JAMA: Prevalence of Detection of CDI (C. difficile) Among Asymptomatic Children, A Systematic Review and Meta-analysis




Sarah R. Tougas, BScN, MD1Nidhi Lodha, MBBS, MSc1Ben Vandermeer, PhD2et alDiane L. Lorenzetti, PhD3Phillip I. Tarr, MD4,5Gillian A. M. Tarr, PhD6Linda Chui, PhD7Otto G. Vanderkooi, MD8,9Stephen B. Freedman, MDCM, MSc10,11

JAMA Pediatr. Published online August 2, 2021. doi:10.1001/jamapediatrics.2021.2328


Question  What is the prevalence of Clostridioides difficile detection among asymptomatic children across the age spectrum?

Findings  In this systemic review and meta-analysis of 95 studies with 19 186 participants, the prevalence of detection of toxigenic and nontoxigenic C difficile was greatest (41%) among infants aged 6 to 12 months and was lowest (12%) among children aged 5 to 18 years. The prevalence of toxigenic C difficile detection was greatest (14%) among infants aged 6 to 12 months.

Meaning  These findings suggest that test result interpretation should include consideration of the high likelihood of C difficile colonization in young children.


Importance  Detection of Clostridioides difficile has frequently been described in asymptomatic infants and children, but accurate estimates across the age spectrum are unavailable.

Objective  To assess the prevalence of C difficile detection among asymptomatic children across the age spectrum.

Data Sources  This systematic review and meta-analysis included a search of the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, Scopus, and Web of Science for articles published from January 1, 1990, to December 31, 2020. Search terms included Clostridium difficilePeptoclostridium difficileClostridioides difficileCDF OR CDI OR c diff OR c difficileClostridium infections OR cd positive diarrhea OR cd positive diarrhea OR Clostridium difficile OR Peptoclostridium difficile OR pseudomembranous colitis OR pseudomembranous enterocolitisenterocolitis, and pseudomembranous. These were combined with the following terms: bacterial colonization and colonization OR colonized OR colonizing OR epidemiology OR prevalence OR seroprevalence.

Study Selection  Studies were screened independently by 2 authors. Studies were included if they reported testing for C difficile among asymptomatic children (ie, children without diarrhea) younger than 18 years.

Data Extraction and Synthesis  Data were extracted independently and in duplicate by 2 reviewers. Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines were used. Data were pooled using a random-effects model.

Main Outcomes and Measures  The primary outcome was prevalence of C difficile detection among asymptomatic children. Secondary outcomes included prevalence of toxigenic vs nontoxigenic strains of C difficile and prevalence of C difficile detection stratified by geographic region, income status, testing method, and year of testing.

Results  A total of 95 studies with 19 186 participants were included. Rates of detection of toxigenic or nontoxigenic C difficile were greatest among infants aged 6 to 12 months (41%; 95% CI, 32%-50%) and decreased to 12% (95% CI, 7%-18%) among children aged 5 to 18 years. The prevalence of toxigenic C difficile colonization was lower, peaking at 14% (95% CI, 8%-21%) among infants aged 6 to 12 months and decreasing to 6% (95% CI, 2%-11%) among children older than 5 years. Although prevalence differed by geographic region (ie, North and South America vs Europe: β, −0.151, P = .001; North and South America vs Western Pacific: β, 0.136, P = .007), there was no difference by testing method (ie, culture vs polymerase chain reaction: β, 0.069, P = .052; culture vs enzyme immunoassay: β, −0.178, P = .051), income class (low-middle income vs high income: β, −0.144, P = .23; upper-middle vs high income: β, −0.020, P = .64), or 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, −0.006, P = .86).

Conclusions and Relevance  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. These estimates may provide context for interpreting C difficile test results among young children.

To review the article in its entirety please click on the following link to be redirected.  Thank you.