GI IMPACT Study

The Diarrhea Study

Clostridium difficile - Information for Clinicians

Type of infection

Clostridium difficile is an anaerobic spore-forming gram-positive rod. Disease causing strains produce toxins A and/or B.

Sources of infection

  1. C. difficile commonly colonizes the intestines of chilren younger than 1. Rates of colonization fall to about adult levels (1-3%) by school age. It is shed in large quantities by people with C. difficile associated diarrhea (CDAD).
  2. C. difficile spores contaminate many surfaces and are resistant to many disinfectants.
  3. Older children usually acquire the organism in health care settings from contact with contaminated surfaces.
  4. Most disease follows antibiotic exposure but other risk factors include proton pump inhibitors, gastrointestinal surgery, and severe underlying illness.

Usual symptoms

  1. Diarrhea, abdominal pain and tenderness, and occassionally fever.

Complications

  1. Diarrhea can become very severe or bloody.
  2. Toxic megacolon, intestinal perforation, renal failure.
  3. Rarely, severe damage to the intestines can occur requiring emergency surgery.
  4. Severe disease can occur in children with Hirschsprung's disease.

Duration of illness

  1. Typically 5-7 days. Relapse can occur in up to 25%.

Treatment

  1. Other causes of diarrhea should always be considered for children younger than 1 who test positive for C. difficile.
  2. For children 1-5, the predictive value of a positive test, especially using molecular detection methods, is not known and other causes of diarrhea should be considered.
  3. Stop other antibiotic therapy, prevent dehydration, and treat dehydration. Children with mild disease often recover without treatment after stopping antibiotics.
  4. Oral metronidazole (30 mg/kg/day div q8h) can be used for mild to moderate disease.
  5. Oral vancomycin (40 mg/kg/day div q6h) is preferred for more severe disease.
  6. Oral vancomycin should be used for the first recurrence of CDAD.

Comments

  1. Use gown and gloves on entering the room and wash hands with soap and water when caring for patients with CDAD. Alcohol-based hand sanitizers do not inactivate C. difficile.
  2. Use disinfecting wipes containing bleach on surfaces that come into contact with the patient or their stool.
  3. If possible, stop or limit all other antibiotics in patients with CDAD.
  4. Management of a second recurrence is complex. Consider GI or ID referral.

Resources

  1. AAP Statement: Schutze and Willoughby. Committee on Infectious Diseases. Clostridium difficile infection in infants and children. Pediatr 2013 Jan; 131(1):196-200.
  2. Sammons et al. Clostridium difficile infection in children. JAMA Pediatr 2013 Jun; 167(6):567-73.