Clostridioides difficile Infection in Hospitalized Pediatric Patients: Comparisons of Epidemiology, Testing, and Treatment from 2013 to 2019.

OBJECTIVES: To compare the incidence, epidemiology, testing patterns, treatment, and outcomes of Clostridioides difficile infection (CDI) among hospitalized pediatric patients from 2013 to 2019. STUDY DESIGN: The Pediatric Health Information System database was queried for patient admissions (age 0-17 years) with International Classification of Diseases, 9th and 10th edition, codes for diagnoses of CDI with a billing code for a CDI-related antibiotic treatment. RESULTS: We identified 17 142 pediatric patients, representing 23 052 admissions, with CDI. The adjusted annual CDI incidence decreased over the study period from 7.09 cases per 10 000 patient-days (95% CI, 6.15-8.18) in 2013 to 4.89 cases per 10 000 patient-days (95% CI, 4.03-5.93) in 2019 (P < .001). C difficile-specific testing also decreased during the study period (P < .001). Chronic gastrointestinal conditions (36%) and malignancy (32%) were the most common comorbidities in CDI encounters. Oral metronidazole use decreased during the study period (P < .01) and oral vancomycin use increased (P < .001). CONCLUSIONS: Our study demonstrates a decrease in CDI incidence in hospitalized pediatric patients, a notable change from prior studies, although this may have been influenced by altered testing patterns. We found a high incidence of CDI in patients with cancer and gastrointestinal conditions: groups that warrant targeted evaluation of CDI prevention and treatment.

Liver enzyme elevations within 3 months of diagnosis of inflammatory bowel disease and likelihood of liver disease.

BACKGROUND: Inflammatory bowel disease-associated liver diseases (IBD-LDs) include autoimmune hepatitis (AIH), primary sclerosing cholangitis (PSC), and an overlap syndrome. Prospective unbiased multicenter data regarding the frequency of IBD-LD in patients with pediatric inflammatory bowel disease (IBD) are lacking. We examined early alanine aminotransferase (ALT) and γ-glutamyl transpeptidase (GGT) elevations in children diagnosed as having IBD and assessed the likelihood of IBD-LD. METHODS: Data collected from the prospective observational Pediatric Inflammatory Bowel Disease Collaborative Research Group Registry enrolling children of age <16 years within 30 days of diagnosis. AIH, PSC, and overlap syndrome were diagnosed using local institutional criteria. RESULTS: A total of 1569 subjects had liver enzymes available. Of the total, 757 had both ALT and GGT, 800 had ALT only (no GGT), and 12 had GGT only (no ALT). Overall, 29 of 1569 patients (1.8%) had IBD-LD. IBD-LD was diagnosed in 1 of 661 (0.15%) of patients with both ALT and GGT ≤ 50 IU/L compared with 21 of 42 (50%) of patients with both ALT and GGT > 50 (odds ratio 660, P < 0.0001). Of the 29 patients with IBD-LD, 21 had PSC, 2 had AIH, and 6 had overlap syndrome. IBD-LD was more common in patients with ulcerative colitis and IBD-unclassified (indeterminate colitis) than in those with Crohn disease (4% vs 0.8%, respectively, P < 0.001). CONCLUSIONS: Elevation of both ALT and GGT within 90 days after the diagnosis of IBD is associated with a markedly increased likelihood of IBD-LD. Both ALT and GGT levels should be measured in all of the pediatric patients newly diagnosed as having IBD.

Malnutrition increases the risk of 30-day complications after surgery in pediatric patients with Crohn disease.

BACKGROUND: Pediatric patients with Crohn disease (CD) are frequently malnourished, yet how this affects surgical outcomes has not been evaluated. This study aims to determine the effects of malnourishment in children with CD on 30-day outcomes after surgery. STUDY DESIGN: The ACS NSQIP-Pediatric database from 2012 to 2015 was used to select children aged 5-18 with CD who underwent bowel surgery. BMI-for-age Z-scores were calculated based on CDC growth charts and 2015 guidelines of pediatric malnutrition were applied to categorize severity of malnutrition into none, mild, moderate, or severe. Malnutrition's effects on 30-day complications. Propensity weighted multivariable regression was used to determine the effect of malnutrition on complications were evaluated. RESULTS: 516 patients were included: 349 (67.6%) without malnutrition, 97 (18.8%) with mild, 49 (9.5%) with moderate, and 21 (4.1%) with severe malnutrition. There were no differences in demographics, ASA class, or elective/urgent case type. Overall complication rate was 13.6% with malnutrition correlating to higher rates: none 9.7%, mild 18.6%, moderate 20.4%, and severe 28.6% (p < 0.01). In propensity-matched, multivariable analysis, malnutrition corresponded with increased odds of complications in mild and severely malnourished patients (mild OR = 2.1 [p = 0.04], severe OR 3.26 [p = 0.03]). CONCLUSION: Worsening degrees of malnutrition directly correlate with increasing risk of 30-day complications in children with CD undergoing major bowel surgery. These findings support BMI for-age z scores as an important screening tool for preoperatively identifying pediatric CD patients at increased risk for postoperative complications. Moreover, these scores can guide nutritional optimization efforts prior to elective surgery. LEVEL OF EVIDENCE: IV.

Nonadherence with thiopurine immunomodulator and mesalamine medications in children with Crohn disease.

OBJECTIVES: To assess the prevalence of adherence to prescribed medications in children with Crohn disease and to identify possible factors associated with nonadherence. PATIENTS AND METHODS: This was a cross-sectional study of 51 pediatric patients with Crohn disease who were prescribed maintenance therapy with a thiopurine immunomodulator (6-mercaptopurine or azathioprine) and/or mesalamine during a 180-day period. Medication adherence rates were calculated from a validated formula using pharmacy records, and nonadherence was defined as a refill rate of <80% of the prescribed medication. Seventy-five percent of patients were prescribed thiopurine immunomodulators and 86% were prescribed mesalamine. RESULTS: The prevalence of nonadherence was 50% for the thiopurine immunomodulators and 66% for mesalamine. The mean number of emergency department visits for patients adherent to mesalamine was significantly greater than the nonadherent group (P < 0.0008). Having an emergency department visit increased the chances of a patient being adherent to mesalamine therapy by >9-fold (odds ratio, 9.6; 95% confidence interval, 1.87-52.17). The mean number of total health care visits was significantly greater for patients adherent to mesalamine (6.1 +/- 0.8) compared with those who were not adherent (3.0 +/- 0.4) (P < 0.001). CONCLUSIONS: These findings suggest that nonadherence to thiopurine immunomodulator or mesalamine therapy in pediatric patients with Crohn disease is common. Having a health care visit was associated with being adherent.