Vigilância hospitalar de Clostridioides difficile: avaliação de prevalência e fatores de riscos associados à infecção na pediatria

Abstract

The colonization of the human body by microorganisms begins at birth, and around two years of age, the child has a microbiota like that of an adult. This microbiota plays important roles such as amplifying the nutritional function of the intestine, protecting against pathogenic bacteria, and modulating the immune system. The imbalance of the microbiota compromises the physiological state of the intestinal epithelium. Some medications and clinical conditions can contribute to the imbalance of the normal microbiota, favoring infection by Clostridioides difficile (C.difficile). C. difficile disease manifests as diarrhea and is one of the main infections associated with healthcare. This work aimed to evaluate the prevalence of C. difficile in a pediatric hospital in Belo Horizonte and identify risk factors associated with the infection in children and adolescents. This is a case-control study, carried out by active surveillance of all patients between zero and 18 years old admitted to the Hospital Infantil João Paulo II - Fundação Hospitalar de Minas Gerais (FHEMIG), treated as a suspected case of Clostridioides difficile, during the period from July 2019 to July 2022. Two hundred fifty-one patients were included in the study, of which 62 (24.7%) had toxins A or B or GDH detectable in fecal samples. To evaluate the risk factors associated with infection, a comparative analysis was carried out between the case group, composed of children less than two years of age with detection of toxins A or B, and patients aged two years or older with a positive GDH test, or presence of toxins; with the control group, made up of patients with negative tests and who did not receive specific treatment for the infection. To evaluate the effect of risk factors on the treatment and outcome of patients with infection, the logistic regression model was used. To determine the Odds Ratio (OR), a 95% confidence interval was considered, with the value of p<0.05 as the threshold for statistical significance. During the study period, 14,091 patients were admitted to the hospital; thus, the prevalence of C. difficile detection was 0.4%, and the incidence density rate of the infection was 4.4 per 1,000 patient-days. The risk factors that were associated with the infection were hypoalbuminemia (p-value: 0.047), a previous inflammatory disease (p-value: 0.005), an altered radiological image (0.026), and hemodynamic instability (0.003) during colitis. The clinical outcomes were death (0.034), recurrence (<0.001), and persistence of diarrhea (0.001) were also associated with confirmed C.difficile infection. Having previously been medicated with quinolones was also a risk factor associated with having detectable toxins A or B (0.007) in fecal samples. In the univariate analysis, the presence of some clinical conditions during hospital admission was associated with a greater chance of patients receiving specific treatment for C.difficile infection. A previous hospitalization increased the chance of receiving treatment by 81% (OR=1.81 95% CI: 1.06-3.10). Using proton pump inhibitors increased the chance of receiving treatment by 81% (OR=1.81 95% CI: 1.06-3.10). Having an inflammatory disease increased the chance three times (OR=3.13 95% CI: 1.35-7.26). Having gastrointestinal tract surgery increased the chance by 91% (OR=1.91 95% CI: 1.05-3.48). If the child developed hemodynamic instability, the chance of receiving specific treatment for Clostridioides infection was five times greater (OR=4.86 95% CI: 2.06-11.46). Moreover, if there was metabolic acidosis, the chance was 2.4 times higher (OR=2.40 95% CI: 1.06-5.44). C.difficile infection increases the length of hospital stay and nutritional risks for patients with persistent and recurrent diarrhea, in addition to increasing the chance of toxic megacolon, intestinal perforation, and death associated with the infection. The diagnosis of this infection, therefore, impacts not only the clinical management of the patient himself but also the evaluation of the quality of the strategies adopted by the Hospital Infection Control Service and the adherence of the care team to adequate hand hygiene, cleaning and disinfection routines, environments, and equipment. The findings underscore the need for vigilant monitoring of this infection, particularly in patients with risk factors, and the adoption of more stringent prevention strategies to control Clostridioides infections within a hospital settings.