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Guidelines for Managing Clostridium Difficile Infection in Younger Transplant Recipients

By: Sarah Campen, PharmD
Posted: Tuesday, October 23, 2018

As Clostridium difficile infection rates continue to rise, the condition has emerged as an important health-care issue in children and adolescents with cancer and pediatric recipients of hematopoietic stem cell transplantation (HSCT). A multidisciplinary panel of experts recently developed a clinical practice guideline for the prevention and treatment of C difficile infection in this population. The panel, led by Caroline Diorio, MD, of McMaster Children’s Hospital in Ontario, Canada, published its recommendations in the Journal of Clinical Oncology.

The panel strongly recommends administering either oral metronidazole or oral vancomycin for the initial treatment of nonsevere C difficile infection, based on similar cure and recurrence rates with both options. However, oral vancomycin is preferred for the initial treatment of severe C difficile infection. Fidaxomicin may be considered in the setting of recurrent infection.

 The panel suggests probiotics not be routinely used for the prevention of C difficile infection due to the rare but observed complication of invasive infection from either a probiotic itself or contamination of the probiotic in pediatric patients with cancer. In addition, routine use of monoclonal antibodies and probiotics for treatment is not recommended. A strong recommendation against fecal microbiota transplantation was made in this patient population.

It is important to note that of the 65 randomized studies that provided the main evidence base for the guidelines, few included immunocompromised children. “A striking finding across the evidence informing this [clinical practice guideline] is the lack of high-quality evidence as a result of the omission of pediatric patients with cancer and HSCT patients from randomized trials,” concluded the panel. Future studies should “include children with cancer and pediatric HSCT patients to improve the management of [C difficile infection] in this population.”

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