Clostridioides difficile infection
Clostridioides difficile is commonly found in the intestine in children under 2 years old. Even infants carrying toxin-producing strains may have asymptomatic colonisation which does NOT require treatment.
Risk factors for infection may include: immunocompromise (e.g. haematological malignancy), inflammatory bowel disease, PPI use, recent antibiotic treatment.
Clostridioides difficile infection (CDI) is defined as
- 3 or more episodes of loose stool within 24hrs i.e. Bristol stool chart types 5-7
- Diarrhoea that is not attributable to any other cause or therapy, including medicines
- The presence of a positive toxin assay and/or endoscopic evidence of pseudo-membranous colitis.
When to test
- Testing for CDI should not be routinely recommended for infants under 2 years of age with diarrhoea.
- In children 2 years and over, only consider testing patients with prolonged or worsening diarrhoea, when other infectious/non-infectious causes have been excluded and the child has risk factors listed above
Assess severity of CDI
There is no validated tool for scoring severity of CDI in children. Signs of severe disease in adults include:
- Acute abdomen: Ileus, peritonitis, perforation
- Temperature over 38.5°C
- White Cell Count (WCC) of 15 x109/L or greater
- Acutely rising serum creatinine (more than 50% increase above baseline)
- Imaging: megacolon, colonic wall thickening, pericolonic fat stranding
Complications of severe CDI
- Toxic megacolon
- Colitis: Colonic mucosal oedema, no dilatation
- Colonic perforation: with peritonitis
Management
STOP all other antibiotics if possible and review need for PPI (if taking)
See Clostridioides difficile for IPC advice.
Empirical treatment of suspected or confirmed CDI: mild to moderate disease
- Supportive measures: resuscitate patient with IV fluids and correct electrolytes if required
- Treat for 10 days with metronidazole po (dosing table below)
|
Age |
metronidazole oral dose |
|
2 –11 years |
7.5 mg/kg (max 400 mg) TDS |
|
12–17 years |
400 mg TDS |
N.B. Do not use metronidazole liquid: Crush the tablets, mix with 5ml of water and draw up the required dose.
Empirical treatment of suspected or confirmed CDI: severe disease
- Supportive measures: resuscitate patient with IV fluids and correct electrolytes
- Abdominal imaging
- Consider discussing with paediatric gastroenterology +/- paediatric surgery
- Treat for 10 days with vancomycin po (dosing table below)
- metronidazole iv to be added if unable to take PO Vancomycin reliably or not responding to PO treatment (dosing table below)
vancomycin po dosing table:
|
Age |
vancomycin oral dose |
|
2-11 years |
10mg/kg QDS (Max 2g per day) |
|
12-17 years |
500mg QDS |
Speak to pharmacy if the patient has an enteral feeding tube or swallowing difficulties to access vancomycin oral liquid.
metronidazole iv dosing table:
|
Age |
metronidazole iv dose |
|
2 –17 years |
7.5 mg/kg (Max 500 mg) TDS |
Clinical concerns, relapse or suspected case in child under 2 years
Discuss with Paediatric ID team