Recurrent CDI is the most common complication of pediatric CDI, occurring in approximately 22% of cases.27 Recurrent CDI is defined as an episode of symptom onset and positive assay results at least 60 days after the completion of a primary treatment regimen for CDI.1,2,8 Recurrent episodes can be caused by persistence of dormant spores within intestines, relapse of previous infecting strain, infection with a new strain, or low levels of antitoxin antibody levels.29 Pediatric patients with IBD are also more likely to have recurrent disease.6,25 Infection with the virulent NAP1 strain of C difficile has also been associated with an increased likelihood of recurrence.11

Studies report that approximately 3% to 7% of pediatric CDI patients develop fulminant disease.32,33 Fulminant disease is characterized by hemodynamic instability, respiratory failure, a megacolon greater than 7 cm in diameter, hypotension, or shock.8 Aggressive and prompt diagnostic and therapeutic interventions are necessary in fulminant disease.8


Children with suspected or confirmed CDI should be isolated with strict contact precautions enforced. C difficile spores can linger on surfaces for up to 5 months.2 Spores are resistant to extreme temperatures and alcohol-based cleaning agents, making prevention of transmission extremely difficult.2,11 When disinfecting surfaces in the child’s room or hospital room, sporicidal agents such as hypochlorite are preferred.2 Bleach, hydrogen peroxide vapor, and ultraviolet light are other methods of disinfecting hospital rooms of patients with CDI.2,11

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Hospital environments are the most common source of C difficile acquisition among hospitalized pediatric patients.8 Colonization risk increases with the length of hospital stay.1 Health care personnel must wear gowns and gloves before contact with the patient occurs. Proper hand hygiene should be performed before and after contact with a pediatric patient with CDI, and after removal of gloves.2,11 Use of alcohol-based hand rubs are not adequate to eradicate C difficile spores from hands.8 Soap and water are the preferred agents for handwashing because they are more effective at removing spores from hands.2,11


The efficacy of probiotics in the prevention of pediatric CDI has been studied in randomized trials.34,35 In an analysis of 31 studies, which included 8672 patients, probiotics reduced the risk for CDI: 1.5% with probiotics and 4% without (relative risk [RR]=0.4 [95% CI, 0.3-0.52]). Baseline CDI rates from the included studies ranged from 0 to 40%, with only those studies with baseline CDI rates >5% (n=13) showing a significant reduction in CDI risk. The subgroup analysis of 6 pediatric studies with 1141 patients demonstrated a 65% reduction in the risk for CDI (RR=0.35 [95% CI, 0.19-0.63]).34

Antibiotic Stewardship

Another important aspect of pediatric CDI prevention is eliminating antibiotic exposure. Antibiotic stewardship programs (ASPs) are coordinated programs that aid reduction of unnecessary antibiotic prescribing, thus helping to control pediatric CDI rates.2,8,9 Co-implementation of infection control measures with ASPs have been shown to be more efficacious than ASPs alone.2,7 These programs have been shown to significantly reduce the incidence of CDI infections in hospitalized patients, combatting the progression of the contemporary antibiotic resistance crisis.9

Unfortunately, many primary care providers do not recognize antibiotic resistance and inappropriate prescribing as a problem in their office. In a recent survey, more primary care providers agreed that antibiotic resistance was a problem in the United States (94%) than in their practice (55%) and that inappropriate antibiotic prescribing was a problem in outpatient settings (91%) but not in their practice (37%). Most respondents (91%) believed that antibiotic stewardship was appropriate in office-based practices, but they ranked antibiotic resistance as less important than other public health issues, such as obesity, diabetes, opioids, smoking, and vaccine hesitancy. 36


Pediatric CDI is becoming increasingly common. It is essential that health care professionals recognize the growing incidence of pediatric CDI in both the community and in health care facilities. Newer treatments such as rifaximin, fidaxomicin, and FMT are promising. More studies aiming to elucidate the efficacy of these medications in pediatric populations would further the cause of adequately preventing and treating CBI in children.

Heather Adams, MSPAS, PA-C, works at Women’s Wellness and Gynecology in Erie, Pennsylvania, and is an associate professor at Gannon University in the Physician Assistant program. Elizabeth Nguyen, PA-C, recently graduated from the Gannon University Physician Assistant Program. She works in psychiatry at Piedmont Access to Health Services (PATHS) in Danville, Virginia.


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