sp. nov.) to mice with chronic CDI was able to eliminate disease and shedding by restoring a more diverse intestinal microbiota [
22].
Conclusions
It is accepted that
C. difficile is present relatively frequently in neonates, though its significance and effects on the microbiota in later life have yet to be determined. Possible hypotheses for lack of
C. difficile disease in this population include: immaturity of bowel mucosa with a lack of receptors for
C. difficile toxins, immunoglobulin fractions present in breast milk preventing binding of toxins to their receptors, as well as the nature and composition of infant gut microflora being protective against
C. difficile overgrowth [
71]. Further studies are needed to determine the significance of asymptomatic
C. difficile colonisation and consequent changes in the microbiota throughout infancy and childhood and into later life.
There is a huge body of literature on
C. difficile infection in adults, and now an expanding body of work on its role in children. There remains a great deal of disagreement on what constitutes paediatric
C. difficile infection, and the differentiation between symptomatic manifestation and what is believed to be presence of the organism as a bystander in diarrheal disease caused by other organisms. A collaborative policy document published by the Society for Healthcare Epidemiology of America supports the view that in the setting of high prevalence of asymptomatic carriage,
C. difficile cannot be assumed to be the causative agent of diarrhoea prior to adolescence (particularly in younger children) [
72].
Defining paediatric CDI is further complicated by the lack of a standardized scoring system for paediatric infection, making it more difficult to quantify disease burden in those thought to have CDI and thus to know whom to treat. Crews et al. [
55] suggest a framework as to how severity of disease may be defined in children, and clearly consideration of the presence of risk factors should play an additional role in ascertaining the likelihood of CDI versus incidental finding. Given the consensus that children who do have CDI run a much milder disease course than adults, it is appropriate to tailor treatment as such, with the first steps being supportive care (rehydration) and discontinuation of unnecessary antibiotics, or at least narrowing spectrum and reviewing course length, prior to considering active treatment with metronidazole/vancomycin.
Longitudinal exploration of the role of the intestinal microbiota and the development of serological host response to C. difficile during carriage and disease and the age at which this occurs would prove valuable approaches to this issue. This, alongside more detailed work on local gut response to C. difficile in diarrheal children, would provide a firm basis for the mechanistic understanding of pathogenesis of CDI in early life. Further work is also warranted on the hypothesis that children are a major community reservoir for community-attributable CDI cases in adults, as this would have important public health implications.
Please note that references 73 onwards in the reference list below are cited not in the main text, but in the electronic supplementary material.