AAP Releases New C. Diff Guidance

Even when infants have a positive test for Clostridium difficile, clinicians should search for other causes of disease, according to a policy statement from the American Academy of Pediatrics (AAP).

That’s because children younger than 12 months have high rates of colonization with the bacteria (37% before 1 month, 30% from 1 to 6 months, and 14% from 6 to 12 months), the authors noted in the statement published online ahead of the January issue of Pediatrics.

For children ages 1 to 2 years, a positive C. difficile test indicates possible infection, although other causes of disease should be sought, according to the recommendations.

For those ages 3 and older  –  who have rates of colonization similar to those seen in nonhospitalized adults (0% to 3%)  –  a positive test reflects probable infection. Factors that have been associated with a greater risk of C. difficile in these older children include antimicrobial therapy, use of proton pump inhibitors, underlying bowel disease, renal insufficiency, and impaired humoral immunity, the authors wrote.

As in adults, endoscopic or histologic test results positive for pseudomembranous colitis are indicative of definite infection with C. difficile in children.

The AAP released the recommendations to update information about C. difficile infections in a pediatric population for two reasons: Infections have been increasing among hospitalized children in the U.S. in recent years, possibly related to the emergence of North American pulsed field type 1 (NAP1), the epidemic strain of toxin-producing C. difficile. Also, recent guidelines for management in adults do not necessarily reflect issues specific to infections in children.

The authors addressed diagnostic testing for C. difficile in children, noting that “it is prudent to avoid routine testing … in children younger than 1 year” because of the high rates of carriage.

However, breastfed infants have lower carriage rates (14%) compared with formula-fed infants (30%).

“Testing for C. difficile can be considered in children 1 to 3 years of age with diarrhea, but testing for other causes of diarrhea, particularly viral, is recommended first,” they wrote. “For children older than 3 years, testing can be performed in the same manner as for older children and adults.”

Among other recommendations for testing:

• Testing for C. difficile colonization or toxins should only be performed when clinical and age conditions are met.
• In infants, testing should be limited to those with Hirschsprung disease or other severe motility disorders or during an outbreak.

With regard to treatment, the guidelines state that following treatment, a test of cure is not recommended because the bacteria, its toxins, and genome are shed for weeks after diarrhea is resolved. Testing for recurrences less than 4 weeks after initial testing is only useful when the results of repeat testing are negative.

Also, discontinuing antimicrobial agents is the first step for treatment and might be sufficient for resolving the infection. Anti-peristaltic medications should not be used because they can obscure symptoms and cause complications.

For moderate disease, the drug of choice for a first episode or first recurrence is metronidazole given orally (30 mg/kg/day) in four divided doses (maximum of 2 g/day).

Finally, for severe disease or a second recurrence, clinicians should use oral vancomycin (40 mg/kg/day) given in four divided doses (maximum of 2 g/day), with or without metronidazole.

The statement also dealt with infection control, calling on healthcare professionals to use gloves with symptomatic patients to prevent patient-to-patient spread; wash their hands with soap and water, which is more effective for removing the spores than using an alcohol-based hand sanitizer; and use chlorine products for environmental cleaning.

Source: http://www.medpagetoday.com/InfectiousDisease/GeneralInfectiousDisease/36655?