Eradication of Persistent C. difficile Infection (CDI) in Pediatric Patients Requiring Complex Medical Care: Experience with Use of Golytely and Vancomycin Enema

Abstract

Introduction: C. difficile infections is a potentially lethal condition and also the leading cause of nosocomial infections affecting care of patients with complex needs in post-acute care facilities. Eradication of C. diff is very important to prevent outbreaks of nosocomial infection but has been difficult in some patients because of emergence of a virulent strain resistant to multiple antibiotics. There is paucity of data on management of persistent CDI in pediatric post—acute care facilities; most of the data pertain to geriatric facilities. We describe our experience with use of Golytely (polyethylene glycol 3350 and electrolyte) followed by vancomycin enema to eradicate C. dif from patients with persistently positive C. diff after standard treatment. Methods: We performed a retrospective review of records of patients with persistent CDI treated with Golytely at our facility over period of one year (7/1/12-6/30/13). The initial stool test for C. diff was done in symptomatic patients; eradication was defined as 3 consecutive negative stool tests for C. diff at weekly intervals after completion of treatment. Standard treatment included enteric metronidazole (M) 30 mg/kg/day for 10-14 days. Enteric vancomycin (V) (40-50 mg/kg/day for 10-14 days) was given if M failed. In some patients, both, M and V were given if V alone failed. All patients were given probiotics. Patients with persistent CDI after above treatment were given Golytely at 20 cc/kg/hour via gastrostomy tube until the patients passed clear stool followed by 2 weeks of vancomycin enema (VE). Results: Golytely + vancomycin enema (G+VE) treatment was given 11 times in 7 patients (age 4 ½ yr. - 13 ½ yr.; 3M:4F; 1 patient received Golytely three times, and 2 patients received twice) with persistent CDI. Of these 7 patients, C. diff was successfully eradicated from 6 patients. One patient who did not respond received G+VE three times (3 months apart) and each time stool for C. diff became positive three weeks after treatment in third stool sample. In two patients who received G+VE twice, C. diff was eradicated successfully first time but recurred after antibiotic use and was successfully treated with G+VE second time also. Conclusion: Persistent CDI is an important problem in pediatric patients receiving complex medical care. Treatment modality consisting of combination of Golytely for 12 hours and vancomycin enema for 2 weeks results in successful eradication of C. diff from the patients with persistent CDI.