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<languages/>
''This page is for <u>pediatric</u> patients; for adult patients see [[Special:MyLanguage/clostridium difficile|clostridium difficile]].''

==Background==

[[File:Pseudomembranous colitis 1.jpg|thumb|Pseudomembranous colitis with yellow pseudomembranes seen on the wall of the sigmoid colon.]]
*[[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
*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>

===Pediatric Risk Factors===

*[[Special:MyLanguage/Antibiotic|Antibiotic]] exposure, particularly [[Special:MyLanguage/penicillins|penicillins]], [[Special:MyLanguage/cephalosporins|cephalosporins]], [[Special:MyLanguage/clindamycin|clindamycin]], [[Special:MyLanguage/fluoroquinolones|fluoroquinolones]]
*[[Special:MyLanguage/PPIs|PPIs]]
*GI feeding tubes
*Comorbidities - cancer, recent surgery, hospitalizations

==Clinical Features==

''Varies according to severity and intrinsic host factors (immunosuppression, etc.).''
*[[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
*Recent discharge from hospital
*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]]

==Differential Diagnosis==

{{Diarrhea DDX}}

==Evaluation==

[[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).]]

===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<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==

*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>
**PO [[Special:MyLanguage/metronidazole|metronidazole]] 30 mg/kg/d in four divided doses, max 2 g/day
*Severe infection or second recurrence:
**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 [[Special:MyLanguage/vancomycin|vancomycin]] max dose may be increased to 2 g/d
**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 [[Special:MyLanguage/vancomycin|vancomycin]] in 50 mL NS
***4-9 year old -- 375 mg [[Special:MyLanguage/vancomycin|vancomycin]] in 75 mL NS
***> 9 year old -- 500 mg [[Special:MyLanguage/vancomycin|vancomycin]] in 100 mL NS
*Multiple recurrences, other strategies, in consult with pediatric GI:
**May benefit from tapering and pulse oral [[Special:MyLanguage/vancomycin|vancomycin]] over 1.5-2 months, as done in adults
**Consider PO [[Special:MyLanguage/fidaxomicin|fidaxomicin]] in ≥ 6 year old patients at 200 mg twice daily for 10 dats

==Disposition==

*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]])

==[[Special:MyLanguage/Antibiotic Sensitivities|Antibiotic Sensitivities]]<ref>Sanford Guide to Antimicrobial Therapy 2014</ref>==

