How do you treat Clostridioides difficile (C-diff) in children?

Treatment of Clostridioides difficile Infection in Children

For children with C. difficile infection (CDI), treatment should be based on disease severity, with metronidazole recommended for initial non-severe episodes and vancomycin for severe cases or recurrences. 1

Initial Treatment Based on Severity

Non-Severe CDI

• Metronidazole for 10 days (oral): 7.5 mg/kg/dose three or four times daily, maximum 500 mg per dose 1, 2
• Alternative: Vancomycin for 10 days (oral): 10 mg/kg/dose four times daily, maximum 125 mg per dose 1

Severe/Fulminant CDI

• Vancomycin for 10 days (oral or rectal): 10 mg/kg/dose four times daily, maximum 500 mg per dose 1
• Consider adding intravenous metronidazole (10 mg/kg/dose three times daily, maximum 500 mg per dose) in cases of critical illness, especially with ileus 1

Treatment of Recurrent CDI

First Recurrence (Non-Severe)

• If metronidazole was used for initial episode: Oral vancomycin for 10 days (10 mg/kg/dose four times daily, maximum 125 mg per dose) 1
• If vancomycin was used for initial episode: Consider metronidazole for 10 days (7.5 mg/kg/dose three or four times daily, maximum 500 mg per dose) 1, 3

Second or Subsequent Recurrences

• Vancomycin in a tapered and pulsed regimen: 10 mg/kg/dose (maximum 125 mg) four times daily for 10-14 days, then twice daily for 7 days, then once daily for 7 days, then every 2-3 days for 2-8 weeks 1
• Alternative: Vancomycin for 10 days followed by rifaximin for 20 days (note: rifaximin is not FDA-approved for children <12 years) 1
• Consider fecal microbiota transplantation for multiple recurrences that have failed appropriate antibiotic treatments 1

Special Considerations

Fidaxomicin

• FDA-approved for children ≥6 months of age with C. difficile-associated diarrhea 4
• May be considered for recurrent CDI, though pediatric-specific data are limited 5
• Advantage: Associated with lower recurrence rates compared to other antibiotics due to its microbiome-sparing properties 5, 6

Risk Factors for Recurrent CDI

• Children with inflammatory bowel disease or cancer have significantly higher risk of recurrence (odds ratios of 7.5 and 6.3, respectively) 7
• Monitoring these high-risk populations more closely is warranted 7

Treatment Failures

• If no improvement after 3-5 days of appropriate therapy, reassess severity and consider switching antibiotics 1, 8
• Approximately 6% of children treated with metronidazole may require switching to vancomycin due to intolerance or treatment failure 7

Pitfalls and Caveats

• Do not continue the inciting antibiotic if possible, as this increases risk of treatment failure and recurrence 9, 6
• Avoid repeated or prolonged courses of metronidazole due to risk of peripheral neuropathy 1
• Recurrence rates can approach 20% after initial treatment, requiring vigilant follow-up 9, 8
• Always confirm diagnosis with appropriate testing before initiating treatment to avoid unnecessary antibiotic exposure 6, 8