Advice on antimicrobial management of Clostridioides difficile (C.diff) Infection (CDI) in children

The National Institute for health and Care Excellence (NICE) guideline on Clostridioides difficile infection: antimicrobial prescribing was published in July 2021. Scottish Antimicrobial Prescribing Group (SAPG) and the Paediatric Stewardship Steering Group (PSSG) has reviewed the guidance and has made updated recommendations below. These antibiotic choice recommendations supersede those included in Scottish guidance on Clostridioides difficile infection (CDI) published by the Scottish Health Protection Network (SHPN). Only antibiotic prescribing advice has been updated and the remainder of the guideline remains relevant to clinical practice and will be updated within the full guideline review.

These recommendations for first and second line treatments of CDI in children differ from current guidance and clinical practice in Scotland and SAPG and PSSG recommends boards review their current recommendations and adapt guidance locally.

For drug doses please refer to the British National Formulary for Children (BNFC) or Summary of Product Characteristics (SmPC)

General guidance:
Where possible rationalise or stop antibiotics not treating CDI, review medication and stop laxatives, anti-motility agents (eg loperamide, opiates) and gastric acid suppression if safe to do so eg Proton Pump Inhibitors, H2 antagonists and antacids.  Ensure patient is well hydrated.

Changes in recommendation:

First line treatment First line treatment of CDI: vancomycin irrespective of severity*
Second line treatment Definition: Patients who fail to improve after 7 days or worsen with oral vancomycin
Discuss with paediatric infection specialist. Treatment will depend on severity

Either: fidaxomicin or high dose* oral vancomycin PLUS intravenous metronidazole (see notes below)
First and second line treatment ineffective OR life-threatening CDI

Seek urgent specialist advice. Treatment may involve surgery. Antibiotic therapy offered may include: High dose* oral vancomycin PLUS intravenous metronidazole (see notes below)

Further CDI within 12 weeks of symptom resolution (relapse) ​ Treat with fidaxomicin
1. Treatment failure identified as incomplete primary treatment course -
treat as per first line treatment
2. Children weighing <12.5kg – oral vancomycin PLUS IV metronidazole (where fidaxomicin granules not available)
Further CDI after 12 weeks of symptom resolution (recurrence)

Treat with oral vancomycin as per first line treatment

Second recurrence of CDI Second recurrence of CDI: Discuss with paediatric infection specialist

Special considerations:

*Vancomycin dosing:  The BNFC and SmPC recommend a single dosing schedule for children aged 2-11 years which is applied at all stages where vancomycin is recommended treatment.  For children aged 12 years and above, ‘high dose’ oral vancomycin refers to recommendations in the BNFC and SmPC for life-threatening or refractory infection.

Community setting: Metronidazole may be prescribed in community if delays in supply of oral vancomycin would result in delayed initiation of treatment. Metronidazole should be substituted with oral vancomycin as soon as availability is resolved to complete a total of 10 days treatment. Where patients cannot swallow vancomycin capsules, fidaxomicin should be considered the first line option in community setting.

Hospital setting: Vancomycin injection can be used via the oral route in the hospital setting where capsules are not available or where the calculated dose cannot be administered using available capsule strengths.  Guidance on administration is available in the SmPC.

Fidaxomicin: Fidaxomicin tablets are licensed for children weighing at least 12.5kg.  Fidaxomicin granules for oral suspension (40mg/ml) will be available in the UK from May 2022.  For children weighing less than 12.5kg consider oral vancomycin PLUS IV metronidazole if fidaxomicin granules are unavailable or seek specialist advice.

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For more details on evidence supporting the guideline please refer to the NICE guidance.

Scottish Antimicrobial Prescribing Group (SAPG) Paediatric Stewardship Steering Group (PSSG)
June 2022 for review June 2025
Content updated: June 2024