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Pediatric Clostridium difficile infection (CDI)-related hospitalizations are increasing. We sought to describe the epidemiology of pediatric CDI at a quaternary care hospital.Nested case-control study within a cohort of children <18 years tested for C. difficile between January and August 2008. The study included patients who were ≥1 year with a positive test and diarrhea; those without diarrhea (ie, presumed colonization) were excluded. Two unmatched controls per case were randomly selected from patients ≥1 year with a negative test. Potential predictors of CDI included age, gender, comorbidities, prior hospitalization, receipt of C. difficile-active antibiotics in the prior 24 hours, and recent (≤4 weeks) exposure to antibiotics or acid-blocking medications. Multivariate logistic regression models were created to identify independent predictors of CDI.Of 1891 tests performed, 263 (14%) were positive in 181 children. Ninety-five patients ≥1 year with CDI were compared with 238 controls. In multivariate analyses, predictors of CDI included solid organ transplant (odds ratio [OR], 8.09; 95% confidence interval [CI], 2.10–31.12), lack of prior hospitalization (OR, 8.43; 95% CI, 4.39–16.20), presence of gastrostomy or jejunostomy (G or J) tube (OR, 3.32; 95% CI 1.71–6.42), and receipt of fluoroquinolones (OR, 17.04; 95% CI, 5.86–49.54) or nonquinolone antibiotics (OR, 2.23; 95% CI, 1.18–4.20) in the past 4 weeks. Receipt of C. difficile-active antibiotics within 24 hours before testing was associated with a lower odds of CDI (OR, 0.22; 95% CI, 0.09–0.58).Recent antibiotic exposure and certain comorbid conditions (solid organ transplant, presence of a gastrostomy or jejunostomy tube) were associated with CDI. Diagnostic testing has less utility in patients being treated with C. difficile-active antibiotics.