Clostridium difficile associated diarrhea - initial episode, mild/moderate

Mild/Moderate disease defined by lack of the following: 
WBC >=15,000 cells/uL

Creatinine > 1.5x pre-disease baseline

Ileus, shock, megacolon or perforation

Metronidazole 10mg/kg/dose PO 3 times daily (max 500mg/dose) x 10-14 days

Note: IV Metronidazole is suboptimal for C. difficile treatment compared to PO metronidazole

Discontinue inciting antimicrobials

Avoid re-testing unless symptoms of C. difficile infection recur

If no response to Metronidazole in 5 days, CHANGE to:

Vancomycin 10mg/kg/dose PO 4 times daily (max 125mg/dose) x 10-14 days

Clostridium difficile associated diarrhea - initial episode, severe, uncomplicated

Severe, uncomplicated disease defined by:

WBC >=15,000 cells/uL

OR

Creatinine > 1.5x pre-disease baseline 

WITHOUT

Ileus, shock, megacolon, or perforation

Discontinue inciting antimicrobials

Avoid re-testing unless symptoms of C. difficile infection recur

Clostridium difficile associated diarrhea - initial episode, severe, complicated

Severe, complicated disease defined by: ileus, shock, megacolon or perforation

Vancomycin 10mg/kg/dose 4 times daily (max 500mg/dose) x 14 days

AND

Metronidazole 10mg/kg/dose IV q8h (max 500mg/dose)

ID consult recommended for consideration of adjunctive therapies

Surgical consult recommended

Clostridium difficile associated diarrhea - recurrence

Definition: Re-appearance of symptoms and signs of CDI within 8 weeks after completion of therapy for prior episode for which symptoms and signs had resolved

First recurrence:

Repeat course of first choice therapy, stratified by illness severity - e.g. if recurrent episode is severe, treated with Vancomycin, but if recurrent episode is mild-moderate, treat with Metronidazole

ID and GI consults recommended for second recurrence

Second recurrence:

Vancomycin taper and pulse per the following regimen: 

10mg/kg/dose (max 125mg/dose) PO 4 times daily x 14 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 (5 doses)

References:

Cohen, SH, et al. Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010;31:431-455.

Schutze, GE, et al. Clostridium difficile infection in infants and children. Pediatrics 2013;131:196-200.

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. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP).