What is the treatment for pseudomembranous colitis in children?

Treatment of Pseudomembranous Colitis in Children

Immediately discontinue the inciting antibiotic and initiate oral vancomycin or metronidazole as first-line therapy, with oral vancomycin being preferred for severe disease. 1, 2, 3

Immediate Management Steps

• Stop the causative antibiotic immediately upon suspicion of Clostridioides difficile infection, as continued use significantly increases recurrence risk 1, 4
• If ongoing antibiotic therapy is essential for another infection, switch to agents less commonly associated with CDI: parenteral aminoglycosides, sulfonamides, macrolides, vancomycin, or tetracycline/tigecycline 4, 1
• Provide supportive care with close fluid management, which is crucial for survival 3

First-Line Antibiotic Therapy

Mild-to-Moderate Disease

• Oral metronidazole is effective with 97% cure rates in non-severe cases and offers advantages of lower cost and reduced selection pressure for vancomycin-resistant enterococci 1
• Discontinuation of antibiotics combined with supportive therapy usually leads to resolution 2

Severe Disease

• Oral vancomycin is superior to metronidazole in severe disease 1
• The FDA-approved oral vancomycin formulation must be used, as it is not systemically absorbed and works locally in the gastrointestinal tract 5
• Parenteral vancomycin is not effective for pseudomembranous colitis treatment 5

Special Considerations in Children

• Pseudomembranous colitis has a lower incidence in children compared to adults 2
• The clinical spectrum ranges from mild non-specific diarrhea to severe colitis with toxic megacolon, perforation, and death 2
• Ampicillin, amoxicillin, second- and third-generation cephalosporins, and clindamycin are the drugs most frequently associated with PMC in pediatric patients 2, 3
• Most cases in children resolve promptly when the implicated antibiotic is stopped 3

When to Escalate Therapy

• Persistent diarrhea after discontinuing the offending antibiotic requires oral vancomycin therapy 3
• For severe-complicated disease showing signs of systemic toxicity, peritonitis, or worsening despite medical therapy, urgent surgical consultation is mandatory 1
• Toxic megacolon and acute peritonitis secondary to colonic perforation are the most serious complications requiring immediate intervention 6

Recurrent Disease Management

• Consider extended/pulsed vancomycin or fidaxomicin before fecal microbiota transplantation 1
• Fecal microbiota transplantation (FMT) should be considered after failure of three courses of antibiotics, with 92% clinical resolution rates 1
• For FMT failure specifically in pseudomembranous colitis, repeat FMT every 3 days until resolution of pseudomembranes 1
• Relapses occur in 5-50% of treated patients 6

Monitoring and Safety Considerations

With Oral Vancomycin Use

• Monitor for potential systemic absorption in patients with inflammatory disorders of the intestinal mucosa, as clinically significant serum concentrations can occur 5
• In patients >65 years of age (less relevant for pediatrics but important for context), renal function monitoring is recommended to detect vancomycin-induced nephrotoxicity 5
• Serial auditory function tests may be helpful to minimize ototoxicity risk, particularly with concomitant aminoglycoside therapy 5
• Discontinue vancomycin immediately if severe dermatologic reactions (TEN, SJS, DRESS, AGEP, or LABD) develop 5

Critical Pitfalls to Avoid

• Do not perform "test of cure" after treatment, as 56% of successfully treated patients asymptomatically shed C. difficile spores for up to 6 weeks 1
• Do not repeat testing after initiating treatment unless there are clear clinical changes, as test positivity does not correlate with treatment failure 1
• Do not treat asymptomatic carriage with C. difficile 1
• Distinguish recurrent CDI from post-infectious irritable bowel syndrome, which can cause symptoms in up to 35% of patients during the first 2 weeks and 4.3% beyond 3 months 1
• Remember that virtually all antibiotics except parenterally administered aminoglycosides can cause pseudomembranous colitis 6, 7

Diagnostic Confirmation

• Proctoscopy or sigmoidoscopy showing typical plaques of pseudomembranes establishes the diagnosis 3
• Flexible sigmoidoscopy may be helpful when there is high clinical suspicion but stool assays are negative 4
• However, colonoscopy may be hazardous in fulminant colitis due to increased perforation risk 4