Treatment of Clostridium difficile infection in pediatric patients

Abstract

Clostridium difficile causes infections that can either remain asymptomatic or manifest as clinical disease. In this report, problems, possible solutions, and future perspectives on the treatment of C. difficile infections (CDIs) in pediatric patients are discussed. CDI, despite increasing as a consequence of the overuse and misuse of antibiotics, remains relatively uncommon in pediatrics mainly because younger children are poorly susceptible to the action of C. difficile toxins. In most such cases, C. difficile disease is mild to moderate and discontinuation of the administered antibiotics in patients receiving these drugs when CDI develops, or administration of metronidazole, is sufficient to solve this problem. In severe or frequently relapsing cases, vancomycin is the drug of choice. Probiotics do not seem to add significant advantages. Other treatment options must be reserved for severe cases and be considered as a salvage treatment, although potential advantages in pediatric patients remain unclear.

Keywords:

• antibiotic therapy
• children
• Clostridium difficile
• fecal microbiological transplantation
• gastrointestinal infection
• probiotics

Financial & competing interests disclosure

The authors were supported by a grant from the Italian Ministry of Health (Bando Giovani Ricercatori 2009). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Clostridium difficile infections (CDI), despite increasing as a consequence of the overuse and misuse of antibiotics, remain relatively uncommon in pediatrics.

• The first problem to address upon detection of C. difficile and its toxins in a stool specimen from a pediatric patient should be the differentiation between simple colonization that does not require treatment and actual C. difficile disease for which a therapeutic approach is necessary.

• In most cases, discontinuation of the administered antibiotics in patients receiving these drugs when CDI develops or administration of metronidazole is sufficient to solve the problem.

• In severe cases or frequently relapsing cases, vancomycin is the drug of choice.

• Probiotic use does not appear to show marked advantages.

• Other treatment options, including fecal microbiological transplantation, should be reserved for very severe cases and must be considered as a salvage treatment.

• Several new antibiotics with activity against C. difficile have recently been developed and shown to be effective in numerous adult cases, but data regarding the use of these drugs in children with CDI are very limited.

• The greatest amount of data has been collected regarding fidaxomicin, a macrocyclic drug with a selective spectrum of activity, which has been shown to be superior to vancomycin in achieving a successful and sustained clinical response to therapy and should be prescribed to patients with severe recurrence at risk for further episodes.

• Other potentially usable antibiotics for CDI are rifaximin, ramoplanin, nitazoxanide, tigecycline, bacitracin, fusidic acid and teicoplanin.

• Several attempts to treat CDI with immune-modifying agents have been made, with good results in some cases, but all should be considered only salvage measures for patients with frequent recurrences not responding to more commonly used therapies.

• Regarding surgical options, further evaluations and comparisons with other approaches are needed in children with very severe complicated CDI.