| Condition | Major Pathogens | First-choice Therapy | Alternative Therapy | Comments |
|---|---|---|---|---|
|
Clostridioides difficile infection - initial episode, non-severe Non-severe disease defined by lack of the following: WBC ≥ 15,000 cells/mL Creatinine > 1.5x pre-disease baseline Hypotension or shock, ileus, or megacolon |
Clostridioides difficile |
Metronidazole OR Vancomycin Note: IV Metronidazole is suboptimal for C. difficile treatment compared to enteral metronidazole If failure to respond to Metronidazole in 5-7 days, switch to above Vancomycin regimen |
Discontinue inciting antimicrobials as soon as possible Avoid re-testing unless symptoms of C. difficile infection recur Oral vancomycin is usually preferred in pediatric oncology patients or stem cell transplant recipients Duration: 10 days |
|
|
Clostridioides difficile infection - initial episode, severe or fulminant Severe disease defined by: WBC ≥ 15,000 cells/mL OR Creatinine > 1.5x pre-disease baseline Fulminant disease defined by: Hypotension or shock, ileus or megacolon |
Same |
Vancomycin ADD Metronidazole |
Alternative administration for Vancomycin, consider when ileus is present: Vancomycin rectal enema |
Consider ID consult, particularly if not improving with initial therapy Discontinue inciting antimicrobials as soon as possible Avoid re-testing unless symptoms of C. difficile infection recur Duration: 10 days |
|
Clostridioides difficile infection - first recurrence, non-severe Definition: Re-appearance of symptoms and positive assay within 2-8 weeks after completion of therapy for prior episode for which symptoms and signs had resolved |
Same |
Metronidazole OR Vancomycin |
Consider Fidaxomicin in consultation with ID for recurrence in pediatric oncology patients or stem cell transplant recipients | Duration: 10 days |
|
Clostridioides difficile infection - second or subsequent recurrence Definition: Re-appearance of symptoms and positive assay within 2-8 weeks after completion of therapy for prior episode for which symptoms and signs had resolved |
Same |
Vancomycin taper and pulse per the following regimen: 10 mg/kg/dose (max 125 mg/dose) enterally 4 times daily x 10 days THEN bid x 7 days THEN daily x 7 days THEN every other day x 8 days (4 doses) THEN every 3 days x 2 weeks |
Consider Fidaxomicin in consultation with ID for recurrence in pediatric oncology patients or stem cell transplant recipients Consider evaluation for fecal microbiota transplantation in clinically appropriate situations |
ID and GI consults recommended for second recurrence Duration: per taper schedule |
References
McDonald LC, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America. Clin Infect Dis 2018;66:e1-e48.
Diorio C, et al. Guideline for the management of Clostridium difficile infection in children and adolescents with cancer and pediatric hematopoietic stem-cell transplantation recipients. J Clin Oncol 2018; 36:3162-71.
American Academy of Pediatrics. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2021.
Davidovics ZH, et al. Fecal microbiota transplantation for recurrent Clostridium difficile infection and other conditions in children: a joint position paper from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2019;68:130-143.
Pediatric Empiric Antimicrobial Therapy Guidelines
This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites.
These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.
For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK.
The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.