| 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.