Clostridium difficile (CD) is a gram-positive anaerobic spore-forming microorganism. Although frequent in the microbiota of asymptomatic children, it can cause colitis if the toxinogenic strain is present.1 Enterotoxins A and B disrupt the cytoskeleton and tight junctions, causing leaks in the enterocyte barrier and promoting neutrophil recruitment.2 The colitis can cause a mild to severe diarrhea, sometimes complicated by protein-losing enteropathy or bacteraemia.3 The incidence and severity of C. difficile infection (CDI) increased in the last 10 years, up to 4 per 10 000 hospital patient-days in 2011 in Europe4 and even more for American children.5 Risk factors in children are the young age, antibiotic exposure, gastric acid suppression, and chronic comorbidities, while the role of prolonged hospital stay and coinfections is debated.6
In transplant recipients, CDI is 5 times more frequent, from 2% to 12% depending on the organ.7 Intestinal transplantation (ITx) is unique with regard to CDI, with a high level of immunosuppression and the transplanted organ being the target.8 Our aim was to analyse the epidemiology, clinical symptoms and evolution of CDI in children after ITx, to discuss guidelines for screening and treatment.
PATIENTS AND METHODS
This retrospective cross-sectional study enrolled all children transplanted between 1987 and 2015 in Necker-Enfants Malades Hospital, with at least 1 year of graft survival. We recorded age, gender, transplantation (Tx) details (including major complications), and immunosuppressive regimen. In case of proven CDI, additional data were symptoms, antibiotic use, immunosuppression during infection, endoscopy if performed and pathology, treatment and associated infections.
Screening for CD was performed in the annual protocol follow-up and in case of acute or persistent diarrhea. Until the 1990s, CD was cultured on specific agar media, and toxin A was detected with an enzyme immunoassay (EIA). From the 2000s, an EIA was performed on the stools, to detect simultaneously the CD glutamate dehydrogenase (GDH) antigen, and toxins A and B (C.diff-quick-check-complete, Alere). The infection was diagnosed when both GDH and toxins were present. If GDH was present without toxins, PCR for toxin B was performed (GenXpert, Cepheid).
CDI was defined according to the guidelines of the European Society of Clinical Microbiology and Infectious Diseases9 as a combination of clinical symptoms and toxin-producing CD in stools, or endoscopic and pathological pseudomembranous colitis. CDI was recurrent if symptoms reappeared within 8 weeks from the onset of a previous episode. It was severe if there were systemic signs and shock, intensive care unit admission, colectomy or death.
All variables are expressed as absolute number (percentage), median (range) or mean and SD.
Statistical analysis was performed using IBM SPSS Statistics 21. Continuous variables were analyzed with the ANOVA Oneway variance test or the nonparametric Kruskal–Wallis test and t-test independent sample or Mann–Whitney test. Categorical variables were compared using χ2 or Fisher exact test and multivariate analysis when appropriate. Kolmogorov–Smirnov test was used to assess Gaussian distribution of the data. Correlations were analyzed by Pearson or Spearman test in case of Gaussian or nonparametric variables.
This article corresponds to a service evaluation audit that was designed as a retrospective case series, thus not requiring ethics committee evaluation.
Among 111 children transplanted between 1987 and 2016, a total of 57 were alive with a graft survival longer than 1 year, with a total of 60 Txs. The average age at ITx was 5 years (0.4–13.5). Indications were as follows: short bowel syndrome (n = 19), congenital diarrhea (n = 21), and motility disorders (n = 18). Thirty-five children received an isolated small bowel, 20 a liver-small bowel, and 5 a multivisceral graft. Follow-up was 8 years (1–24).
C. difficile Infection
CDI was diagnosed in 22 children (39%) (Figure 1). There was no significant difference in basic clinical parameters between patients with or without CDI (Table 1). The average age at CDI was 8 years (4–18), and delay after ITx was 4 years (1–12).
Twenty patients had diarrhea, with rectal bleeding in 8, fever in 4, and hypothermia in 1 patient. Two patients had only watery stools, <3 times a day (Table 2).
Nine patients (40%) were hospitalized for an average time of 6.5 days (2–20): 5 for persistent diarrhea without protein-losing enteropathy and 4 for severe dehydration, renal failure, and protein-losing enteropathy with a mean albumin level of 2.6 g/L.
The immunosuppressive treatment was tacrolimus and steroids in all patients, with azathioprine in 4, mycophenolate mofetil in 3, and sirolimus in 3. Three children had received previously cycles of metronidazole (3 wk monthly) to control abdominal bloating. Among the 22 patients, 40% had received antibiotics, an average of 19 days (8–45) before CDI. These were penicillins in 33% of patients, cephalosporins in 4, imipenem and ciprofloxacin in one each. Three patients had received antifungal drugs (fluconazole and amphotericin B) <3 months before CDI.
Six children underwent gastrointestinal endoscopy: 1 showed a pseudomembranous colitis and 1 a nonspecific pancolitis, and the others were normal.
During the period 2007–2016, totally 150 patients underwent liver Tx in our institute. Seven (4.5%) presented CDI. Ten patients beneficiated of combined liver-kidney Tx and 1 suffered from CDI (10%).
Treatment and Evolution
The treatment was metronidazole in half of the patients, vancomycin in 6, and both in 3 patients. Two patients had a positive stool culture but without symptoms and did not receive antibiotics.
