Clostridium difficile (peds): Difference between revisions

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''This page is for <u>pediatric</u> patients; for adult patients see [[clostridium difficile]].''
<languages/>
==Background==
<translate>
<!--T:1-->
''This page is for <u>pediatric</u> patients; for adult patients see [[Special:MyLanguage/clostridium difficile|clostridium difficile]].''
 
==Background== <!--T:2-->
 
<!--T:3-->
[[File:Pseudomembranous colitis 1.jpg|thumb|Pseudomembranous colitis with yellow pseudomembranes seen on the wall of the sigmoid colon.]]
[[File:Pseudomembranous colitis 1.jpg|thumb|Pseudomembranous colitis with yellow pseudomembranes seen on the wall of the sigmoid colon.]]
*[[Clostridium]] is a genus of [[Gram-positive bacteria]]
*[[Special:MyLanguage/Clostridium|Clostridium]] is a genus of [[Special:MyLanguage/Gram-positive bacteria|Gram-positive bacteria]]
*Most common cause of infectious diarrhea in hospitalized patients
*Most common cause of infectious diarrhea in hospitalized patients
*Use contact isolation if suspect
*Use contact isolation if suspect
*Alcohol-based hand sanitizers do not reduce spores, but good hand washing does<ref>Leffler DA and Lamont JT. Clostridium difficile Infection. N Engl J Med. 2015; 372:1539-1548.</ref>
*Alcohol-based hand sanitizers do not reduce spores, but good hand washing does<ref>Leffler DA and Lamont JT. Clostridium difficile Infection. N Engl J Med. 2015; 372:1539-1548.</ref>


===Risk factors (pseudomembranous colitis)===
*Recent antibiotic use (any)
*GI surgery
*Severe underlying medical illness
*Chemo
*Elderly


===Pediatrics===
===Pediatric Risk Factors=== <!--T:4-->
*Testing in infants < 1 year of age not recommended due to high rates of colonization
 
**~40% of infants < 1 month are colonized and asymptomatic<ref>Asymptomatic colonization by Clostridium difficile in infants: implications for disease in later life. Jangi S, Lamont JT. J Pediatr Gastroenterol Nutr. 2010 Jul; 51(1):2-7.</ref>
<!--T:5-->
**~15% in infants 6-12 months
*[[Special:MyLanguage/Antibiotic|Antibiotic]] exposure, particularly [[Special:MyLanguage/penicillins|penicillins]], [[Special:MyLanguage/cephalosporins|cephalosporins]], [[Special:MyLanguage/clindamycin|clindamycin]], [[Special:MyLanguage/fluoroquinolones|fluoroquinolones]]
**By 2 years of age, normal flora is established, similar to adults<ref>Clostridium difficile Infection in children. Sammons JS, Toltzis P, Zaoutis TE. JAMA Pediatr. 2013 Jun; 167(6):567-73.</ref>
*[[Special:MyLanguage/PPIs|PPIs]]
*Risk factors for pediatrics
*GI feeding tubes
**Antibiotic exposure, particularly penicillins, cephalosporins, clindamycin, fluoroquinolones
*Comorbidities - cancer, recent surgery, hospitalizations
**PPIs
 
**GI feeding tubes
 
**Comorbidities - cancer, recent surgery, hospitalizations
==Clinical Features== <!--T:6-->


==Clinical Features==
<!--T:7-->
===History===
''Varies according to severity and intrinsic host factors (immunosuppression, etc.).''
*[[Diarrhea]] that develops during antibiotic use or within 2 weeks of discontinuation
*[[Special:MyLanguage/Diarrhea|Diarrhea]] that develops during antibiotic use or within 2 weeks of discontinuation
*Usually occurs after 7-10 days of antibiotics, as diarrhea before that time is more often poor tolerance to antibiotic
*Usually occurs after 7-10 days of antibiotics, as diarrhea before that time is more often poor tolerance to antibiotic
*Recent discharge from hospital
*Recent discharge from hospital
*Profuse watery diarrhea
*Profuse watery diarrhea
*[[Special:MyLanguage/Abdominal pain|Abdominal pain]]/tenderness
*[[Special:MyLanguage/Fever|Fever]]
*At the extreme, may present with [[Special:MyLanguage/sepsis|sepsis]] secondary to intestinal perforation or [[Special:MyLanguage/toxic megacolon|toxic megacolon]]


