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

This guidance is on the antimicrobial management of Clostridioides difficile (C.diff) Infection (CDI) in children and young people under 18 years and should be used alongside the Guidance on prevention and control of Clostridioides difficile Infection (CDI) in community-based settings in Scotland by Public Health Scotland. 

It was developed by Scottish Antimicrobial Prescribing Group (SAPG) and the Paediatric Stewardship Steering Group (PSSG)  following review of the National Institute for Health and Care Excellence (NICE) guideline on Clostridioides difficile infection: antimicrobial prescribing published in July 2021.

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

General guidance

1. In severe life-threatening disease, seek infection specialist advice and refer for urgent surgical assessment. (Refer to section on severe life threatening infection below)

2. Review medication and where possible,

  • rationalise or stop antibiotics not treating CDI
  • stop laxatives, anti-motility agents (eg loperamide, opiates) and gastric acid suppression (eg proton pump inhibitors, H2 antagonists and antacids) if safe to do so

3. Advice patients on the following;

  • drink enough fluids so they are well hydrated
  • measures to prevent the spread of infection
  • how to seek medical help if symptoms worsen rapidly or significantly at any time

Recommendations

1st episode of CDI

1st line

Antibiotics for first episode of mild or moderate or severe CDI
 Oral vancomycin four times a day for 10 days

2nd line

Antibiotics for first episode of mild or moderate or severe CDI if oral vancomycin is ineffective

(Patients who fail to improve after 7 days or worsen with oral vancomycin)

Discuss with paediatric infection specialist

Treatment will depend on severity and clinical setting

Either: oral fidaxomicin twice a day for 10 days
or
High dose oral vancomycin four times a day for 10 days
Recurrent CDI

Relapse

Antibiotics for a further episode of CDI within 12 weeks of symptom resolution

Oral fidaxomicin twice a day for 10 days

Exception – If the initial treatment course was not completed then treat as per first line treatment, ie oral vancomycin four times a day for 10 days

1st recurrence

Antibiotics for a further episode of CDI more than 12 weeks after symptom resolution 

 Oral vancomycin four times a day for 10 days (as per first line treatment)
2nd recurrence

Discuss with paediatric infection specialist 
Severe life-threatening infection

Severe life threatening infection

(See below for symptoms of severe life-threatening CDI)

Seek urgent specialist advice, including surgical review

Specialists may offer high dose oral vancomycin four times a day for 10 days
with
intravenous metronidazole three times a day
Review need for intravenous therapy daily

Life-threatening CDI is when a patient has any of the following attributable to CDI:

  • admission to intensive care unit
  • hypotension
  • ileus or significant abdominal distension
  • mental status changes
  • white blood cells (WBC) higher than 35 x109 / L or less than 2 x 109/ L
  • serum lactate greater than 2.2 mmol/L
  • end organ failure (mechanical ventilation, renal failure)

 

Special considerations

1. If preferred antibiotic option or formulation is unavailable or inappropriate, consider alternative antibiotic or route. Choice should be guided by treatment setting.

  • In community setting;
    • metronidazole may be prescribed 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
  • In hospital setting;
    • vancomycin injection can be used via the oral route if capsules are not available or where the calculated dose cannot be administered using available capsule strengths.  Guidance on administration is available in the SmPC

2. Ensure antibiotic dose and formulation are suitable for the patient. Consider patient age and weight.  

  • Vancomycin
    • 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
  • Fidaxomicin
    • Fidaxomicin tablets are licensed for children weighing at least 12.5kg 
    • For children weighing less than 12.5kg, consider high dose oral vancomycin if fidaxomicin granules are unavailable or seek specialist advice.

Click here to enlarge image.

For CDI management in adults, please refer to SAPG's advice on antimicrobial management of CDI in adults 18 years and over.

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

 

Scottish Antimicrobial Prescribing Group (SAPG) | April 2025 for review April 2028
Content updated: April 2025