Treatment of Clostridioides difficile Infection in Children

Initial Treatment Based on Severity

The Infectious Diseases Society of America recommends metronidazole for 10 days (oral): 7.5 mg/kg/dose three or four times daily, maximum 500 mg per dose for non-severe CDI 1, 2, 3
The Infectious Diseases Society of America recommends vancomycin for 10 days (oral): 10 mg/kg/dose four times daily, maximum 125 mg per dose as an alternative for non-severe CDI 1, 2
The Infectious Diseases Society of America recommends vancomycin for 10 days (oral or rectal): 10 mg/kg/dose four times daily, maximum 500 mg per dose for severe or fulminant CDI 2, 4

The Infectious Diseases Society of America recommends oral vancomycin for 10 days (10 mg/kg/dose four times daily, maximum 125 mg per dose) for first recurrence of non-severe CDI if metronidazole was used for initial episode 2, 5
The Infectious Diseases Society of America recommends vancomycin in a tapered and pulsed regimen for second or subsequent recurrences: 10 mg/kg/dose (maximum 125 mg) four times daily for 10-14 days, then twice daily for 7 days, then once daily for 7 days, then every 2-3 days for 2-8 weeks 2, 5
The Infectious Diseases Society of America suggests considering fecal microbiota transplantation for multiple recurrences that have failed appropriate antibiotic treatments 6, 7

The Infectious Diseases Society of America advises avoiding repeated or prolonged courses of metronidazole due to risk of peripheral neuropathy 7

The American Society of Infectious Diseases emphasizes that oral vancomycin has a lower risk of side effects than metronidazole due to its non-absorbable nature 8, 9, 10
For non-severe Clostridioides difficile infection in children, both metronidazole and vancomycin are options, but vancomycin has a lower risk of systemic side effects 9, 10
For severe disease, vancomycin is recommended over metronidazole 8, 9
To avoid neuropathy with repeated exposure, metronidazole should be avoided in cases of multiple recurrences 8
The use of metronidazole in children is generally well-tolerated, but it can cause frequent gastrointestinal side effects (nausea in approximately 12% of patients) and, more importantly, there is a risk of peripheral neuropathy with prolonged or repeated use 8, 9
Patients should be specifically warned about these reactions and instructed to discontinue the medication and report immediately if neurological symptoms appear, and to avoid repeated or prolonged courses of metronidazole due to the risk of cumulative and potentially irreversible neurotoxicity 8