===Exam===
*[[Abdominal pain]]
*[[Fever]]


==Differential Diagnosis==
==Differential Diagnosis== <!--T:8-->
 
</translate>
{{Diarrhea DDX}}
{{Diarrhea DDX}}
<translate>


==Evaluation==
 
==Evaluation== <!--T:9-->
 
<!--T:10-->
[[File:MPX1834 synpic40781.png|thumb|Pseudomembranous colitis from ''C. difficile'' on abdominal CT demonstratin diffuse colonic wall thickening and a shaggy endoluminal contour.]]
[[File:MPX1834 synpic40781.png|thumb|Pseudomembranous colitis from ''C. difficile'' on abdominal CT demonstratin diffuse colonic wall thickening and a shaggy endoluminal contour.]]
[[File:PMC5137169 gr1.png|thumb|Pseudomembranous colitis with (A) Accordion sign in transverse colon (thin arrows). (B) Colonic wall thickness, target sign (thick arrow), peritoneal fluid (thin arrow) and pericolonic fat stranding (arrowhead).]]
[[File:PMC5137169 gr1.png|thumb|Pseudomembranous colitis with (A) Accordion sign in transverse colon (thin arrows). (B) Colonic wall thickness, target sign (thick arrow), peritoneal fluid (thin arrow) and pericolonic fat stranding (arrowhead).]]
===Labs===
 
===Labs=== <!--T:11-->
 
<!--T:12-->
*C. diff toxin assay
*C. diff toxin assay
**Sn 63-94%, Sp 75-100%
**Sn 63-94%, Sp 75-100%
Line 48: Line 57:
**Positive culture only means C. diff present, not necessarily that it is causing disease
**Positive culture only means C. diff present, not necessarily that it is causing disease


===Testing Algorithm===
 
===Testing Algorithm=== <!--T:13-->
 
<!--T:14-->
''For patients with suspected Clostridium difficile associated diarrhea (CDAD)''
''For patients with suspected Clostridium difficile associated diarrhea (CDAD)''
*'''Low''' suspicion
*'''Low''' suspicion
Line 59: Line 71:
***Negative → Consider discussion with ID (false negative tests may occur); eval for other causes of diarrhea
***Negative → Consider discussion with ID (false negative tests may occur); eval for other causes of diarrhea


===Repeat testing===
 
===Repeat testing=== <!--T:15-->
 
<!--T:16-->
*Never a need for repeat testing within 7 days of a previous test
*Never a need for repeat testing within 7 days of a previous test
*NO NEED to repeat positive tests as symptoms resolve as a “test of cure”
*NO NEED to repeat positive tests as symptoms resolve as a “test of cure”
*NO NEED to repeat test soon after initial negative test (more likely to be a false positive test than a true positive test)
*NO NEED to repeat test soon after initial negative test (more likely to be a false positive test than a true positive test)


==Management==
===Asymptomatic===
*No diagnostic testing or treatment required<ref>Bagdasarian, N, et al. Diagnosis and Treatment of Clostridium difficile in Adults. JAMA. 2015; 313(4):398-408.</ref>
===Mild===
*Either discontinue offending antibiotics (if possible) or give [[metronidazole]] 500mg PO q6hr x10-14d
===Moderate===
{{Moderate Cdiff Antibiotics}}
===Severe===
'''Criteria:'''<ref name="IDSA">IDSA Guidelines [http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/cdiff2010a.pdf PDF]</ref><ref>ACG Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections http://gi.org/guideline/diagnosis-and-management-of-c-difficile-associated-diarrhea-and-colitis/</ref>
*Serum lactate levels >2.2 mmol/l
*[[Hypotension]] with or without required use of vasopressors
*[[Ileus]] or significant abdominal distention
*Mental status changes
*WBC ≥35,000 cells/mm3 or <2,000 cells/mm3
*Patient requiring ICU admission
*End organ failure (mechanical ventilation, renal failure, etc.)
====Management====
{{Severe Cdiff Antibiotics}}
*Emergency colectomy should be considered if:
**WBC >20K
**[[Lactate]] >5
**Age >75
**Immunosuppression
**Toxic megacolon
**Colonic perforation
**Multi-organ system failure


