C. Diff in Kids

C Diff

Obviously diarrheal illness can be quite debilitating and even devastating in children.  Often the main concern is Dehydration and that focusing on Oral Rehydration Therapy many of these children will do just fine.  While most often the diarrhea is due to a non-specific “virus,” there are a few specific considerations that may cross your mind, like HUS or Salmonella.  In addition, one consideration that is often thought of in adults, but perhaps overlooked in children, is C. Diff.

 

C. Diff Basics

  • Clostridium difficile (C. Diff) is a spore-forming, obligate anaerobic, Gram-Positive bacillus.
  • It produces toxins (Toxin A and B) that lead to intestinal injury.
  • It is the MOST COMMON cause of antibiotic-associated diarrhea.
  • C. Diff incidence has been increasing in hospitalized children. [Zilberger, 2010]
  • C. Diff infection is associated with longer hospitalizations and increased mortality. [Sammons, 2013]
  • Recent evidence also describes the importance of antibiotic stewardship and community-associated cases. [Khanna, 2012Wendt, 2014]

 

C. Diff Diagnosis

  • The diagnosis of C. Diff disease is based on the presence of diarrhea and C. difficile toxins in a diarrheal stool specimen. [Schutze, 2013]
  • Isolation of the organism is not clinically useful.
  • Testing for the toxin is preferred.
  • Testing by age: [Schutze, 2013]
    • < 1 year of age – avoid routine testing.
      • Asymptomatic carriage is common.
      • Testing should be limited to those with motility disorders (ex, Hirshsprung’s disease) or during an outbreak.
    • 1-3 years of life – search for other alternatives first.
      • Interpretation of results is challenging.
      • A positive result may indicate C. Diff infection.
    • After 3 years of life – a positive result indicates probably infection.
      • Still needs to be interpreted within the clinical setting.
      • The mere presence of a virulent pathogen does not necessary mean that that pathogen is the cause of the patients current symptoms. [Denno, 2012]
      • Pediatric oncology patients can also harbor C. Diff and be asymptomatic. [Dominguez, 2014]
      • To recap… C. Diff disease is Difficult to diagnosis accurately.
  • Do not “test for cure” as the toxin, the organism, and its genome are present for long periods after resolution of diarrhea. [Schutze, 2013]

 

C. Diff Therapy

  1. First stop the offending antimicrobial therapy!
    • May be sufficient enough to resolve symptoms.
  2. Avoid anti-peristaltic medications.
    • May worsen condition and lead to toxic megacolon.
  3. Oral Metronidazole is the drug of choice for initial therapy.
    • 30mg/kg/day in 4 divided doses, Max 2 grams/day.
    • Metronidazole-resistant C. Diff is rare.
  4. For severe disease/non-responders to 1st line, oral vancomycin or rectal vancomycin with or without IV metronidazole is used.
    • Oral vancomycin 40mg/kg/day in 4 divided doses, Max 2 grams/day.
    • Severe disease is more likely in patients with neutropenia, or intestinal stasis (ex, Hirshsprung’s disease).
  5. Up to 30% will have a recurrence after therapy ends.

 

References

Dominguez SR1, Dolan SA2, West K2, Dantes RB3, Epson E4, Friedman D5, Littlehorn CA6, Arms LE6, Walton K5, Servetar E5, Frank DN7, Kotter CV7, Dowell E6, Gould CV8, Hilden JM9, Todd JK1. High colonization rate and prolonged shedding of Clostridium difficile in pediatric oncology patients. Clin Infect Dis. 2014 Aug;59(3):401-3. PMID: 24785235. [PubMed] [Read by QxMD]

Martinelli M1, Strisciuglio C, Veres G, Paerregaard A, Pavic AM, Aloi M, Martín-de-Carpi J, Levine A, Turner D, Del Pezzo M, Staiano A, Miele E; Porto IBD Working Group of European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). Clostridium difficile and pediatric inflammatory bowel disease: a prospective, comparative, multicenter, ESPGHAN study. Inflamm Bowel Dis. 2014 Dec;20(12):2219-25. PMID: 25268634. [PubMed] [Read by QxMD]

Wendt JM1, Cohen JA, Mu Y, Dumyati GK, Dunn JR, Holzbauer SM, Winston LG, Johnston HL, Meek JI, Farley MM, Wilson LE, Phipps EC, Beldavs ZG, Gerding DN, McDonald LC, Gould CV, Lessa FC. Clostridium difficile infection among children across diverse US geographic locations. Pediatrics. 2014 Apr;133(4):651-8. PMID: 24590748. [PubMed] [Read by QxMD]

Schutze GE, Willoughby RE; Committee on Infectious Diseases; American Academy of Pediatrics. Clostridium difficile infection in infants and children. Pediatrics. 2013 Jan;131(1):196-200. PMID: 23277317. [PubMed] [Read by QxMD]

Denno DM1, Shaikh N, Stapp JR, Qin X, Hutter CM, Hoffman V, Mooney JC, Wood KM, Stevens HJ, Jones R, Tarr PI, Klein EJ. Diarrhea etiology in a pediatric emergency department: a case control study. Clin Infect Dis. 2012 Oct;55(7):897-904. PMID: 22700832. [PubMed] [Read by QxMD]

Khanna S1, Baddour LM, Huskins WC, Kammer PP, Faubion WA, Zinsmeister AR, Harmsen WS, Pardi DS. The epidemiology of Clostridium difficile infection in children: a population-based study. Clin Infect Dis. 2013 May;56(10):1401-6. PMID: 23408679. [PubMed] [Read by QxMD]

Sammons JS1, Localio R, Xiao R, Coffin SE, Zaoutis T. Clostridium difficile infection is associated with increased risk of death and prolonged hospitalization in children. Clin Infect Dis. 2013 Jul;57(1):1-8. PMID: 23532470. [PubMed] [Read by QxMD]

Zilberberg MD1, Tillotson GS, McDonald C. Clostridium difficile infections among hospitalized children, United States, 1997-2006. Emerg Infect Dis. 2010 Apr;16(4):604-9. PMID: 20350373. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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