Clostridioides (Clostridium) Difficile Infection (CDI) in children: diagnosis and management

In all cases, testing results must be carefully evaluated against the clinical background of the patient.

In GGC diagnostic labs test diarrhoeal samples for CDI in two stages. Firstly all diarrhoeal stool samples are tested using a sensitive screening test – GDH (glutamate dehydrogenase).

If the GDH test is negative the stool sample is reported as negative for CDI
If the GDH test is positive the lab proceeds to the second stage of testing which is toxin detection.

The interpretation of results is as follows;

GDH and toxin positive sample with diarrhoea and one or more of the following

• Significant co morbidity – Gastrointestinal disease, haemato-oncological condition
• Antibiotic use in the last 4 weeks
• Severe GI disease with bloody diarrhoea and an unlikely alternative diagnosis.

Further investigation:

• Send FBC , CRP and U+Es
• Request imaging ( abdominal X-ray) if toxic megacolon or ileus is suspected
• Test for clearance is not required

Patients who meet the above case definition should undergo daily severity scoring as below and be managed accordingly

Score:

1-2 = Mild disease
3-4 = Moderate disease
≥5 = Severe disease

• Review all antibiotics. Where possible discontinue or switch to less C.diffogenic agents.
• PPI /H2 antagonist use should be reviewed and if possible discontinued

Treatment

All drug doses as per BNF for Children or Summary of Product Characteristics (SmPC)

For first recurrence of CDI please follow the management advice below. If relapse/recurrence is severe/life threatening seek urgent specialist advice as above. For second recurrence discuss with an infection specialist.

Please refer to the NHSGGC CDI infection control policy 

Management in Primary Care:
Metronidazole may be prescribed in community if delays in supply of oral vancomycin would result in delayed initiation of treatment. Metronidazole should be substituted with oral vancomycin as soon as availability is resolved to complete a total of 10 days treatment. For patients who cannot swallow vancomycin capsules, fidaxomicin should be considered the first line option in community setting.

Fidaxomicin:
Fidaxomicin tablets are licensed in children weighing at least 12.5kg. Fidaxomicin granules for oral suspension (40mg/ml) became available in the UK in May 2022. For children weighing less than 12.5kg consider oral vancomycin PLUS IV metronidazole if granules unavailable and/or seek specialist advice.

Vancomycin:
Vancomycin injection can be used via the oral route in the hospital setting where capsules are not available or where the calculated dose cannot be administered using available capsule strengths. Guidance on administration is available below:

To administer vancomycin via an NGT;

• Use vancomycin injection, 500mg vial.
• Reconstitute a 500mg vial with 10ml water for injection to give a 50mg/ml solution.
• Calculate the dose and withdraw the required amount from the vial. Discard the remainder of the vial.
• Flush the enteral feeding tube with 15mls sterile water prior to administration. The dose can be further diluted with water for injection if required.
• Administer the dose and flush with a further 15ml sterile water.