{| class="wikitable"
| align="center" style="background:#f0f0f0;"|'''Category'''
| align="center" style="background:#f0f0f0;"|'''Antibiotic'''
| align="center" style="background:#f0f0f0;"|'''Sensitivity'''
|-
| [[Special:MyLanguage/Penicillins|Penicillins]]||[[Special:MyLanguage/Penicillin G|Penicillin G]]||X2
|-
| ||[[Special:MyLanguage/Penicillin V|Penicillin V]]||X1
|-
| Anti-Staphylocccal [[Special:MyLanguage/Penicillins|Penicillins]]||[[Special:MyLanguage/Methicillin|Methicillin]]||X1
|-
| ||[[Special:MyLanguage/Nafcillin|Nafcillin]]/[[Special:MyLanguage/Oxacillin|Oxacillin]]||X1
|-
| ||[[Special:MyLanguage/Cloxacillin|Cloxacillin]]/[[Special:MyLanguage/Diclox.|Diclox.]]||X1
|-
| Amino-[[Special:MyLanguage/Penicillins|Penicillins]]||[[Special:MyLanguage/AMP|AMP]]/[[Special:MyLanguage/Amox|Amox]]||X1
|-
| ||[[Special:MyLanguage/Amox-Clav|Amox-Clav]]||X1
|-
| ||[[Special:MyLanguage/AMP-Sulb|AMP-Sulb]]||X2
|-
| Anti-Pseudomonal [[Special:MyLanguage/Penicillins|Penicillins]]||[[Special:MyLanguage/Ticarcillin|Ticarcillin]]||X1
|-
| ||[[Special:MyLanguage/Ticar-Clav|Ticar-Clav]]||X1
|-
| ||[[Special:MyLanguage/Pip-Tazo|Pip-Tazo]]||X1
|-
| ||[[Special:MyLanguage/Piperacillin|Piperacillin]]||X2
|-
| [[Special:MyLanguage/Carbapenems|Carbapenems]]||[[Special:MyLanguage/Doripenem|Doripenem]]||X2
|-
| ||[[Special:MyLanguage/Ertapenem|Ertapenem]]||X2
|-
| ||[[Special:MyLanguage/Imipenem|Imipenem]]||X2
|-
| ||[[Special:MyLanguage/Meropenem|Meropenem]]||X2
|-
| ||[[Special:MyLanguage/Aztreonam|Aztreonam]]||R
|-
| [[Special:MyLanguage/Fluroquinolones|Fluroquinolones]]||[[Special:MyLanguage/Ciprofloxacin|Ciprofloxacin]]||R
|-
| ||[[Special:MyLanguage/Ofloxacin|Ofloxacin]]||X1
|-
| ||[[Special:MyLanguage/Pefloxacin|Pefloxacin]]||X1
|-
| ||[[Special:MyLanguage/Levofloxacin|Levofloxacin]]||R
|-
| ||[[Special:MyLanguage/Moxifloxacin|Moxifloxacin]]||R
|-
| ||[[Special:MyLanguage/Gemifloxacin|Gemifloxacin]]||X1
|-
| ||[[Special:MyLanguage/Gatifloxacin|Gatifloxacin]]||R
|-
| 1st G [[Special:MyLanguage/Cephalo|Cephalo]]||[[Special:MyLanguage/Cefazolin|Cefazolin]]||X1
|-
| 2nd G. [[Special:MyLanguage/Cephalo|Cephalo]]||[[Special:MyLanguage/Cefotetan|Cefotetan]]||X1
|-
| ||[[Special:MyLanguage/Cefoxitin|Cefoxitin]]||R
|-
| ||[[Special:MyLanguage/Cefuroxime|Cefuroxime]]||X1
|-
| 3rd/4th G. [[Special:MyLanguage/Cephalo|Cephalo]]||[[Special:MyLanguage/Cefotaxime|Cefotaxime]]||R
|-
| ||[[Special:MyLanguage/Cefizoxime|Cefizoxime]]||R
|-
| ||[[Special:MyLanguage/CefTRIAXone|CefTRIAXone]]||X1
|-
| ||[[Special:MyLanguage/Ceftaroline|Ceftaroline]]||X1
|-
| ||[[Special:MyLanguage/CefTAZidime|CefTAZidime]]||X1
|-
| ||[[Special:MyLanguage/Cefepime|Cefepime]]||R
|-
| Oral 1st G. [[Special:MyLanguage/Cephalo|Cephalo]]||[[Special:MyLanguage/Cefadroxil|Cefadroxil]]||X1
|-
| ||[[Special:MyLanguage/Cephalexin|Cephalexin]]||X1
|-
| Oral 2nd G. [[Special:MyLanguage/Cephalo|Cephalo]]||[[Special:MyLanguage/Cefaclor|Cefaclor]]/[[Special:MyLanguage/Loracarbef|Loracarbef]]||X1
|-
| ||[[Special:MyLanguage/Cefproxil|Cefproxil]]||X1
|-
| ||[[Special:MyLanguage/Cefuroxime axetil|Cefuroxime axetil]]||X1
|-
| Oral 3rd G. [[Special:MyLanguage/Cephalo|Cephalo]]||[[Special:MyLanguage/Cefixime|Cefixime]]||X1
|-
| ||[[Special:MyLanguage/Ceftibuten|Ceftibuten]]||X1
|-
| ||[[Special:MyLanguage/Cefpodox|Cefpodox]]/[[Special:MyLanguage/Cefdinir|Cefdinir]]/[[Special:MyLanguage/Cefditoren|Cefditoren]]||X1
|-
| [[Special:MyLanguage/Aminoglycosides|Aminoglycosides]]||[[Special:MyLanguage/Gentamicin|Gentamicin]]||R
|-
| ||[[Special:MyLanguage/Tobramycin|Tobramycin]]||R
|-
| ||[[Special:MyLanguage/Amikacin|Amikacin]]||R
|-
| ||[[Special:MyLanguage/Chloramphenicol|Chloramphenicol]]||I
|-
| ||[[Special:MyLanguage/Clindamycin|Clindamycin]]||X1
|-
| [[Special:MyLanguage/Macrolides|Macrolides]]||[[Special:MyLanguage/Erythromycin|Erythromycin]]||X1
|-
| ||[[Special:MyLanguage/Azithromycin|Azithromycin]]||X1
|-
| ||[[Special:MyLanguage/Clarithromycin|Clarithromycin]]||X1
|-
| Ketolide||[[Special:MyLanguage/Telithromycin|Telithromycin]]||X1
|-
| Tetracyclines||[[Special:MyLanguage/Doxycycline|Doxycycline]]||X1
|-
| ||[[Special:MyLanguage/Minocycline|Minocycline]]||X1
|-
| Glycylcycline||[[Special:MyLanguage/Tigecycline|Tigecycline]]||X1
|-
| ||[[Special:MyLanguage/Daptomycin|Daptomycin]]||X1
|-
| Glyco/Lipoclycopeptides||[[Special:MyLanguage/Vancomycin|Vancomycin]]||'''S'''
|-
| ||[[Special:MyLanguage/Teicoplanin|Teicoplanin]]||'''S'''
|-
| ||[[Special:MyLanguage/Telavancin|Telavancin]]||'''S'''
|-
| ||[[Special:MyLanguage/Fusidic Acid|Fusidic Acid]]||X1
|-
| ||[[Special:MyLanguage/Trimethoprim|Trimethoprim]]||X1
|-
| ||[[Special:MyLanguage/TMP-SMX|TMP-SMX]]||X1
|-
| Urinary Agents||[[Special:MyLanguage/Nitrofurantoin|Nitrofurantoin]]||X1
|-
| ||[[Special:MyLanguage/Fosfomycin|Fosfomycin]]||X1
|-
| Other||[[Special:MyLanguage/Rifampin|Rifampin]]||X1
|-
| ||[[Special:MyLanguage/Metronidazole|Metronidazole]]||'''S'''
|-
| ||[[Special:MyLanguage/Quinupristin dalfoppristin|Quinupristin dalfoppristin]]||I
|-
| ||[[Special:MyLanguage/Linezolid|Linezolid]]||I
|-
| ||[[Special:MyLanguage/Colistimethate|Colistimethate]]||X1
|}

==See Also==

*[[Special:MyLanguage/Diarrhea|Diarrhea]]
*[[Special:MyLanguage/Clostridium|Clostridium]]

==References==

<references/>

[[Category:ID]]
[[Category:GI]]

Clostridium difficile (peds)/en - Revision history

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