Prospective Study of Clostridium Difficile in Children Undergoing Colonoscopy
Prospective Study of Clostridium Difficile in Children Undergoing Colonoscopy
The investigators found that community acquired C. diff occurs in children undergoing a
 colonoscopy. When they were treated their symptoms got better. But, the investigators do not
 know if the treatment for the C. diff made them better or another other factor made them feel
 better. So, the investigators designed the following study. Children undergoing a colonoscopy
 who are found to be C. diff positive at the time of the colonoscopy are randomized to one
 group that gets immediate treatment or a second group that gets delayed treatment. Both
 groups are closely monitored for symptoms.
Clostridium difficile (CD) is a gram positive, spore forming anaerobic bacillus that is not a
 normal commensal of the gastrointestinal tract. It was initially named "difficult
 clostridium" because it was difficult to isolate and grow on culture media. CD can exist in
 spore and vegetative forms. Outside the colon, it survives in a spore form that is resistant
 to heat, acid and antibiotics. In the colon, CD is found in the vegetative, toxin-producing
 form and is susceptible to antibiotics. CD is widely distributed and infection is acquired
 through the fecal-oral route from person to person contact, although the organism can be
 cultured from toilets, bedpans, floors, telephones, shoes of hospital personnel and other
 items. CD is most often identified as a disease acquired from medical facilities, but
 community-acquired CD (CACD) is also described. CD infection is positively associated with
 the use of antibiotics and gastric acid suppressing agents. CD infection is described in
 patients who have inflammatory bowel disease and is significantly associated with their need
 for hospitalization. Those who are hospitalized for inflammatory bowel disease and CD have
 higher mortality and longer hospital stays than patients with inflammatory bowel disease but
 no CD infection.

 CD is a serious problem among adults. Less is known about CD in children. Although CD was
 first identified in newborns, it is not considered a pathogen in children less than one year
 of age. In older children CD causes a spectrum of disease similar to that seen in adults but
 at a lower rate and with less severity. The epidemiology of CD in children has not been
 studied extensively or in a systematic manner. However, intestinal colonization occurs in 5%
 of all children older than 2 years of age. Recently, the investigators found colonic
 aspirates positive for CD toxin from children at the time of their colonoscopies and in whom
 CD was not suspected.

 Our retrospective chart review of children undergoing colonoscopy from 9/1/2006 through
 8/30/2008 identified 41 (17%) CD positive colonic aspirates. There was no difference between
 CD positive and negative patients except abdominal pain and weight loss together occurred
 significantly more often in the CD positive group. Significantly more CD positive patients (p
 = 0.01) used an H2RA within one month of colonoscopy. Too few patient charts contained
 information on antibiotic use to determine if a relationship existed with CD. Of the CD
 positive patients 5 were lost to follow up, 36 were treated and all except 1 patient had
 resolution of symptoms. The investigators concluded that CD infection, likely acquired in the
 community, is common in children undergoing a colonoscopy and symptoms cannot be used to
 discriminate which children will be positive for CD.

 The investigators also cultured patient care sites at Women and Children's Hospital and found
 no CD contamination of colonoscopes, medical areas, or supplies was identified. Colonic
 aspirates were obtained from 73% of colonoscopies.

 This retrospective chart review had several weaknesses. The most important weakness is that
 the study design did not allow us to discriminate between intestinal colonization that occurs
 in 5% of all children (15) older than 2 years of age or infection. The study did not permit
 an assessment of whether treatment had a significant effect on the symptoms for which the
 children presented because there was no control group. The investigators address these
 weaknesses in this prospective study.

 d. Experimental or Study Design: i. Brief: Double blind crossover study with a control arm.
 ii. Detailed: Patients undergoing colonoscopy will be screened at time of initial recruitment
 for exclusion criteria. At time of endoscopy a stool aspirate culture (routine) will be
 collected. At time of endoscopy patients will be subjected to a second round of exclusion
 criteria based on visual findings. Patients with CD (+) stool by aspirate will be randomized
 into one of two treatment arms (early, delay). In addition, a third arm of CD (-) age match
 controls will also be followed.

 e. Sample Size i. A power calculation performed by Chang-Xing Ma PhD. based on an improvement
 in symptoms of 1 point between groups on pain scale was performed. Recruiting 25 patients to
 each sample group and assuming a 30% drop out rate, final group sample sizes of 17 and 17
 achieve 80.7% power to detect a difference of 1.0 between two group means with estimated
 group standard deviations of 1.0 and 1.0 and with a significance level (alpha) of 0.05000
 using a two-sided two-sample t-test.

 ii. Based on the data from the retrospective review the investigators know that there is a
 large amount of variability in this population and expect 1-2 patients enrolled per month.

 f. Variables of Interest i. Subjective: nausea, bloating, ii. Objective: pain, stool
 frequency, stool consistency, vomiting, weight loss, antibiotic use, use of acid suppression
 iii. Biochemical: stool glutamate dehydrogenase, lactoferrin, CD culture, CD toxin

 g. Completion i. Recruitment period: 18 months ii. Completion of therapy after recruitment: 1
 month iii. Data analysis: 1 month iv. Total anticipated duration: 2 years

