If metronidazole was used for initial treatment, patients should receive oral vancomycin. Careful evaluation and selection of all candidate stool donors is therefore important to minimize the risk for an iatrogenic infection and to maximize the likelihood for a successful treatment outcome. Cancer and Pediatric Hematopoietic Stem-Cell Transplantation Recipients” developed by the Pediatric Oncology Group of Ontario (POGO) was endorsed by the COG Supportive Care Guideline Committee in February 2019. Nonetheless, studies have demonstrated that vancomycin exposure promotes carriage of vancomycin-resistant enterococci in the intestinal flora of treated patients, although available data suggest that metronidazole use is also associated with this outcome [307, 384].There are no well-designed trials that examine the comparative effectiveness of metronidazole and oral vancomycin for the initial treatment of children with severe CDI.
During that period, patients who were toxin positive were twice as likely to have repeat testing and 3 times more likely to be positive compared with toxin-negative/PCR-positive patients. Rifaximin is recommended in the guidelines as an adjunctive post-vancomycin treatment regimen for patients with recurrent CDI. By March 2016, >1945 patients (reported as single case reports and larger case series) with recurrent CDI had been described in the peer-reviewed literature (J. S. Bakken, unpublished data).Despite the large number of anecdotal reports that have consistently demonstrated high efficacy of FMT, the first prospective randomized clinical trial that compared the outcome of standard antibiotic therapy to FMT was published in 2013 [367]. However, terminal disinfection with a sporicidal agent has not been associated with consistent reductions in CDI in nonoutbreak settings. Oral vancomycin should be used as a tapered and pulsed-dose regimen if a standard 10-day course of vancomycin was used for the initial episode. Anecdotal treatment success rates of fecal microbiota transplantation (FMT) for recurrent CDI have been high regardless of route of instillation of feces, and have ranged between 77% and 94% with administration via the proximal small bowel [358, 362]; the highest success rates (80%–100%) have been associated with instillation of feces via the colon [360, 363–366]. Tedesco et al defined diarrhea as >5 loose stools per day in 1974 [167]; Teasley et al as >6 loose stools over a period of 36 hours in 1983 [168]; Fekety et al as liquid stools or >4 bowel movements per day for at least 3 days in 1989 [169]; and Johnson et al as ≥3 loose or watery bowel movements in 24 hours in 2013 [170]. England has seen a dramatic decrease in 027 prevalence since the establishment of a nationwide ribotyping network in 2007 [56].
The reader of these guidelines should be mindful of this when the list of disclosures is reviewed.
If patients have improved, but have not had symptom resolution by 10 days, extension of the treatment duration to 14 days should be considered [314]. At home, CDI patients with diarrhea should use a separate bathroom if possible. See Acknowledgments section for disclosures reported to IDSA.At annual intervals and more frequently if needed, IDSA and SHEA will determine the need for revisions to the guideline on the basis of an examination of the current literature and the likelihood that any new data will have an impact on the recommendations. Other indicators of CDI morbidity include recurrent CDI, readmissions to the hospital, and discharge to LTCFs. Severity of CDI has been variably defined based on laboratory data, physical examination findings, ICU stay, colectomy, and/or mortality. However, several potential confounders were not assessed including compliance with isolation precautions, effect of environmental cleaning, and knowledge of Antibiotic restriction may be one of the most useful control measures for a CDI outbreak.
Three studies evaluated the change in incidence rate of CDI as a result of antibiotic change. Accordingly, a formal GRADE rating was not pursued for those statements as these statements would make it clear that they would do greater good than harm or greater harm than good, and thus a study would not be warranted to address such a question. However, a recent study in 6 Canadian hospitals evaluating CDI cases in 2006–2007 found an attributable mortality of 1.7%, similar to historic data [46].
Thus, recommendations about the therapeutic approach to children with multiply recurrent CDI must be guided by evidence drawn from the studies performed in adults and an assessment of the theoretical benefits and harms associated with various treatment regimens.