Introduction: Clostridium difficile (C. difficile) is the main cause of nosocomial and antibiotic-associated diarrhea in adults and represents a major public health issue. C. difficile infection in children, initially considered clinically unimportant, has recently been seen to have an increased incidence in hospitalized children. Both healthy children without significant risk factors and children with complex medical problems have been reported to suffer significant morbidity from C. difficile infections. We sought to characterize the patient population requiring surgical intervention for C. difficile infection at a tertiary care pediatric hospital.

Methods: Children (<18y) admitted to a single tertiary care pediatric hospital, between 1/1/2003 and 12/31/2008 were eligible for this study. Case status was determined by the presence of an International Classification of Diseases, Ninth Revision, Clinical Modification code for C. difficile infection (code 008.45). Only cases with billing for a C. difficile toxin assay and an initial dose of antimicrobial therapy were included. This project was reviewed and approved for exemption by the University of Pittsburgh Institutional Review Board.

Results: We identified 767 patients with C. difficile infection over a 5 year period out of 77,455 hospital admissions (0.99%). Of these, 7 patients (0.91%) required surgical therapy for management of their C. difficile colitis. The average age of these patients was 10.3 years (range 5 months to 16 years) with an average length of stay of 23 days. Two of these patients had undergone solid organ transplantation (1 liver and 1 isolated small bowel transplant). The only death was due to liver failure in the patient with a prior liver transplant. Four of the 7 patients received subtotal colectomies, 2 required ileocecectomies, and the small bowel transplant patient required a small bowel resection. Prior to undergoing subtotal colectomies, 2 of the patients developed abdominal compartment syndrome.

Conclusion: C. difficile infection is a recognized problem in the pediatric population; however, fulminant C. difficile colitis requiring surgical intervention appears to be rare. Specific risk factors are unclear, although solid organ transplant recipients due seem to be disproportionally represented. Unlike our observation in adult patients where the presence of hypervirulent strains did not correlate with severity (Muto et al. JID 2009 and Zuckerbraun unpublished observation), future studies would be required in the pediatric population. Diarrhea in pediatric patients should prompt evaluation for C. difficile and initiation of therapy as indicated.