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Spatial and Temporal Analysis of Clostridium difficile Infection in Patients at a Pediatric Hospital in California

  • Carmen E. Rexach (a1), Yajarayma J. Tang-Feldman (a2) and Stuart H. Cohen (a2)



To examine the usefulness of temporal and spatial analysis in identifying nosocomial transmission of Clostridium difficile among pediatric patients hospitalized on four wards at The Children's Hospital of Central California from September 8,1998, to January 16,1999.


Stool specimens obtained from the clinical microbiology laboratory during the study period were tested by culture and latex agglutination for C. difficile. Polymerase chain reaction was used to identify toxin genes. Isolates obtained were mapped to a grid for each ward and were analyzed using the Knox test. Results were compared with DNA fingerprints generated by arbitrarily primed polymerase chain reaction.


Total occupancy of these 4 wards was 438 during the study period. Stool specimens were available for 256 (58%) of these patients, yielding 67 C. difficile isolates and generating 2,211 case pairs for analysis by the Knox test. After stratification by toxin status, 5 clustered pairs of toxigenic isolates were identified on 1 of the wards by this method. Fingerprint analysis identified 4 clusters with indistinguishable banding patterns on 2 of the 4 wards. Two of the identified clusters were toxigenic and 2 were nontoxigenic. None of these clusters corresponded to clusters identified by the Knox test.


The Knox test is an ineffective method for identifying cases resulting from nosocomial transmission of C. difficile in a pediatric setting due to the persistence of C. difficile spores and the unique environment of a pediatric hospital. Molecular analysis remains the most effective method.


Corresponding author

University of California, Merced, Division of Natural Sciences, PO. Box 2039, Merced, CA 95344.,


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1.Schuller, I, Saha, V, Lin, L, et al.Investigation and management of Clostridium difficile colonisation in a paediatric oncology unit. Arch Dis Child 1995;72:219222.
2.Simor, AE, Yake, SL, Tsimidis, K. Infection due to Clostridium difficile among elderly residents of a long-term care facility. Clin Infect Dis 1993;17:672678.
3.Dodson, AP, Bordello, SP. Clostridium difficile infection of the gut. J Clin Pathol 1996;49:529532.
4.Rohner, P, Pittet, D, Pepey, B, et al.Etiological agents of infectious diarrhea: implications for requests for microbial culture. J Clin Microbiol 1997;35:14271432.
5.Brunetto, AL, Pearson, ADJ, Craft, AW, et al.Clostridium difficile in an oncology unit. Arch Dis Child 1988;63:980982.
6.McFarland, LV, Mulligan, ME, Kwok, RYY, et al.Nosocomial acquisition of Clostridium difficile infection. N Engl J Med 1989;320:204210.
7.Meropol, SB, Luberti, AA, De Jong, AR. Yield from stool testing of pediatric inpatients. Arch Pediatr Adolesc Med 1997;151:142145.
8.Tang, YJ, Houston, ST, Gumerlock, PH, et al.Comparison of arbitrarily primed PCR with restriction endonuclease and immunoblot analyses for typing Clostridium difficile isolates. J Clin Microbiol 1995;33:31693173.
9.Cohen, SH, Tang, YJ, Silva, J Jr.Analysis of the pathogenicity locus in Clostridium difficile strains. J Infect Dis 2000;181:659663.
10.Elting, LS, Rubenstein, EB, Rolston, KVI, et al.Outcomes of bacteremia inpatients with cancer and neutropenia: observations from two decades of epidemiological and clinical trials. Clin Infect Dis 1997;25:247259.
11.McFarland, LV, Brandmarker, SA, Guandalini, S. Pediatric Clostridium difficile: a phantom menace or clinical reality? J Pediatr Gastroenterol Nutr 2000;31:220223.
12.Knox, G. Epidemiology of childhood leukaemia in Northumberland and Durham. British Journal of Preventive and Social Medicine 1964; 18:1724.
13.Knox, G. The detection of space-time interactions. Applied Statistics 1964;13:2529.
14.Carpenter, TE, Bates, TW. Spatial Statistics, version 4.5. Sacramento, CA: University of California, Davis; 1999.


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