CDI can hit children without prior antibiotic exposure

Clostridioides difficile infection (CDI) is possible in children with no previous exposure to antibiotics, especially in community settings, suggests a Japan study, supporting the consideration of changes to current management practices for paediatric CDI.

“[T]his first-of-its-kind large-scale, nationwide study characterized the distinct epidemiology of paediatric CDI in Japan, revealing comparable incidence rates across all paediatric age groups, including infants younger than 2 years, in contrast to previous assumptions,” the investigators said. 

They also found “unique risk factor profiles in children that differ from those in adults and vary by age and onset setting, as well as a reduced role of prior antibiotics in community-onset CDI.”

A total of 4,090 CDI cases were identified in this study, of which 248 were paediatric. The incidence of CDI was similar between children aged 0‒2 years and older ones, contesting current assumptions. [Pediatr Infec Dis J 2026;doi;45:126-131]

A previous study in Japan also reported the highest number of CDI cases in children 0‒2 years of age, using criteria that included confirmed toxin positivity and the exclusion of asymptomatic carriers. [Pediatr Gastroenterol Hepatol Nutr 2022;25:387-395]

“Our findings reinforce the validity of these earlier results and highlight a gap in our understanding of CDI burden in infants,” the investigators said. 

“This is particularly important because CDI in this age group has traditionally been considered rare, due to factors such as immature toxin receptors and high rates of asymptomatic C. difficile colonization,” they added. [https://www.cdc.gov/nhsn/pdfs/pscmanual/12pscmdro_cdadcurrent.pdf] 

Current guidelines do not recommend routine testing and treatment for CDI in children aged <2 years unless other causes of diarrhoea have been ruled out.

“However, our case definition, which required both diagnostic testing and anti-CDI medication claims, suggests that clinicians in real-world Japanese practice are identifying and treating a meaningful number of cases in this age group, despite guideline recommendations,” the investigators said.

Risk factor

Variations in risk factor profiles were also noted, particularly by age group and setting. One of the most pronounced risk factors in children was inflammatory bowel disease (IBD; 28.9 percent vs 14.8 percent in adults), particularly in adolescents (43.5 percent). Notably, nearly half of community-onset CDI cases in children had no previous antibiotic exposure.

Antibiotic exposure remained the most prominent risk factor for adult CDI, supporting previous findings, but it was less frequently seen in children. [BMJ Open 2014;4:e005665; Antimicrob Agents Chemother 2020;64:e02169-e02119]

“Instead, conditions such as IBD and tube feeding were more prevalent in children, in line with known paediatric comorbidity patterns,” the investigators said. [JAMA Pediatr 2013;167:567-573; World J Pediatr 2022;18:27-36; J Hosp Infect 2022;130:112-121]

Specifically, tube feeding was most prevalent in children aged 3‒5 years, while IBD was most common in adolescents aged 13‒17 years.

“[O]ur results suggest that clinicians should consider CDI in the differential diagnosis of diarrhoea even in children without recent antibiotic exposure,” the investigators said. “Future prospective studies are warranted to validate these findings and inform evidence-based revisions to management strategies for paediatric CDI.”

The current retrospective study utilized the claims database of the Japan Medical Data Center from 2013 to 2022. CDI cases were characterized by the presence of both diagnostic testing and anti-CDI treatment within 7 days. Episodes that relapsed within 8 weeks were not included in the analysis.

Finally, the investigators classified CDI onset setting according to the CDC/NHSN criteria and assessed risk factors by age and onset setting.