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

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Background

In adults Clostridium difficile is a common cause of hospital acquired diarrhoea.  In children the role of C difficile is less well understood and in the majority likely represents gut colonisation. Recent studies however have shown that C difficile is an emerging pathogen in the paediatric setting particularly in patient with underlying haemato-oncology and gastrointestinal disorders. Other risk factors include recent antibiotics, proton pump inhibitors and prolonged hospitalisation. 

Health Protection Scotland now recommends that diagnostic labs test diarrhoeal stools in all children aged 3 years or older for CDI.  Testing of diarrhoeal stools from children under the age of 3 years should be at the clinicians request only. 

Interpretation of results

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;

Result

Interpretation

GDH negative

No CDI or colonisation

GDH positive, toxin negative

Colonised with C difficile. Unlikely to require treatment. Send repeat samples if symptoms persist

GDH positive, toxin positive

CDI possible if case definition met

 

Case definition

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

  • Significant co morbidity – Gastrointestinal disease, haematooncological 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
Severity scoring

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

Criteria

Point

Diarrhoea > 5 times/day

1

Abdominal pain and discomfort

1

Rising white cell count

1

Raised CRP

1

Pyrexia > 38oC

1

Evidence of pseudomembranous colitis

2

Intensive care requirement

2

Score:

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

Medical management

In all cases the need for antibiotics should be reviewed by medical staff. If possible discontinue or switch to less C diffogenic agents. 

PPI /H2 antagonist use should be reviewed and if possible discontinued

Mild disease (score 1-2)

Mild disease may not require treatment. Consider oral metronidazole for 10-14 days if symptoms persist

 

Moderate disease (score 3-4)

Oral metronidazole for 10-14 days. 

Consider escalation to oral Vancomycin if non resolution of symptoms

 

Severe disease ≥5

Oral Vancomycin and iv metronidazole. Consider surgical intervention/ colectomy if evidence of caecal dilatation on imaging

 

Recurrent CDI following completion of treatment course

For recurrence of CDI please contact a paediatric ID physician or microbiology  for advice on management

Infection control precautions
Editorial Information

Last reviewed: 27 November 2017

Next review: 29 November 2019

Author(s): Ysobel Gourlay

Version: 1

Approved By: Antimicrobial Utilisation Committee