Clostridium difficile Diarrhea in Children: Diagnosis, Management, and Prevention

Jonathan D. Crews, MD


January 24, 2014

Severe Pediatric CDI

For children with severe disease, oral vancomycin (40 mg/kg/day in 4 divided doses; maximum, 2 g/day) given with or without metronidazole is recommended.[1] This recommendation is informed by a randomized trial in adults that found that in severe disease, a clinical cure was achieved more frequently with vancomycin than metronidazole (97% vs 76%; P = .02).[22] Vancomycin is poorly absorbed and achieves high concentrations in the stool.

Up to 30% of children with CDI will experience a recurrence in the 2 months following the primary episode.[1,10] For children with a first recurrence, the AAP recommends the use of metronidazole. For a second recurrence, they recommend oral vancomycin.[1] The AAP does not provide recommendations for the child with 3 or more recurrences of CDI. For this difficult situation, a vancomycin taper is often used. Long-term use of metronidazole should be avoided owing to risk for neurotoxicity.[18]

Additional antibiotics with activity against C difficile include fidaxomicin, nitazoxanide, and rifaximin. Currently, there are no recommendations for their use in pediatric CDI because there are few data on their use in children.

Fidaxomicin was recently approved for CDI in adults. In phase 3 trials in adults, fidaxomicin was associated with a similar rate of clinical cure and a lower recurrence rate than oral vancomycin.[23] Fidaxomicin is currently undergoing investigation in children.

Nitazoxanide, approved for the treatment of Giardia and Cryptosporidium infection in children older than 1 year, was found to have a similar cure rate as vancomycin in a small trial in adults.[24] Rifaximin, an agent approved for traveler's diarrhea in individuals older than 12 years, has been given as "chaser" following a conventional agent for recurrent CDI in adults.[25]

Fecal microbiota transplantation (FMT) has recently emerged as a promising treatment modality for recurrent CDI. Donor stool is administered by nasogastric tube, enema, or colonoscope to restore the proper balance of the intestinal microbiota. A recent clinical trial in adults found FMT to be more effective than vancomycin for the management of recurrent CDI.[26] At the time of this writing, there has only been a single case report on FMT for the treatment of CDI in a child.[27] FMT in children remains experimental and should only be performed at centers experienced in donor screening and stool processing for children refractory to conventional C difficile therapies.


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