===Recurrent Infection===
===Pediatrics=== <!--T:17-->
*Relapse occurs in 10-25% of patients
*Occurs <=4 weeks after the completion of therapy
**Otherwise consider other (more common) causes
*Antimicrobial resistance is not clinically problematic, first recurrence treated with the same agent used to treat the initial episode
*2nd recurrence - tapered vancomycin with pulse doses
*3rd recurrence - PO vancomycin 10-14 days followed immediately by rifaximin "chaser" 400mg TID x20 days <ref>Melville NA. Rifaximin 'Chaser' Reduces C difficile Recurrent Diarrhea. June 07, 2011. http://www.medscape.com/viewarticle/744157</ref>
*Other options:
**[[IVIG]]
**Fecal transplant
**Fidamoxicin 200mg BID x10 days noninferior to PO vancomycin, and reduces recurrences at 4 weeks after treatment (~15% vs 25%) <ref>Louie TJ et al. Fidaxomicin versus [[Vancomycin]] for Clostridium difficile Infection. N Engl J Med 2011; 364:422-431.</ref>


===Pediatrics===
<!--T:18-->
*Testing in infants < 1 year of age not recommended due to high rates of colonization
**~40% of infants < 1 month are colonized and asymptomatic<ref>Asymptomatic colonization by Clostridium difficile in infants: implications for disease in later life. Jangi S, Lamont JT. J Pediatr Gastroenterol Nutr. 2010 Jul; 51(1):2-7.</ref>
**~15% in infants 6-12 months
**By 2 years of age, normal flora is established, similar to adults<ref>Clostridium difficile Infection in children. Sammons JS, Toltzis P, Zaoutis TE. JAMA Pediatr. 2013 Jun; 167(6):567-73.</ref>
 
 
==Management== <!--T:19-->
 
<!--T:20-->
*Stop offending antimicrobial agents, if possible
*Stop offending antimicrobial agents, if possible
*Initial occurrence and first recurrence of mild-moderate disease:<ref>D'Ostroph AR and So TY. Treatment of pediatric Clostridium difficile infection: a review on treatment efficacy and economic value. Infect Drug Resist. 2017; 10: 365–375.</ref>
*Initial occurrence and first recurrence of mild-moderate disease:<ref>D'Ostroph AR and So TY. Treatment of pediatric Clostridium difficile infection: a review on treatment efficacy and economic value. Infect Drug Resist. 2017; 10: 365–375.</ref>
**PO metronidazole 30 mg/kg/d in four divided doses, max 2 g/day
**PO [[Special:MyLanguage/metronidazole|metronidazole]] 30 mg/kg/d in four divided doses, max 2 g/day
*Severe infection or second recurrence:
*Severe infection or second recurrence:
**PO vancomycin 40 mg/kg/d in four divided doses, max 500 mg/day
**PO [[Special:MyLanguage/vancomycin|vancomycin]] 40 mg/kg/d in four divided doses, max 500 mg/day
**If no improvement after 24-48 hours, oral vancomycin max dose may be increased to 2 g/d
**If no improvement after 24-48 hours, oral [[Special:MyLanguage/vancomycin|vancomycin]] max dose may be increased to 2 g/d
**Q6hr IV metronidazole, 30 mg/kg/d, may be added to intracolonic/enema vancomycin for ileus, inability to tolerate PO antibiotics
**Q6hr IV [[Special:MyLanguage/metronidazole|metronidazole]], 30 mg/kg/d, may be added to intracolonic/enema [[Special:MyLanguage/vancomycin|vancomycin]] for ileus, inability to tolerate PO antibiotics
***1-3 year old -- 250 mg vancomycin in 50 mL NS
***1-3 year old -- 250 mg [[Special:MyLanguage/vancomycin|vancomycin]] in 50 mL NS
***4-9 year old -- 375 mg vancomycin in 75 mL NS
***4-9 year old -- 375 mg [[Special:MyLanguage/vancomycin|vancomycin]] in 75 mL NS
***> 9 year old -- 500 mg vancomycin in 100 mL NS
***> 9 year old -- 500 mg [[Special:MyLanguage/vancomycin|vancomycin]] in 100 mL NS
*Multiple recurrences, other strategies, in consult with pediatric GI:
*Multiple recurrences, other strategies, in consult with pediatric GI:
**May benefit from tapering and pulse oral vancomycin over 1.5-2 months, as done in adults
**May benefit from tapering and pulse oral [[Special:MyLanguage/vancomycin|vancomycin]] over 1.5-2 months, as done in adults
**Consider PO fidaxomicin in ≥ 6 year old patients at 200 mg twice daily for 10 dats
**Consider PO [[Special:MyLanguage/fidaxomicin|fidaxomicin]] in ≥ 6 year old patients at 200 mg twice daily for 10 dats
 
