Clostridium Difficile Infection (CDI) in children: diagnosis and management
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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.
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 |
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.
- 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
|
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
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
Please refer to the NHSGGC CDI infection control policy
- Recommended protocol for testing for Clostridium difficile and subsequent culture. Health Protection Scotland , October 2016
- Pai S et al. Five years experience of Clostridium difficile infection in children at a UK tertiary hospital: proposed criteria for diagnosis and management. PLOS 2012;71-6
Last reviewed: 17 November 2020
Next review: 30 November 2023
Author(s): Susan Kafka
Version: 2
Co-Author(s): Guideline development group: Dr T Inkster, Infection Control Doctor; Dr C Doherty, Paediatric ID Physician; Dr A Deshpande, Consultant Microbiologist; Kathleen Harvey-Wood, Clinical Scientist; Pamela Joannidis , Nurse Consultant Infection Control; Laura Cottom, ST5 Microbiology
Approved By: Antimicrobial Utilisation Committee