Major articleInvestigation of a cluster of Clostridium difficile infections in a pediatric oncology setting

- Hospital-onset Clostridium difficile infections increased over 3 months.
- Risk factors for Clostridium difficile infection included recent cefepime use.
- Strain diversity suggests complex modes of acquisition and transmission.
- Strategies to reduce patient susceptibility in this population are needed.
- Rates returned to baseline with enhanced infection control measures.

BackgroundWe investigated an increase in Clostridium difficile infection (CDI) among pediatric oncology patients.MethodsCDI cases were defined as first C difficile positive stool tests between December 1, 2010, and September 6, 2012, in pediatric oncology patients receiving inpatient or outpatient care at a single hospital. A case-control study was performed to identify CDI risk factors, infection prevention and antimicrobial prescribing practices were assessed, and environmental sampling was conducted. Available isolates were strain-typed by pulsed-field gel electrophoresis.ResultsAn increase in hospital-onset CDI cases was observed from June-August 2012. Independent risk factors for CDI included hospitalization in the bone marrow transplant ward and exposure to computerized tomography scanning or cefepime in the prior 12 weeks. Cefepime use increased beginning in late 2011, reflecting a practice change for patients with neutropenic fever. There were 13 distinct strain types among 22 available isolates. Hospital-onset CDI rates decreased to near-baseline levels with enhanced infection prevention measures, including environmental cleaning and prolonged contact isolation.ConclusionC difficile strain diversity associated with a cluster of CDI among pediatric oncology patients suggests a need for greater understanding of modes and sources of transmission and strategies to reduce patient susceptibility to CDI. Further research is needed on the risk of CDI with cefepime and its use as primary empirical treatment for neutropenic fever.