 
==Disposition== <!--T:21-->
 
<!--T:22-->
*Admit:
**Severe [[Special:MyLanguage/diarrhea|diarrhea]]
**Outpatient antibiotic failure
**Systemic response ([[Special:MyLanguage/fever|fever]], [[Special:MyLanguage/leukocytosis|leukocytosis]], severe [[Special:MyLanguage/abdominal pain|abdominal pain]])


===[[Antibiotic Sensitivities]]<ref>Sanford Guide to Antimicrobial Therapy 2014</ref>===
 
==[[Special:MyLanguage/Antibiotic Sensitivities|Antibiotic Sensitivities]]<ref>Sanford Guide to Antimicrobial Therapy 2014</ref>== <!--T:23-->
 
<!--T:24-->
{| class="wikitable"
{| class="wikitable"
| align="center" style="background:#f0f0f0;"|'''Category'''
| align="center" style="background:#f0f0f0;"|'''Category'''
Line 124: Line 124:
| align="center" style="background:#f0f0f0;"|'''Sensitivity'''
| align="center" style="background:#f0f0f0;"|'''Sensitivity'''
|-
|-
| [[Penicillins]]||[[Penicillin G]]||X2
| [[Special:MyLanguage/Penicillins|Penicillins]]||[[Special:MyLanguage/Penicillin G|Penicillin G]]||X2
|-
|-
| ||[[Penicillin V]]||X1
| ||[[Special:MyLanguage/Penicillin V|Penicillin V]]||X1
|-
|-
| Anti-Staphylocccal [[Penicillins]]||[[Methicillin]]||X1
| Anti-Staphylocccal [[Special:MyLanguage/Penicillins|Penicillins]]||[[Special:MyLanguage/Methicillin|Methicillin]]||X1
|-
|-
| ||[[Nafcillin]]/[[Oxacillin]]||X1
| ||[[Special:MyLanguage/Nafcillin|Nafcillin]]/[[Special:MyLanguage/Oxacillin|Oxacillin]]||X1
|-
|-
| ||[[Cloxacillin]]/[[Diclox.]]||X1
| ||[[Special:MyLanguage/Cloxacillin|Cloxacillin]]/[[Special:MyLanguage/Diclox.|Diclox.]]||X1
|-
|-
| Amino-[[Penicillins]]||[[AMP]]/[[Amox]]||X1
| Amino-[[Special:MyLanguage/Penicillins|Penicillins]]||[[Special:MyLanguage/AMP|AMP]]/[[Special:MyLanguage/Amox|Amox]]||X1
|-
|-
| ||[[Amox-Clav]]||X1
| ||[[Special:MyLanguage/Amox-Clav|Amox-Clav]]||X1
|-
|-
| ||[[AMP-Sulb]]||X2
| ||[[Special:MyLanguage/AMP-Sulb|AMP-Sulb]]||X2
|-
|-
| Anti-Pseudomonal [[Penicillins]]||[[Ticarcillin]]||X1
| Anti-Pseudomonal [[Special:MyLanguage/Penicillins|Penicillins]]||[[Special:MyLanguage/Ticarcillin|Ticarcillin]]||X1
|-
|-
| ||[[Ticar-Clav]]||X1
| ||[[Special:MyLanguage/Ticar-Clav|Ticar-Clav]]||X1
|-
|-
| ||[[Pip-Tazo]]||X1
| ||[[Special:MyLanguage/Pip-Tazo|Pip-Tazo]]||X1
|-
|-
| ||[[Piperacillin]]||X2
| ||[[Special:MyLanguage/Piperacillin|Piperacillin]]||X2
|-
|-
| [[Carbapenems]]||[[Doripenem]]||X2
| [[Special:MyLanguage/Carbapenems|Carbapenems]]||[[Special:MyLanguage/Doripenem|Doripenem]]||X2
|-
|-
| ||[[Ertapenem]]||X2
| ||[[Special:MyLanguage/Ertapenem|Ertapenem]]||X2
|-
|-
| ||[[Imipenem]]||X2
| ||[[Special:MyLanguage/Imipenem|Imipenem]]||X2
|-
|-
| ||[[Meropenem]]||X2
| ||[[Special:MyLanguage/Meropenem|Meropenem]]||X2
|-
