A 13 year old male presents to the emergency department for 2 days of abdominal pain and diarrhea. He has no past medical or surgical history other than a tooth extraction for which he recently completed a week of clindamycin. The abdominal pain is generalized and associated with greater than 5 episodes of watery diarrhea daily. He denies any vomiting or recent travel. Vitals signs are: HR 120, BP 108/60, T 38.3 C, RR 20, SpO2 99% RA. On exam, he is tired but non-toxic appearing and not in acute distress. Mucous membranes are dry, and his cap refill is between 2 to 3 seconds. His abdomen is minimally tender to palpation diffusely with no guarding or rigidity. IV access is obtained and fluid resuscitation is started. What is the appropriate antibiotic treatment for this patient’s suspected condition?
A: IV vancomycin and cefepime
B: PO metronidazole
C: PO vancomycin
D: PO vancomycin and IV metronidazole
Answer: PO metronidazole
This patient’s fever, abdominal pain, and profuse diarrhea in the setting of recent antibiotic use is worrisome for Clostridium difficile (C. Diff) infection. Oral metronidazole is the treatment of choice in mild to moderate cases of pediatric C. Diff colitis. It is first-line due to being less expensive than vancomycin and avoids the potential risk of developing vancomycin-resistant enterococci. IV vancomycin and cefepime are broad spectrum agents commonly used in sepsis but are not preferred for suspected C. Diff colitis. In addition, the combination lacks anaerobic coverage for gastrointestinal infections. PO vancomycin with or without IV metronidazole is reserved for recurrent or severe infection which includes hypotension, ileus, or inability to tolerate PO antibiotics.
| Pediatric Clostridium Difficile Colitis Treatment | |
|---|---|
| All patients | Fluid resuscitation and electrolyte repletion Discontinue offending antimicrobial agents if possible |
| Mild to moderate disease | PO metronidazole |
| Severe disease | PO or rectal vancomycin + IV metronidazole |
References:
Freedman S.B., & Thull-Freedman J (2020). Vomiting, diarrhea, and dehydration in infants and children. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill.