The recurrence of CDI was observed in 9 children, symptomatic in 7. Six patients had received metronidazole for the first episode and 1 metronidazole and vancomycin. Recurrence was diagnosed at a mean of 2 (1–6) years after the end of the first treatment. Three relapses were treated with metronidazole and 4 with vancomycin. Three patients completely recovered, 1 had a chronic infection with symptoms despite several cycles of vancomycin, and 2 still had positive stool culture without symptoms.
Acute rejection was diagnosed in 3 children, at an average time of 3 months (0–3 y) after the first CDI. One of them presented a severe colitis with protein-losing enteropathy 3 months after liver-small bowel Tx, while on tacrolimus, steroids, and azathioprine. CDI was confirmed, but graft biopsies showed acute cellular rejection. The child received high-dose steroids, antilymphocyte globulins and infliximab, together with metronidazole and vancomycin, and recovered from both rejection and CDI. Another patient had together CDI, adenovirus, and a mild rejection. He was treated with cidofovir and metronidazole, no change in immunosuppression, and symptoms resolved. The third patient presented rejection 3 years after CDI and died later of complications.
In treated patients, the stools decreased in number to <3 a day, except in 2, one who had 4 without CDI, and one with chronic symptomatic CDI despite 2 courses of vancomycin.
During the last follow-up in the 20 patients, 5 years after the end of CDI, the mean albumin level was 3.9 g/L.
Univariate analysis failed to detected risk factors for CDI.
This retrospective study shows a high prevalence of CDI in children after ITx (39%). We failed to detect any specific risk factor, such as type of Tx, immunosuppression or previous complications. Forty percent of infected patients had previously received antibiotics; 5 presented a symptomatic recurrence and 3 a chronic asymptomatic infection. Standard antibiotics were efficient (metronidazole and vancomycin) except in one. Graft rejection was diagnosed during CDI episode in 2 patients concomitantly with CDI.
To our knowledge, the present study is the first focusing on CDI after ITx in children. Several studies evaluated CDI in solid organ Tx (SOT). Our population of intestinal transplanted children showed a higher prevalence of CDI than the patients who received a liver Tx in the same institution. Prevalence of CDI in liver transplanted children in our unit was comparable to recently published data.10 Recently, a meta-analysis of 30 studies, 2 including adults after ITx (60 ITx), reported a prevalence of 8% after ITx.11-13 It was 11% after lung and 9% after liver Tx, with no distinction between adults and children. This meta-analysis triggered in the United States a large study of CDI in children after SOT14: the incidence was 6.6 times higher than in nontransplanted children. It was 5% after ITx, second only to pancreatic Tx (7.7%). Infections diagnosed in outpatients were not included, because data came from hospital discharge charts. In a small single-centre experience, CDI was diagnosed in 4 of 7 patients after multivisceral Tx.15 In another study on bacterial infections after ITx, 3 of 124 patients (adults and children) had CDI.16 The higher prevalence in our series could be due to the single-center experience limiting bias due to different practices, a longer follow-up, the large use of antibiotics in transplanted children and the early admission and exploration of patients with diarrhoea after ITx. We could also have overestimated CDI with the systematic screening, misdiagnosing viruses, lactose intolerance or osmotic diarrhea.
We neither saw any impact of CDI on survival nor had a large series of patients after SOT (mortality 7% vs 2%).16 However, complications such as dehydration, hypovolemic shock, and severe colon dilatation were not rare, 3% in the Swiss series10 and 13% in ours. The severity was supposed to be linked to a hypervirulent ribotype.17
In most cases, symptoms of CDI were not specific and benign. However, a recent study in transplanted patients (no ITx) showed that, despite mild symptoms and a good response to treatment, CDI was associated with 2.24 more risks of graft loss.18 None of our patients lost his graft of CDI; however, 2 of them developed acute rejection. Although causality cannot be established, we suggest to rapidly perform an endoscopy in CDI with protein-losing enteropathy. It is conceivable that graft rejection could be triggered together with the immune response to the bacteria.
Guidelines for CDI after SOT were proposed in 2013.19 Metronidazole is recommended for mild-to-moderate cases of CDI and vancomycin in severe cases and relapse.9 This protocol was efficient in all our patients except one. Recurrence is a major concern, about 19% in SOT.17 In severe relapsing cases, faecal microbiota Tx has been performed and was reported as effective and safe even in immunocompromised patients.20 It has however not yet been performed after ITx. As the interaction of the transplanted intestine and microbiota is still largely unexplored, such a procedure should be discussed and performed with great care and control. New antibiotics such as fidaxomicin are also promising.21
In the only study in SOT recipients, where adults only and none after ITx were included, risk factors for CDI were older age (>55 y), liver Tx, and retransplantation.22 We did not find any additional independent risk factor. However, the incidence in our patients could mean that the risk is higher in young children.
The limitations of our study are its retrospective design, the relatively small numbers, and the absence of a control group. We had, however, homogeneous practices and a long follow-up, in a group of patients probably at high risk, due to the level of immunosuppression, type of organ, frequent antibiotic use, and maybe age.
In conclusion, CDI is frequent in children after ITx and follows most of the time a benign course. It seems to be a very rare trigger rejection. An early diagnosis is key to the prevention of progression toward invasive infection. The standard treatment is effective in most cases, although in some patients new antibiotics or fecal microbiome Tx could be discussed.
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