First recurrence of C. difficile infection in children younger than 18 years

For an overview of managing Clostridioides difficile infection in children, see Overview of managing a new episode of diarrhoea in children younger than 18 years with risk factors for Clostridioides difficile infection.

Recurrent disease is defined as C. difficile infection occurring within 2 months of the previous episode, after resolution of symptoms.

Seek expert advice for severe, complicated or fulminant disease (for definitions, see Severity assessment of C. difficile infection in children). For treatment recommendations, see Severe, complicated or fulminant Clostridioides difficile infection.

Investigate for other causes of diarrhoea in children younger than 18 years with recurrent disease because C. difficile infection or recurrence is not common in children. Seek expert advice for children with recurrent disease.

In addition to starting antibiotics for C. difficile infection, management includes:

  • starting rehydration strategies
  • stopping any implicated antibiotics unless there is a strong rationale for continuing them. In up to 25% of patients in whom antibiotics are stopped, symptoms resolve and the risk of relapse is reduced. If antibiotics cannot be stopped, seek expert advice
  • avoiding proton pump inhibitors (PPIs) and antimotility drugs
  • considering whether any of the following may be contributing to ongoing symptoms and addressing these, if possible:
    • other factors (eg diet, caffeine, lactose) or medications (eg lactulose) that may exacerbate diarrhoea
    • concomitant conditions that can cause similar symptoms (eg inflammatory bowel disease).
Note: Do not give vancomycin intravenously to treat C. difficile infection.

For a first recurrence of C. difficile infection in children younger than 18 years, useJohnson, 2021van Prehn, 2021:

vancomycin 10 mg/kg up to 125 mg orally or enterally, 6-hourly for 10 days123. vancomycin vancomycin vancomycin

Consider tapering the vancomycin dose before stopping. For example, after the initial 10 days of therapy, use Johnson, 2021van Prehn, 2021:

vancomycin 10 mg/kg up to 125 mg orally, 12-hourly for 1 week; then 10 mg/kg up to 125 mg orally, daily for 1 week; then 10 mg/kg up to 125 mg orally every 2 or 3 days for 2 to 8 weeks123.

Diarrhoea may take several days to respond to appropriate treatment. Data suggest that the median time to resolution of diarrhoea is 2 to 3 days, with most patients responding by 5 daysLouie, 2006.

For children who have clinically improved, complete the course. For information about follow-up testing and patient education, see Follow-up for patients with Clostridioides difficile infection.

For children who have not clinically improved after 5 days of therapy, consider alternative diagnoses and seek advice from an infectious diseases physician.

1 Injectable vancomycin can be given orally or enterally, as an alternative to oral capsules. Dissolve 500 mg of vancomycin powder in 10 mL of water, measure the appropriate dose (eg 125 mg = 2.5 mL), and give orally or enterally. Flavouring syrups can be added before administration to improve palatability. Alternatively, an oral vancomycin suspension is available through the Special Access Scheme.Return
2 Intravenous vancomycin is not effective against C. difficile infection because of inadequate penetration of the drug into the lumen of the colon.Return
3 Systemic absorption of vancomycin can occur with oral or enteral administration. If toxicity is suspected, consider measuring vancomycin plasma concentrations; otherwise, therapeutic drug monitoring is not required.Return