Epidemiology of Clostridium difficile Infection in a Pediatric Transplantation Center in Ukraine

Background

Patients undergoing hematopoietic stem cell transplantation (HSCT) are at high risk for Clostridium difficile infection (CDI) due to factors such as antibiotic exposure, prolonged hospitalization, conditioning mucosal damage and graft-versus-host disease. In low-middle and middle-income countries (LMIC’s) such as Ukraine, limited availability of CDI testing and variability in management approaches are barriers for understanding the burden of CDI and the outcomes. Here we describe the epidemiology of CDI at our institution, following the implementation of microbiology testing and standardized management guidelines.

Methods

This prospective single-center objective is to evaluate CDI epidemiology and outcomes after implementing a new diagnostic algorithm with management guidelines. The 2017 CDI SHEA/IDSA Guidelines were translated into Ukrainian. Afterward, a local standard operating procedure was developed to standardize diagnostic, treatment, and infection control practices. Suspected CDI cases were defined as a patient experiencing 3 unformed stools during a 24 hours period. if a diagnostic test was positive, these were considered proven CDI.

Proven CDI episodes were identified through a multistep diagnostic algorithm consisting of the use of an enzyme immunoassays for toxins A & B and glutamate dehydrogenase, for those tests with inconclusive results, a nucleic acid amplification testing (NAAT) were used. Treatment, and infection control measures were implemented following IDSA recommendations.

Results

Over 2 years (2022-2024) a total of 130 children-adolescents-young adults (CAYA) patients (0-25 years) underwent HSCT in our center. Of these 82 (63%) had suspected CDI, while 16 patients (19.5%) experienced at least one proven CDI episode. Three patients experienced CDI relapse within two months of resolution, while one recurrence occurred after two months. Only one patient with active CDI died due to relapsed thrombotic microangiopathy post-transplant. A total of 214 tests were performed during the study period, with 26 positive results; 18 tests required NAAT verification due to inconclusive results.

Conclusion

Our study is the first epidemiologic analysis of CDI in CAYA HSCT recipients in Ukraine. Compared to CDI events in high-income countries (HIC) with our center, CDI incidence in HIC ranges between 8% and 15%, but our center demonstrated a 19.5%, mostly due to prolonged antibiotic exposure. Despite the advances made with the introduction of routine CDI diagnostics and management, there remains a critical need for improved antimicrobial stewardship and infection prevention. Future efforts will focus on sustaining our center capacity using optimum CDI management; disseminating best care practices in CDI and reduce the burden of CDI in other transplant centers in Ukraine.