C Difficile Rates Decrease Throughout Childhood

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Infants between 6-12 months old had the highest prevalence of C difficile detection.

The prevalence of Clostridioides difficile infections (CDI) is greatest among young infants, but ultimately decreases as the child continues to age, according to new research.

A team, led by Sarah R. Tougas, BScN, MD, Cumming School of Medicine, Department of Pediatrics, University of Calgary, assessed the prevalence of CDI detection among asymptomatic children across different age groups.

C difficile infections have significantly increased in recent decades among the pediatric population. For example, the rate of C difficile infection detection increased from 2.6-32.6 cases per 100,000 individuals between 1991-2009 in Minnesota.

However, it remains a challenge to distinguish colonization from injection in this patient group because many children whose stool samples test positive for C difficile are colonized, but not truly infected.

Many clinicians believe C difficile infections are asymptomatic in the majority of infants and young children, but this theory has not been stratified by age in the past.

The Review

In the systematic review and meta-analysis, the researchers culled various databases for C difficile studies that reported C difficile testing among asymptomatic children between 1990-2020. The investigators identified 95 studies involving 19,186 patients that fit the inclusion criteria.

The data was extracted, screened, and duplicated independently by 2 reviewers, who used Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines and pooled the data using a random-effects model.

The investigators sought primary outcomes of the prevalence of C difficile detection among asymptomatic children. They also sought secondary outcomes of the prevalence of toxigenic and nontoxigenic strains of C difficile and the prevalence of C difficile detection stratified by geographic region, income status, testing method, and year of testing.

Rates of Detection

The rates of detection of toxigenic or nontoxigenic CDI was the largest among individuals between 6-12 months old (41%; 95% CI, 32-50%). The rates also decreased among children between 5-18 years old (12%; 95% CI, 7-18%).

Toxigenic colonization was lower among infants between 6-12 years old, peaking at 14% (95% CI, 8-21%) and decreased to 6% (95% CI, 2-11%) among individuals older than 5 years old.


There were some differences found based on geographic regions (North and South America vs Europe: β, −0.151, P = .001; North and South America vs Western Pacific: β, 0.136, P = .007).

However, there was no differences found based on testing method (culture vs polymerase chain reaction: β, 0.069, P = .052; culture vs enzyme immunoassay: β, −0.178, P = .051). This was also true for income class (low-middle income vs high income: β, −0.144, P = .23; upper-middle vs high income: β, −0.020, P = .64) and period (before 1990 vs 2010-2020: β, −0.125, P = .19; 1990-1999 vs 2010-2020: β, −0.037, P = .42; 2000-2009 vs 2010-2020: β, −0.006P = .86).

“In this systematic review and meta-analysis, C difficile colonization rates among children were greatest at 6 to 12 months of age and decreased thereafter,” the authors wrote. “These estimates may provide context for interpreting C difficile test results among young children.”

The study, “Prevalence of Detection of Clostridioides difficile Among Asymptomatic Children,” was published online in JAMA Pediatrics.