|-
| ||[[Aztreonam]]||R
| ||[[Special:MyLanguage/Aztreonam|Aztreonam]]||R
|-
|-
| [[Fluroquinolones]]||[[Ciprofloxacin]]||R
| [[Special:MyLanguage/Fluroquinolones|Fluroquinolones]]||[[Special:MyLanguage/Ciprofloxacin|Ciprofloxacin]]||R
|-
|-
| ||[[Ofloxacin]]||X1
| ||[[Special:MyLanguage/Ofloxacin|Ofloxacin]]||X1
|-
|-
| ||[[Pefloxacin]]||X1
| ||[[Special:MyLanguage/Pefloxacin|Pefloxacin]]||X1
|-
|-
| ||[[Levofloxacin]]||R
| ||[[Special:MyLanguage/Levofloxacin|Levofloxacin]]||R
|-
|-
| ||[[Moxifloxacin]]||R
| ||[[Special:MyLanguage/Moxifloxacin|Moxifloxacin]]||R
|-
|-
| ||[[Gemifloxacin]]||X1
| ||[[Special:MyLanguage/Gemifloxacin|Gemifloxacin]]||X1
|-
|-
| ||[[Gatifloxacin]]||R
| ||[[Special:MyLanguage/Gatifloxacin|Gatifloxacin]]||R
|-
|-
| 1st G [[Cephalo]]||[[Cefazolin]]||X1
| 1st G [[Special:MyLanguage/Cephalo|Cephalo]]||[[Special:MyLanguage/Cefazolin|Cefazolin]]||X1
|-
|-
| 2nd G. [[Cephalo]]||[[Cefotetan]]||X1
| 2nd G. [[Special:MyLanguage/Cephalo|Cephalo]]||[[Special:MyLanguage/Cefotetan|Cefotetan]]||X1
|-
|-
| ||[[Cefoxitin]]||R
| ||[[Special:MyLanguage/Cefoxitin|Cefoxitin]]||R
|-
|-
| ||[[Cefuroxime]]||X1
| ||[[Special:MyLanguage/Cefuroxime|Cefuroxime]]||X1
|-
|-
| 3rd/4th G. [[Cephalo]]||[[Cefotaxime]]||R
| 3rd/4th G. [[Special:MyLanguage/Cephalo|Cephalo]]||[[Special:MyLanguage/Cefotaxime|Cefotaxime]]||R
|-
|-
| ||[[Cefizoxime]]||R
| ||[[Special:MyLanguage/Cefizoxime|Cefizoxime]]||R
|-
|-
| ||[[CefTRIAXone]]||X1
| ||[[Special:MyLanguage/CefTRIAXone|CefTRIAXone]]||X1
|-
|-
| ||[[Ceftaroline]]||X1
| ||[[Special:MyLanguage/Ceftaroline|Ceftaroline]]||X1
|-
|-
| ||[[CefTAZidime]]||X1
| ||[[Special:MyLanguage/CefTAZidime|CefTAZidime]]||X1
|-
|-
| ||[[Cefepime]]||R
| ||[[Special:MyLanguage/Cefepime|Cefepime]]||R
|-
|-
| Oral 1st G. [[Cephalo]]||[[Cefadroxil]]||X1
| Oral 1st G. [[Special:MyLanguage/Cephalo|Cephalo]]||[[Special:MyLanguage/Cefadroxil|Cefadroxil]]||X1
|-
|-
| ||[[Cephalexin]]||X1
| ||[[Special:MyLanguage/Cephalexin|Cephalexin]]||X1
|-
|-
| Oral 2nd G. [[Cephalo]]||[[Cefaclor]]/[[Loracarbef]]||X1
| Oral 2nd G. [[Special:MyLanguage/Cephalo|Cephalo]]||[[Special:MyLanguage/Cefaclor|Cefaclor]]/[[Special:MyLanguage/Loracarbef|Loracarbef]]||X1
|-
|-
| ||[[Cefproxil]]||X1
| ||[[Special:MyLanguage/Cefproxil|Cefproxil]]||X1
|-
|-
| ||[[Cefuroxime axetil]]||X1
| ||[[Special:MyLanguage/Cefuroxime axetil|Cefuroxime axetil]]||X1
|-
|-
| Oral 3rd G. [[Cephalo]]||[[Cefixime]]||X1
| Oral 3rd G. [[Special:MyLanguage/Cephalo|Cephalo]]||[[Special:MyLanguage/Cefixime|Cefixime]]||X1
|-
|-
| ||[[Ceftibuten]]||X1
| ||[[Special:MyLanguage/Ceftibuten|Ceftibuten]]||X1
|-
|-
| ||[[Cefpodox]]/[[Cefdinir]]/[[Cefditoren]]||X1
| ||[[Special:MyLanguage/Cefpodox|Cefpodox]]/[[Special:MyLanguage/Cefdinir|Cefdinir]]/[[Special:MyLanguage/Cefditoren|Cefditoren]]||X1
|-
|-
| [[Aminoglycosides]]||[[Gentamicin]]||R
| [[Special:MyLanguage/Aminoglycosides|Aminoglycosides]]||[[Special:MyLanguage/Gentamicin|Gentamicin]]||R
|-
|-
| ||[[Tobramycin]]||R
| ||[[Special:MyLanguage/Tobramycin|Tobramycin]]||R
|-
|-
| ||[[Amikacin]]||R
| ||[[Special:MyLanguage/Amikacin|Amikacin]]||R
|-
|-
| ||[[Chloramphenicol]]||I
| ||[[Special:MyLanguage/Chloramphenicol|Chloramphenicol]]||I
|-
|-
| ||[[Clindamycin]]||X1
| ||[[Special:MyLanguage/Clindamycin|Clindamycin]]||X1
|-
|-
| [[Macrolides]]||[[Erythromycin]]||X1
| [[Special:MyLanguage/Macrolides|Macrolides]]||[[Special:MyLanguage/Erythromycin|Erythromycin]]||X1
|-
|-
| ||[[Azithromycin]]||X1
| ||[[Special:MyLanguage/Azithromycin|Azithromycin]]||X1
|-
|-
| ||[[Clarithromycin]]||X1
| ||[[Special:MyLanguage/Clarithromycin|Clarithromycin]]||X1
|-
|-
| Ketolide||[[Telithromycin]]||X1
| Ketolide||[[Special:MyLanguage/Telithromycin|Telithromycin]]||X1
|-
|-
| Tetracyclines||[[Doxycycline]]||X1
| Tetracyclines||[[Special:MyLanguage/Doxycycline|Doxycycline]]||X1
|-
|-
| ||[[Minocycline]]||X1
| ||[[Special:MyLanguage/Minocycline|Minocycline]]||X1
|-
|-
| Glycylcycline||[[Tigecycline]]||X1
| Glycylcycline||[[Special:MyLanguage/Tigecycline|Tigecycline]]||X1
|-
|-
| ||[[Daptomycin]]||X1
| ||[[Special:MyLanguage/Daptomycin|Daptomycin]]||X1
|-
|-
| Glyco/Lipoclycopeptides||[[Vancomycin]]||'''S'''
| Glyco/Lipoclycopeptides||[[Special:MyLanguage/Vancomycin|Vancomycin]]||'''S'''
|-
|-
| ||[[Teicoplanin]]||'''S'''
| ||[[Special:MyLanguage/Teicoplanin|Teicoplanin]]||'''S'''
|-
|-
| ||[[Telavancin]]||'''S'''
| ||[[Special:MyLanguage/Telavancin|Telavancin]]||'''S'''
|-
|-
| ||[[Fusidic Acid]]||X1
| ||[[Special:MyLanguage/Fusidic Acid|Fusidic Acid]]||X1
|-
|-
| ||[[Trimethoprim]]||X1
| ||[[Special:MyLanguage/Trimethoprim|Trimethoprim]]||X1
|-
|-
| ||[[TMP-SMX]]||X1
| ||[[Special:MyLanguage/TMP-SMX|TMP-SMX]]||X1
|-
|-
| Urinary Agents||[[Nitrofurantoin]]||X1
| Urinary Agents||[[Special:MyLanguage/Nitrofurantoin|Nitrofurantoin]]||X1
|-
|-
| ||[[Fosfomycin]]||X1
| ||[[Special:MyLanguage/Fosfomycin|Fosfomycin]]||X1
|-
|-
| Other||[[Rifampin]]||X1
| Other||[[Special:MyLanguage/Rifampin|Rifampin]]||X1
|-
|-
| ||[[Metronidazole]]||'''S'''
| ||[[Special:MyLanguage/Metronidazole|Metronidazole]]||'''S'''
|-
|-
| ||[[Quinupristin dalfoppristin]]||I
| ||[[Special:MyLanguage/Quinupristin dalfoppristin|Quinupristin dalfoppristin]]||I
|-
|-
| ||[[Linezolid]]||I
| ||[[Special:MyLanguage/Linezolid|Linezolid]]||I
|-
|-
| ||[[Colistimethate]]||X1
| ||[[Special:MyLanguage/Colistimethate|Colistimethate]]||X1
|}
|}


