Clostridium difficile (peds)

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

Pediatric Risk Factors

• Antibiotic exposure, particularly penicillins, cephalosporins, clindamycin, fluoroquinolones
• PPIs
• GI feeding tubes
• Comorbidities - cancer, recent surgery, hospitalizations

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

• Viral (e.g. rotavirus)
• Bacterial
  • Campylobacter
  • Shigella
  • Salmonella (non-typhi)
  • Escherichia coli
    • E. coli 0157:H7
  • Yersinia enterocolitica
  • Vibrio cholerae
  • Clostridium difficile
• Parasitic
  • Giardia lamblia
  • Cryptosporidium
  • Entamoeba histolytica
  • Cyclospora
  • Microsporidium
• Toxin
  • Staphylococcus aureus
  • Bacillus cereus

Noninfectious

• GI Bleed
• Appendicitis
• Mesenteric Ischemia
• Diverticulitis
• Adrenal Crisis
• Thyroid Storm
• Toxicologic exposures
• Antibiotic or drug-associated
• Inflammatory bowel disease
  • Crohn's disease
  • Ulcerative colitis

Watery Diarrhea

• Enterotoxigenic E. coli (most common cause of watery diarrhea)
• Norovirus (often has prominent vomiting)
• Campylobacter
• Non-typhoidal Salmonella
• Enteroaggregative E. coli (EAEC)
• Enterotoxigenic Bacteroides fragilis

Traveler's Diarrhea

• Giardia lamblia
• Cryptosporidiosis
• Entamoeba histolytica
• Cyclospora
• Clostridium perfringens
• Listeriosis
• Helminth infections
• Marine toxins
  • Ciguatera
  • Scombroid poisoning
  • Paralytic shellfish poisoning
  • Neurotoxic shellfish poisoning
  • Diarrheal shellfish poisoning

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
  • ~15% in infants 6-12 months
  • By 2 years of age, normal flora is established, similar to adults

Management

• Stop offending antimicrobial agents, if possible
• Initial occurrence and first recurrence of mild-moderate disease:
  • PO metronidazole 30 mg/kg/d in four divided doses, max 2 g/day
• 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
    • 1-3 year old -- 250 mg vancomycin in 50 mL NS
    • 4-9 year old -- 375 mg vancomycin in 75 mL NS
    • > 9 year old -- 500 mg vancomycin in 100 mL NS
• 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

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

Antibiotic Sensitivities

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

• Diarrhea
• Clostridium