What is the treatment for Clostridioides (C.) difficile infection in toddlers?

Treatment of Clostridioides difficile Infection in Toddlers

For toddlers with C. difficile infection, treatment should be based on disease severity, with either metronidazole or oral vancomycin as first-line therapy for non-severe cases, while oral vancomycin is strongly recommended for severe cases. 1

Disease Classification and Initial Treatment

Non-severe Initial Episode:

• First-line options:
  • Metronidazole: 7.5 mg/kg/dose three or four times daily for 10 days (maximum 500 mg per dose)
  • OR
  • Oral vancomycin: 10 mg/kg/dose four times daily for 10 days (maximum 125 mg per dose)

Severe/Fulminant Initial Episode:

• First-line treatment:
  • Oral vancomycin: 10 mg/kg/dose four times daily for 10 days (maximum 500 mg per dose)
  • With or without IV metronidazole: 10 mg/kg/dose three times daily (maximum 500 mg per dose)
  • For critical illness, consider combination therapy with both agents

Recurrent Infections

First Recurrence (Non-severe):

• Treatment options:
  • Metronidazole: 7.5 mg/kg/dose three or four times daily for 10 days (maximum 500 mg per dose)
  • OR
  • Oral vancomycin: 10 mg/kg/dose four times daily for 10 days (maximum 125 mg per dose)

Second or Subsequent Recurrences:

• Treatment options:
  • Vancomycin in a tapered and pulsed regimen:
    • 10 mg/kg/dose (max 125 mg) four times daily for 10-14 days
    • Then 10 mg/kg/dose (max 125 mg) twice daily for 7 days
    • Then 10 mg/kg/dose (max 125 mg) once daily for 7 days
    • Then 10 mg/kg/dose (max 125 mg) every 2-3 days for 2-8 weeks
  • OR
  • Vancomycin for 10 days followed by rifaximin for 20 days (note: rifaximin is not FDA-approved for children <12 years)
  • OR
  • Fecal microbiota transplantation (for multiple recurrences after failed antibiotic treatments)

Clinical Assessment of Severity

Determining the severity of CDI is crucial for selecting appropriate treatment:

• Non-severe CDI: Diarrhea without signs of systemic toxicity
• Severe CDI: Elevated white blood cell count (>15,000 cells/μL), serum albumin <3 g/dL, or serum creatinine ≥1.5 times baseline
• Fulminant CDI: Hypotension, shock, ileus, or megacolon

Special Considerations for Toddlers

1. Diagnostic challenges: C. difficile colonization is common in infants and young children, making it important to rule out other causes of diarrhea before attributing symptoms to CDI

2. Fidaxomicin: FDA-approved for children 6 months and older 2, but not included in the first-line recommendations for toddlers in the IDSA/SHEA guidelines

3. Fecal microbiota transplantation: Consider only after multiple recurrences and failed antibiotic treatments, though evidence in pediatric populations is limited 1

Treatment Pitfalls to Avoid

1. Inappropriate antibiotic selection: Using metronidazole for severe cases instead of vancomycin

2. Failure to adjust therapy based on response: Some patients, particularly those on metronidazole, may have delayed response and require extending treatment to 14 days

3. Inadequate follow-up: Not monitoring for recurrence, which occurs in approximately 20-30% of pediatric cases

4. Unnecessary testing: Testing for cure after symptoms resolve is not recommended as C. difficile and its toxins may persist in stool after clinical recovery

5. Overlooking prevention: Not implementing antimicrobial stewardship and infection control measures to prevent recurrence and transmission

Remember that the treatment approach should be adjusted based on clinical response, and consultation with pediatric infectious disease specialists may be warranted for severe or recurrent cases.