Skip to main content


Log in

Clostridium Difficile, Colitis, and Colonoscopy: Pediatric Perspective

  • Pediatric Gastroenterology (S Orenstein, Section Editor)
  • Published:
Current Gastroenterology Reports Aims and scope Submit manuscript


Purpose of the Review

Review tests available for detection of Clostridium difficile (C. Diff) induced disease, including when such tests should be done in children and how they should be interpreted.

Recent Findings

Multiple tests are available for detecting disease due to C. diff. These include colonoscopy and stool analysis. Colonoscopy with biopsy is the most sensitive test for detecting the presence of colitis. The toxins produced by the C. diff. (toxin A, toxin B, and binary toxin) are the agents that cause injury and disease. Only toxin producing C. diff. Strains will cause disease. Binary toxin by itself is not thought to produce disease. Binary toxin causes disease in humans when present with toxin A and B producing bacteria, and has been implicated with fulminant life threatening disease. Stool analyses vary in sensitivity and specificity depending on the assay used. The presence of toxin producing strains of C diff. in the stool does not equate with disease. The presence of a toxin-producing bacteria or toxins (A or B) only equates with disease if diarrhea or a diseased colon (toxic megacolon, ileus, and sepsis) is present. Nucleic acid amplification testing (NAAT), when used in the stool from patients with diarrhea, appears to be the most efficient study to detect the gene that encodes for toxin A and B and thus to diagnose C. diff.-induced disease. Infants have a high carriage rate of C. diff. and are believed not to develop disease from it or its toxins. Infants should not be tested for C. difficile. The NAAT is most specific when done on patients with diarrhea with liquid stools.


Testing for C. difficile should only be done on patients with diarrhea. One can assume that a patient who has no diarrhea and is not ill does not have C. diff.-induced disease. Treatment should be limited to patients with diarrhea who test positive for C. diff. toxin (A or B) or toxin-producing bacteria. Direct testing for binary toxin is not commercially available. Binary toxin is only thought to cause disease in humans when C. diff. toxin (A and B)-producing bacteria are present.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others


Papers of particular interest, published recently, have been highlighted as: • of importance •• of major importance

  1. Spiro H. Antibiotic-associated colitis and enteritis. In: Spiro H, editor. Clinical Gastroenterology. New York: Macmillan Publishing Co, Inc; 1983. p. 569–70.

    Google Scholar 

  2. Gryboski J, Walker WA. “Diarrhea: Acute and Chronic”. In Gastrointestinal Problems in the Infant, Second Edition. Philadelphia: W.B. Saunders Company; 1983. pp. 558–559.

  3. •• Burnham CA, Caroll KC. Diagnosis of Clostridium dificile infection: an ongoing conundrum for clinicians and for clinical laboratories. Clin Microbiol Rev. 2013;26(3):604–30. Excellent review of C. diff, its biology, testing, and disease in humans.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Hall IC, O’Tooke E. Intestinal flora in newborn infants: with a description of a new pathogenic anaerobe, Bacillus dificilis. Am J Dis Child. 1935;49:390–402.

    Article  Google Scholar 

  5. Larson HE, Parry JV, Price AB, et al. Undescribed toxin in pseudomembranous colitis. Br Med J. 1977;1:1246–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Bartlett JG, Onderdonk AB, Cisneros RL, et al. Clincamycin associated colitis due to a toxin-producing species of Clostridium in hamsters. J Infect Dis. 1977;136:701–5.

    Article  CAS  PubMed  Google Scholar 

  7. Bartlett JG, Chang TW, Gurwith M, et al. Antibiotic associated pseudomembranous colitis due to toxin-producing clostridia. NEJM. 1978;298:531–4.

    Article  CAS  PubMed  Google Scholar 

  8. • Lee I, Mu Y, Cohen J, et al. NAP1 strain type predicts outcome from Clostridium Difficile infections. Clin Infect Dis. 2014;58(10):1394–400. Sobering report of NAP1’s association with severe disease.

    Article  Google Scholar 

  9. • Lessa FC, Mu Y, Bamberg WM, et al. Burden of Clostridium difficile infection in the United States. N Engl J Med. 2015;372:825–34. Excellent study looking at the burden of C. diff. disease in 2011

    Article  CAS  PubMed  Google Scholar 

  10. • McFarland LV, Ozen M, Dinleyici EC, Goh S. Comparison of pediatric and adult antibiotic-associated diarrhea and Clostridium difficile infections. World J Gastroenterol. 2016;22(11):3078–104. Excellent review of pediatric vs. adult C. diff. induced disease

    Article  PubMed  PubMed Central  Google Scholar 

  11. Bartlett JG, Gerding DN. Clinical recognition and diagnosis of Clostridium dificile infection. Clin Infect Dis. 2008;46(Suppl 1):S12–8.

    Article  PubMed  Google Scholar 

  12. Stuart HC, Dale NG, Stuart J. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31(5):431–55.

    Article  Google Scholar 

  13. Bomers MK, van Agtmael MA, Luik H, et al. Using a dog’s superior olfactory sensitivity to identify Clostridium Difficile in stools and patients: proof of principle study. BMJ. 2010;345:e7396. doi:10.1136/bmj.e7396.

    Article  Google Scholar 

  14. Gonzalez del Vecchio M, Alvarez Uria A, Marin M, et al. Clinical significance of Clostridium dificille in children less than 2 years old: a case-control study. Pediatr Infect Dis J. 2016;35(3):281–5.

    Article  PubMed  Google Scholar 

  15. Adler SP, Chandrike T, Berman WF. Clostridium difficile associated with pseudomembranous colitis. Occurrence in a 12 week old infant without prior antibiotic therapy. Am J Dis Child. 1981;135:820.

    Article  CAS  PubMed  Google Scholar 

  16. Kastl A, McConnie R. Clostridium difficile under the microscope: rates of C. Diff toxin detection and clinically significant colitis found at the time of colonoscopy. JPGN. 2015;61(Supplement 2):S154.

    Google Scholar 

  17. Dallas SD, Rolfe RD. Binding of Clostridium difficile toxin: a human milk secretory component. J Med Microbiol. 1998;47(10):879–88.

    Article  CAS  PubMed  Google Scholar 

  18. Rolfe RD, Song W. Immunoglobulin and non-immunoglobulin components of human milk inhibit Clostridium difficile toxin A-receptor binding. J Med Microbiol. 1995;42(1):10–9.

    Article  CAS  PubMed  Google Scholar 

  19. Rousseau C, Poilane I, De Pontual L, et al. Clostridium difficile carriage in healthy infants in the community: a potential reservoir for pathogenic strains. Clin Infect Dis. 2012;55:1209–15.

    Article  PubMed  Google Scholar 

  20. Eglow R, Pohtoulakis C, Itzkowitz S, et al. Diminished Clostridium difficile toxin a sensitivity in newborn rabbit ileum is associated with decreased toxin a receptor. J Clin Invest. 1992;90(3):822–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Schute GE, Willoughby RE. Clostridium difficile infection in infants and children. Pediatrics. 2013;131:196–200.

    Article  Google Scholar 

  22. Ananthakrishnan A. Detetcing and treating Clostridium difficile infections in patients with inflammatory bowel disease. Gastroenterol Clin N Am. 2012;41:339–53.

    Article  Google Scholar 

  23. Issa M, Vijayapal A, Graham MB, et al. Impact of Clostridium difficile infection in inflammatory bowel disease. Clin Gastroenterol Hepatol. 2007;5:345–51.

    Article  PubMed  Google Scholar 

  24. Turco R, Martinelli M, Miele E, et al. Proton pump inhibitors as a risk factor for paediatric Clostridium difficile infection. Aliment Pharmacol Ther. 2010;31(7):754.

    Article  CAS  PubMed  Google Scholar 

  25. Janarthanan S, Ditah I, Adler DG, Ehrinpreis MN. Clostridium difficile-associated diarrhea and proton pump inhibitor therapy: a meta-analysis. Am J Gastroenterol. 2012;107(7):1001.

    Article  CAS  PubMed  Google Scholar 

  26. Freedberg DE, Lamousé-Smith ES, Lightdale JR, et al. Use of acid suppression medication is associated with risk for C. difficile infection in infants and children: a population-based study. Clin Infect Dis. 2015;61(6):912.

    Article  PubMed  PubMed Central  Google Scholar 

  27. • American Academy of Pediatrics, Committee on Infectious Diseases. Clostridium Dificile. In: Kimberlin DW, Brady MR, Jackson MA, Long SS, editors. Red book: 2015 report of the Committee on Infectious Diseases, 30 th. Elk Grove Village: American Academy of Peidatrics. p. 298–301. Presents guidelines regarding treatment in children.

  28. Thomas DW, Greer FR. American Academy of Pediatrics, Committee on nutrition. Probiotics and prebiotics in pediatrics. Pediatrics. 2010;126(6):1217–31.

    Article  PubMed  Google Scholar 

  29. Wilcox MH, Gerding DN, Poxton IR, et. al. Bezlotoxumab for prevention of recurrent Clostridium difficile infection. N Engl J Med. 2017;376:305–17.

  30. Bartlett JG. Bezlotoxumab. A new agent for Clostridium difficile infection. N Engl J Med. 2017;376:381–2.

  31. Koo HL, Van JN, Zhao M, et al. Real–time Plymearase chain reaction detection of asymptomatic Clostricium dificille colonization and rising C. Dificille-associated disease rates. Infect Control Hosp Epidemiol. 2014;36(6):667–73.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Randolph McConnie.

Ethics declarations

Conflict of Interest

Randolph McConnie and Arthur Kastl declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Pediatric Gastroenterology

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

McConnie, R., Kastl, A. Clostridium Difficile, Colitis, and Colonoscopy: Pediatric Perspective. Curr Gastroenterol Rep 19, 34 (2017).

Download citation

  • Published:

  • DOI: