Treatment of Clostridioides difficile infection in children

Treatment of Clostridioides difficile infection in children

Clinical features	Suggested treatment
First episode
Mild or moderate	Vancomycin 40 mg/kg per day orally divided in 4 doses (maximum dose: 125 mg) for 10 days, or Metronidazole 30 mg/kg per day orally divided in 4 doses (maximum dose: 500 mg) for 10 days, or Fidaxomicin, dosed according to body weight: 4 to <7 kg (oral suspension): 80 mg orally twice daily for 10 days 7 to <9 kg (oral suspension): 120 mg orally twice daily for 10 days 9 to <12.5 kg (oral suspension): 160 mg orally twice daily for 10 days ≥12.5 kg (oral suspension): 200 mg orally twice daily for 10 days
Severe*	Vancomycin 40 mg/kg per day orally divided in 4 doses (maximum dose: 125 mg) for 10 days
Fulminant^¶	Metronidazole 30 mg/kg per day IV divided in 3 doses (maximum dose: 500 mg), plus Vancomycin 40 mg/kg per day orally divided in 4 doses (maximum dose: 500 mg) until clinical improvement and then (if applicable) decrease the maximum dose to 125 mg to complete 10 days
Fulminant^¶ disease and ileus	Metronidazole 30 mg/kg per day IV divided in 3 doses (maximum dose: 500 mg), plus Vancomycin 10 mg/kg per dose in normal saline (maximum dose: 500 mg in 100 mL normal saline) administered by retention enema 4 times per day^Δ; the volume of solution varies with age: 1 through 4 years: 50 mL 5 through 11 years: 75 mL ≥12 years: 100 mL
Recurrent episodes
First recurrence, mild or moderate	Repeat regimen used for first episode
Subsequent recurrence, mild or moderate	Either of the following: Pulsed-tapered vancomycin (maximum dose: 125 mg): 10 mg/kg orally 4 times daily for 10 to 14 days, followed by 10 mg/kg orally twice daily for 7 days, followed by 10 mg/kg orally once daily for 7 days, followed by 10 mg/kg orally every other day for 7 days, followed by 10 mg/kg orally every 3 days for 2 to 8 weeks Fidaxomicin, dosed according to weight: 4 to <7 kg (oral suspension): 80 mg orally twice daily for 10 days 7 to <9 kg (oral suspension): 120 mg orally twice daily for 10 days 9 to <12.5 kg (oral suspension): 160 mg orally twice daily for 10 days ≥12.5 kg (oral suspension or tablets): 200 mg orally twice daily for 10 days

This table is meant to be used in conjunction with the UpToDate topic on treatment of C. difficile infection in children.

IV: intravenous.

* There is no consensus definition of severe C. difficile infection in children. Determination of disease severity should be guided by clinician judgment. We use the following criteria to define severe disease: Fever, profuse diarrhea, abdominal pain and tenderness, abdominal distention, white blood cell count >15,000 cells/microL, elevated age-adjusted creatinine level, serum albumin <2.5 g/dL (25 g/L), and pseudomembranous colitis.

¶ Fulminant disease is characterized by hypotension, shock, ileus, or toxic megacolon.

Δ The optimal dose and volume for rectal vancomycin has not been established for children or adults. Dose and volume adjustments may be required depending upon individual circumstances, extent of colonic disease, and patient weight. Caution is required because perforation is possible with rectal installation of vancomycin.

Adapted from: McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2018.

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Treatment of Clostridioides difficile infection in children