Clostridium difficile (peds)
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This page is for pediatric patients; for adult patients see clostridium difficile.
Background
- Clostridium is a genus of Gram-positive bacteria
- Most common cause of infectious diarrhea in hospitalized patients
- Use contact isolation if suspect
- Alcohol-based hand sanitizers do not reduce spores, but good hand washing does[1]
Pediatric Risk Factors
- Antibiotic exposure, particularly penicillins, cephalosporins, clindamycin, fluoroquinolones
- PPIs
- GI feeding tubes
- Comorbidities - cancer, recent surgery, hospitalizations
Clinical Features
Varies according to severity and intrinsic host factors (immunosuppression, etc.).
- Diarrhea that develops during antibiotic use or within 2 weeks of discontinuation
- Usually occurs after 7-10 days of antibiotics, as diarrhea before that time is more often poor tolerance to antibiotic
- Recent discharge from hospital
- Profuse watery diarrhea
- Abdominal pain/tenderness
- Fever
- At the extreme, may present with sepsis secondary to intestinal perforation or toxic megacolon
Differential Diagnosis
Acute diarrhea
Infectious
- Viral (e.g. rotavirus)
- Bacterial
- Campylobacter
- Shigella
- Salmonella (non-typhi)
- Escherichia coli
- E. coli 0157:H7
- Yersinia enterocolitica
- Vibrio cholerae
- Clostridium difficile
- Parasitic
- Toxin
Noninfectious
- GI Bleed
- Appendicitis
- Mesenteric Ischemia
- Diverticulitis
- Adrenal Crisis
- Thyroid Storm
- Toxicologic exposures
- Antibiotic or drug-associated
Watery Diarrhea
- Enterotoxigenic E. coli (most common cause of watery diarrhea)[2]
- Norovirus (often has prominent vomiting)
- Campylobacter
- Non-typhoidal Salmonella
- Enteroaggregative E. coli (EAEC)
- Enterotoxigenic Bacteroides fragilis
Traveler's Diarrhea
Evaluation
Labs
- C. diff toxin assay
- Sn 63-94%, Sp 75-100%
- Culture
- Positive culture only means C. diff present, not necessarily that it is causing disease
Testing Algorithm
For patients with suspected Clostridium difficile associated diarrhea (CDAD)
- Low suspicion
- Send stool for C. diff toxin assay
- Positive → treat (no further testing indicated)
- Negative → do not treat (no further testing indicated)
- Send stool for C. diff toxin assay
- High suspicion
- Send stool for C. diff toxin assay AND treat empirically
- Positive → treat (no further testing indicated)
- Negative → Consider discussion with ID (false negative tests may occur); eval for other causes of diarrhea
- Send stool for C. diff toxin assay AND treat empirically
Repeat testing
- Never a need for repeat testing within 7 days of a previous test
- NO NEED to repeat positive tests as symptoms resolve as a “test of cure”
- NO NEED to repeat test soon after initial negative test (more likely to be a false positive test than a true positive test)
Pediatrics
- Testing in infants < 1 year of age not recommended due to high rates of colonization
Management
- Stop offending antimicrobial agents, if possible
- Initial occurrence and first recurrence of mild-moderate disease:[5]
- PO metronidazole 30 mg/kg/d in four divided doses, max 2 g/day
- Severe infection or second recurrence:
- PO vancomycin 40 mg/kg/d in four divided doses, max 500 mg/day
- If no improvement after 24-48 hours, oral vancomycin max dose may be increased to 2 g/d
- Q6hr IV metronidazole, 30 mg/kg/d, may be added to intracolonic/enema vancomycin for ileus, inability to tolerate PO antibiotics
- 1-3 year old -- 250 mg vancomycin in 50 mL NS
- 4-9 year old -- 375 mg vancomycin in 75 mL NS
- > 9 year old -- 500 mg vancomycin in 100 mL NS
- Multiple recurrences, other strategies, in consult with pediatric GI:
- May benefit from tapering and pulse oral vancomycin over 1.5-2 months, as done in adults
- Consider PO fidaxomicin in ≥ 6 year old patients at 200 mg twice daily for 10 dats
Disposition
- Admit:
- Severe diarrhea
- Outpatient antibiotic failure
- Systemic response (fever, leukocytosis, severe abdominal pain)
Antibiotic Sensitivities[6]
See Also
References
- ↑ Leffler DA and Lamont JT. Clostridium difficile Infection. N Engl J Med. 2015; 372:1539-1548.
- ↑ Marx et al. “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”. Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.
- ↑ Asymptomatic colonization by Clostridium difficile in infants: implications for disease in later life. Jangi S, Lamont JT. J Pediatr Gastroenterol Nutr. 2010 Jul; 51(1):2-7.
- ↑ Clostridium difficile Infection in children. Sammons JS, Toltzis P, Zaoutis TE. JAMA Pediatr. 2013 Jun; 167(6):567-73.
- ↑ D'Ostroph AR and So TY. Treatment of pediatric Clostridium difficile infection: a review on treatment efficacy and economic value. Infect Drug Resist. 2017; 10: 365–375.
- ↑ Sanford Guide to Antimicrobial Therapy 2014