 B. Characteristics of the Research Population

 1. Gender: male/female

 2. Age: age greater than 7 less than 21

 3. Racial and Ethnic Origen: Any

 4. Inclusion Criteria:

 i. Any gender ii. Any race iii. Age between 7-21 iv. Greater then 21 kg v. Able to swallow
 pills e. Exclusion Criteria (at time of screening): i. marked abdominal tenderness and
 distention with minimal diarrhea ii. history of inflammatory bowel disease iii. fever iv.
 systemic toxicity v. allergy to metronidazole vi. short bowel syndrome vii. history of bowel
 resection viii. history of abdominal surgery (excluding appendectomy or cholecystectomy) ix.
 history of hirschsprungs disease x. active pregnancy xi. inability to participate in phone
 surveys xii. inability to maintain scheduled clinic follow up xiii. bloody stools at time of
 screening f. Exclusion Criteria (at time of colonoscopy) i. Visual evidence of
 pseudomembranes ii. Visible ulcerations iii. Mucosal friability iv. Mayo score greater than 4
 v. Fissures/fistulas

 g. Vulnerable Subjects- The impact of chronic abdominal pain is noted to have a high
 prevalence, strong health care use, and considerable restrictions in the daily life of
 children and Adolescents (16, 17). As a result of this disease burden it is prudent to study
 this vulnerable population to determine if a biological trigger is present, and if present
 how can this trigger be monitored and treated. To protect this population in this
 investigation all patients participating under the age of 18 will be required to have both a
 parental consent and a participant assent. Patients older than 18 years of age will be
 required to have a documented consent. Participation in the project is voluntary and
 permission to participate may be withdrawn at any time without risk of changing accepted
 standard of care. All tests and procedures are non-invasive, and monetary reward for
 completion of study is sufficient to compensate for time and travel costs so not to incur a
 financial burden on the family, in addition the monies is not so great as to encourage
 participation for the sake of monetary gain.

 C. Methods and Procedures

 a. Recruitment and enrollment methods i. Patients will be recruited from the Department of
 Pediatrics, Digestive Disease and Nutrition Center. The patient population of interest does
 not necessitate recruitment of patients outside of the normal scope of practice ii.
 Enrollment will be voluntary. Eligible patients will be screened at time of clinic visit and
 offered the potential opportunity to participate in the study pending the results of routine
 screening.

 iii. Patients who fulfill inclusion/exclusion criteria at the end of initial screening and
 have self identified themselves as interested in participation will be given the opportunity
 to participate in the study.

 b. Privacy Protection i. See Section C part e and f.

 c. Research Setting i. Women and Children's Hospital of Buffalo and allied clinics

 d. Summary of Research Design i. See Section A part d.

 e. Randomization i. Group assignment will be assigned at time of colonoscopy ii. Group
 assignment will be in place for those patients assigned to a therapeutic intervention iii.
 Random group assignment list by patient enrollment number was generated by Chang-Xang Ma, PhD

 f. HIPAA i. The patients "Informed Consent Form" (please see section 6 of application) will
 be accompanied by a separate document incorporating Health Insurance Portability and
 Accountability Act (HIPAA) compliant wording by which patients/parents/legal guardian
 authorize the use and disclosure of their Protected Health information by the investigator
 and by those persons who need that information for the purposes of the study.

 The Written Informed Consent will explain that for data verification purposes, study
 personnel, a regulatory authority, or an IRB may require direct access to parts of the
 hospital or practice records relevant to the study, including patients' medical history.

 g. Data Storage and Confidentiality i. All study data will be securely housed at the
 Digestive Disease and Nutrition Center located at 219 Bryant Street ii. All electronic data
 is securely housed in Cerner Powerchart monitored by Kaleida Health

 h. Payments/compensation i. Patients will be compensated $60.00 at the completion of the
 study

 i. Data Analysis Plan i. Statistical analysis will be performed by a professional
 statistician, Chang-Xang Ma, PhD, at the University at Buffalo, Buffalo, NY. Comparisons
 treatment 1 and treatment 2 groups will be performed by SAS statistical software using chi
 square, Fisher's exact tests, t-test and multivariate analysis as indicated.

 D. Risks and Potential Benefits of Participation in the Research a. Subject Risk i. The risk
 to subjects for the initial colonoscopy is no greater than the standard risk. The potential
 risk attributable to home stool collection includes contamination of food, and spread of
 fecal oral organisms if appropriate hand washing is not performed.

 b. Subject potential benefit i. The potential benefit to patients is resolution of abdominal
 pain symptoms

 E. Informed Consent Process (Consent/Permission/Assent)

 a. The principal investigator will ensure that the patient's parent/guardian is given full
 and adequate oral and written information about the nature, purpose, possible risk and
 benefit of the study. As all patients will be greater than assent age, assent will be
 obtained for all children enrolled in the study. Patients and the patient's parent/guardian
 will be given the opportunity to ask questions and allowed time to consider the information
 provided.

 The patient/guardian's signed and dated informed consent as well as the patient's assent will
 be obtained before conducting any procedure or test specifically for the study.
Inclusion Criteria:

 -  Aspirate at colonoscopy positive for C. diff.

 -  Any gender

 -  Any race

 -  Age between 7-21

 -  Greater than 21 kg

 -  Able to swallow pills

 Exclusion Criteria:

 -  Abdominal tenderness and distention with minimal diarrhea

 -  History of inflammatory bowel disease

 -  Fever

 -  Systemic toxicity or allergy to metronidazole

 -  Short bowel syndrome

 -  History of bowel resection vii

 -  History of abdominal surgery (excluding appendectomy or cholecystectomy)

 -  History of hirschsprungs disease x

 -  Pregnant

 -  Inability to participate in phone surveys

 -  Inability to maintain scheduled clinic follow up

 At time of Colonoscopy:

 -  Visual evidence of pseudomembranes

 -  Visible ulcerations

 -  Mucosal friability iv.

 -  Fissures/fistulas