Gates Victoria, Best Emma, Roberts Sally, Swager Terri, Voss Lesley
Department of Paediatric Infectious Diseases, Starship Children's Health, Auckland, New Zealand.
Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.
J Paediatr Child Health. 2021 Apr;57(4):500-506. doi: 10.1111/jpc.15246. Epub 2020 Nov 3.
The optimisation of diagnosis and management of paediatric Clostridioides (formerly Clostridium) difficile (C. difficile) infection (CDI) has importance on multiple levels, from individual patient to population disease management and infection control. This study aimed to evaluate current practice at a paediatric tertiary hospital against Australasian Society for Infectious Diseases 2016 guidelines.
Prospective audit was undertaken. All positive C. difficile tests (by two step immunoassay then polymerase chain reaction) over 6 month period were reviewed for appropriateness of testing, including review of clinical characteristics and treatment of appropriately requested positive tests (CDI cases). Consecutive test requests for C. difficile over 2 month period were reviewed for appropriateness of testing.
Of 70 consecutive test requests, 64 met laboratory criteria for processing. Of these, 31 (48%) out of 64 were asymptomatic or had clinically insignificant or laxative-associated diarrhoea. Overall, 44 (63%) out of 70 were deemed inappropriate requests. Of 45 positive tests, 17 (38%) were appropriately requested. Amongst inappropriate requests, 13 (46%) out of 28 were treated; those aged >2 years were significantly more likely to be treated (P < 0.05). Thirteen children were treated unnecessarily. Only one out of seven positive tests in infants (<1 year) was appropriately requested. Haematology/oncology patients accounted for 41% of cases. Treatment was in accordance with guidelines in 58% of cases.
Inappropriate testing for C. difficile and variable clinical response to positive tests have sequelae including unnecessary antibiotics for hospitalised children. Areas for improvement have been identified and this study confirms the need for establishment of national paediatric CDI guidelines with increased awareness of these by clinicians.
优化儿童艰难梭菌（以前称为梭状芽孢杆菌）感染（CDI）的诊断和管理在多个层面都具有重要意义，从个体患者到群体疾病管理以及感染控制。本研究旨在对照澳大利亚传染病学会2016年指南评估一家儿科三级医院的当前实践。
进行前瞻性审计。对6个月期间所有艰难梭菌检测阳性（通过两步免疫测定然后聚合酶链反应）的病例进行检测适宜性审查，包括审查临床特征以及对适当送检的阳性检测结果（CDI病例）的治疗情况。对连续2个月期间艰难梭菌检测申请进行检测适宜性审查。
在70份连续的检测申请中，64份符合实验室处理标准。其中，64份中有31份（48%）无症状或有临床意义不显著或与泻药相关的腹泻。总体而言，70份中有44份（63%）被认为是不适当的申请。在45份阳性检测结果中，17份（38%）是适当送检的。在不适当的申请中，28份中有13份（46%）接受了治疗；2岁以上儿童接受治疗的可能性显著更高（P<0.05）。13名儿童接受了不必要的治疗。1岁以下婴儿的7份阳性检测结果中只有1份是适当送检的。血液学/肿瘤学患者占病例的41%。58%的病例治疗符合指南。
艰难梭菌的不适当检测以及对阳性检测结果的临床反应不一产生了一系列后果，包括住院儿童使用不必要的抗生素。已确定需要改进的领域，本研究证实有必要制定国家儿童CDI指南并提高临床医生对这些指南的认识。