==Disposition==
*Admit:
**Severe diarrhea
**Outpatient antibiotic failure
**Systemic response (fever, leukocytosis, severe abdominal pain)


==See Also==
==See Also== <!--T:25-->
*[[Diarrhea]]
 
*[[Clostridium]]
<!--T:26-->
*[[Special:MyLanguage/Diarrhea|Diarrhea]]
*[[Special:MyLanguage/Clostridium|Clostridium]]
 
 
==References== <!--T:27-->


==References==
<!--T:28-->
<references/>
<references/>


<!--T:29-->
[[Category:ID]]
[[Category:ID]]
[[Category:GI]]
[[Category:GI]]
</translate>

Latest revision as of 12:32, 7 January 2026

Other languages:

This page is for pediatric patients; for adult patients see clostridium difficile.

Background

Pseudomembranous colitis with yellow pseudomembranes seen on the wall of the sigmoid colon.
  • Clostridium is a genus of Gram-positive bacteria
  • Most common cause of infectious diarrhea in hospitalized patients
  • Use contact isolation if suspect
  • Alcohol-based hand sanitizers do not reduce spores, but good hand washing does[1]


Pediatric Risk Factors


Clinical Features

Varies according to severity and intrinsic host factors (immunosuppression, etc.).

  • Diarrhea that develops during antibiotic use or within 2 weeks of discontinuation
  • Usually occurs after 7-10 days of antibiotics, as diarrhea before that time is more often poor tolerance to antibiotic
  • Recent discharge from hospital
  • Profuse watery diarrhea
  • Abdominal pain/tenderness
  • Fever
  • At the extreme, may present with sepsis secondary to intestinal perforation or toxic megacolon


Differential Diagnosis

Acute diarrhea

Infectious

Noninfectious

Watery Diarrhea

Traveler's Diarrhea


Evaluation

Pseudomembranous colitis from C. difficile on abdominal CT demonstratin diffuse colonic wall thickening and a shaggy endoluminal contour.
Pseudomembranous colitis with (A) Accordion sign in transverse colon (thin arrows). (B) Colonic wall thickness, target sign (thick arrow), peritoneal fluid (thin arrow) and pericolonic fat stranding (arrowhead).

Labs

  • C. diff toxin assay
    • Sn 63-94%, Sp 75-100%
  • Culture
    • Positive culture only means C. diff present, not necessarily that it is causing disease


Testing Algorithm

For patients with suspected Clostridium difficile associated diarrhea (CDAD)

  • Low suspicion
    • Send stool for C. diff toxin assay
      • Positive → treat (no further testing indicated)
      • Negative → do not treat (no further testing indicated)
  • High suspicion
    • Send stool for C. diff toxin assay AND treat empirically
      • Positive → treat (no further testing indicated)
      • Negative → Consider discussion with ID (false negative tests may occur); eval for other causes of diarrhea


Repeat testing

  • Never a need for repeat testing within 7 days of a previous test
  • NO NEED to repeat positive tests as symptoms resolve as a “test of cure”
  • NO NEED to repeat test soon after initial negative test (more likely to be a false positive test than a true positive test)


