title: Diagnosis and Management of Clostridium difficile Infection by Pediatric Infectious Diseases Physicians.
abstract: BACKGROUND
  The incidence of C difficile infection (CDI) has risen among children; however, optimal management of CDI within a diverse pediatric population remains unclear. Although adult guidelines recommend oral vancomycin for treatment of second recurrence or severe CDI, dedicated pediatric data to support pediatric specific management guidelines are lacking. Our objective was to describe current CDI management practices by pediatric infectious diseases (ID) physicians.
  
  
  METHODS
  We surveyed pediatric members of the Emerging Infections Network, a network of infectious diseases (ID) physicians across North America, in October 2012. Clinical vignettes were used to determine how physicians modify CDI management based on clinical presentation or presence of comorbidities, including solid organ transplantation, inflammatory bowel disease, and neutropenia.
  
  
  RESULTS
  Of the 285 physicians surveyed, 167 (59%) responded. There were no significant differences in geography, level of experience, or hospital type between respondents and non-respondents. All respondents (100%) used oral metronidazole for the initial occurrence of mild CDI in a normal host. Management varied substantially for mild CDI in patients with a variety of comorbidities, in whom metronidazole therapy was less frequently preferred (41-79%). For management of severe CDI, 65% preferred oral vancomycin alone or in combination with at least one other agent. For a second recurrence, oral vancomycin alone or in combination was preferred by 92%. Among 125 respondents who reported using alternative therapies for recurrent or severe CDI, 23 (18%) recommend fecal microbiota transplantation, while 20 (16%) reported using fidaxomicin.
  
  
  CONCLUSIONS
  Pediatric ID physicians prefer metronidazole for treatment of mild CDI in healthy children, but management strategies vary for patients with comorbidities or recurrent or severe disease. These findings highlight the need for pediatric comparative effectiveness studies aimed at determining the optimal treatment for pediatric CDI.
authors.affiliation: Division of Infectious Diseases, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia sammonsj@email.chop.edu.
authors.forename: Julia Shaklee
authors.initials: JS
authors.lastname: Sammons
authors.affiliation: Division of Infectious Diseases, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Gerber
authors.affiliation: Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Pranita D
authors.initials: PD
authors.lastname: Tamma
authors.affiliation: Division of Infectious Diseases, Departments of Medicine and Laboratory Medicine, Boston Children's Hospital, Massachusetts.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Sandora
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City.
authors.forename: Susan E
authors.initials: SE
authors.lastname: Beekmann
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City.
authors.forename: Philip M
authors.initials: PM
authors.lastname: Polgreen
authors.affiliation: Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City.
authors.forename: Adam L
authors.initials: AL
authors.lastname: Hersh
keywords: C difficile; health care-associated infection; pediatric; survey