Clostridium difficile Infection (CDI) in Children: Treatment Options and Effectiveness

Background: Despite the importance of the changing epidemiology of CDI, the disease has been less well characterized in children than in adults.  Data on the comparative efficacy of treatment options in this population remains lacking.

Objective: To describe CDI treatment options and their effectiveness in children.

Methods: This retrospective cohort study included children (<18 years) who developed diarrhea following an admission between 7/2008 and 6/2010 for ≥48 hours to the Children’s National Medical Center and had Clostridium difficile toxin A and/or B detected in ≥1 stool samples.  Electronic medical records were reviewed to gather information on demographics, underlying conditions, pre-CDI exposure to antibiotics (ABX), CDI ABX treatment including metronidazole (METRO) versus vancomycin (VANC), diarrhea duration, and relapse defined as a new onset of CDI within 8 weeks following the onset of a previous episode. Statistical analysis included descriptive as well as comparative analysis of diarrhea duration and relapse rate in the treatment groups.  

Results: The study identified 90 patients including 20 (22.2%) infants (≤1 year). Prior to the CDI onset, 54 (60%) patients had ABX exposure within 1 month.  Sixteen patients (18%) were healthy and the remaining had pre-existing medical conditions involving multiple organs (n=17,19%) and single organ (n=57, 63%).  Sixty-six patients (73%) had a history of hospitalization during the year before CDI onset, and 47 (52%) were hospitalized for ≥48 hours.  Following the onset of CDI, 22 patients (24%) received no ABX treatment, 56 (62%) were treated with METRO, 6 (7%) were treated with VANC, and 6 (7%) received both METRO and VANC.  Patients treated with a combination of METRO and VANC had the longest mean duration of diarrhea (9.5 days), followed by VANC alone (8.3 days), METRO alone (7.0 days), and no treatment (4.5 days). The relapse rates in patients treated with METRO alone and VANC alone were 11% and 17% (p=0.67), respectively. There was no relapse in patients without a pre-existing medical condition, compared to 12% in patients with a pre-existing medical condition. Infants and non-infants were comparable with regards of distribution of CDI treatment options, duration of diarrhea, and relapse rate. No patient required surgical intervention and no death occurred that was attributable to CDI.

Conclusions: CDI remains of concern in pediatric patients with chronic medical conditions.  A multi-center study is warranted to further determine the effectiveness of CDI treatment regimens in this vulnerable population.