Pediatrics

  • Testing in infants < 1 year of age not recommended due to high rates of colonization
    • ~40% of infants < 1 month are colonized and asymptomatic[3]
    • ~15% in infants 6-12 months
    • By 2 years of age, normal flora is established, similar to adults[4]


Management

  • Stop offending antimicrobial agents, if possible
  • Initial occurrence and first recurrence of mild-moderate disease:[5]
  • Severe infection or second recurrence:
    • PO vancomycin 40 mg/kg/d in four divided doses, max 500 mg/day
    • If no improvement after 24-48 hours, oral vancomycin max dose may be increased to 2 g/d
    • Q6hr IV metronidazole, 30 mg/kg/d, may be added to intracolonic/enema vancomycin for ileus, inability to tolerate PO antibiotics
  • Multiple recurrences, other strategies, in consult with pediatric GI:
    • May benefit from tapering and pulse oral vancomycin over 1.5-2 months, as done in adults
    • Consider PO fidaxomicin in ≥ 6 year old patients at 200 mg twice daily for 10 dats


Disposition


Antibiotic Sensitivities[6]

Category Antibiotic Sensitivity
Penicillins Penicillin G X2
Penicillin V X1
Anti-Staphylocccal Penicillins Methicillin X1
Nafcillin/Oxacillin X1
Cloxacillin/Diclox. X1
Amino-Penicillins AMP/Amox X1
Amox-Clav X1
AMP-Sulb X2
Anti-Pseudomonal Penicillins Ticarcillin X1
Ticar-Clav X1
Pip-Tazo X1
Piperacillin X2
Carbapenems Doripenem X2
Ertapenem X2
Imipenem X2
Meropenem X2
Aztreonam R
Fluroquinolones Ciprofloxacin R
Ofloxacin X1
Pefloxacin X1
Levofloxacin R
Moxifloxacin R
Gemifloxacin X1
Gatifloxacin R
1st G Cephalo Cefazolin X1
2nd G. Cephalo Cefotetan X1
Cefoxitin R
Cefuroxime X1
3rd/4th G. Cephalo Cefotaxime R
Cefizoxime R
CefTRIAXone X1
Ceftaroline X1
CefTAZidime X1
Cefepime R
Oral 1st G. Cephalo Cefadroxil X1
Cephalexin X1
Oral 2nd G. Cephalo Cefaclor/Loracarbef X1
Cefproxil X1
Cefuroxime axetil X1
Oral 3rd G. Cephalo Cefixime X1
Ceftibuten X1
Cefpodox/Cefdinir/Cefditoren X1
Aminoglycosides Gentamicin R
Tobramycin R
Amikacin R
Chloramphenicol I
Clindamycin X1
Macrolides Erythromycin X1
Azithromycin X1
Clarithromycin X1
Ketolide Telithromycin X1
Tetracyclines Doxycycline X1
Minocycline X1
Glycylcycline Tigecycline X1
Daptomycin X1
Glyco/Lipoclycopeptides Vancomycin S
Teicoplanin S
Telavancin S
Fusidic Acid X1
Trimethoprim X1
TMP-SMX X1
Urinary Agents Nitrofurantoin X1
Fosfomycin X1
Other Rifampin X1
Metronidazole S
Quinupristin dalfoppristin I
Linezolid I
Colistimethate X1


See Also


References

  1. ↑ Leffler DA and Lamont JT. Clostridium difficile Infection. N Engl J Med. 2015; 372:1539-1548.
  2. ↑ Marx et al. “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”. Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.
  3. ↑ Asymptomatic colonization by Clostridium difficile in infants: implications for disease in later life. Jangi S, Lamont JT. J Pediatr Gastroenterol Nutr. 2010 Jul; 51(1):2-7.
  4. ↑ Clostridium difficile Infection in children. Sammons JS, Toltzis P, Zaoutis TE. JAMA Pediatr. 2013 Jun; 167(6):567-73.
  5. ↑ D'Ostroph AR and So TY. Treatment of pediatric Clostridium difficile infection: a review on treatment efficacy and economic value. Infect Drug Resist. 2017; 10: 365–375.
  6. ↑ Sanford Guide to Antimicrobial Therapy 2014
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