Diagnosis and management of paediatric Clostridioides difficile infection in a tertiary centre: A prospective audit.

AIM: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Review of available infertility treatments.

Treatments for infertility vary in their intensity, invasiveness and associated risks. Treatment can range from medication to induce ovulation to invasive manipulation of eggs and sperm outside of the body. The type of treatment utilized is dependent upon the cause, degree and duration of infertility; the patient's age; the tolerance of side effects; the history of responsiveness and side effects in previous treatments; and the specific treatment preferences of the associated physician and facility. Infertility medications are specifically used for ovulation induction or for controlled ovarian hyperstimulation. In ovulation induction, the goal is to stimulate growth, maturation and ovulation of a single follicle. The single follicle is then fertilized secondary to timed intercourse or artificial insemination, where semen is injected directly into the uterus. Artificial insemination or intrauterine insemination can also be used with either natural or drug-induced ovulation. In controlled ovarian hyperstimulation (COH), multiple follicles are stimulated to grow and mature with medications. COH is necessary for assisted reproductive techniques (ART). The most commonly utilized type of ART is in vitro fertilization. ART are much more complex and invasive than ovulation induction in that they involve techniques to manipulate and fertilize the egg outside of the body. The goal of ART is to cause recruitment and maturation of multiple follicles. After a sufficient number of follicles have grown and matured, they are retrieved and transferred to an incubator for fertilization. The resulting embryos are returned to the uterus for implantation or cryopreserved. Both ovulation induction and ART require medications for the recruitment, development and maturation of eggs. Both techniques utilize similar medications; however, the doses of medication and the specific protocols for their use are varied. This review will discuss the range of available infertility treatments from medications alone to medications in combination with invasive medical procedures. The mechanism of action, side effects, use and effectiveness of the different classes of medications will be discussed. Because there are multiple medications in specific classes, comparisons of their protocols for use, effectiveness and side effect profiles will be detailed. Lastly, new variations of traditional assisted reproductive techniques will be presented.