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C. difficile is a gut germ that can cause bad diarrhoea, often after antibiotics. In children having cancer treatment it is treated with an antibiotic by mouth, chosen by how severe it is. Children with it are kept apart from others to stop it spreading, and probiotics and faecal transplants are not used routinely during treatment.
The 2024 update from an international panel led by the Pediatric Oncology Group of Ontario (96 randomised trials in any population, GRADE), endorsed by the Children's Oncology Group in August 2024, covers children and adolescents aged 1 to 18 with cancer or undergoing haematopoietic cell transplant; infants under 1 are excluded because C. difficile in them is usually colonisation. Treat non-severe infection with oral metronidazole or oral vancomycin (strong, low) and severe infection (colitis, pneumatosis, pseudomembranous colitis, ileus or surgery) with oral vancomycin or, new in 2024, oral fidaxomicin (strong, low), after a trial including children with cancer showed higher cure at follow-up and fewer recurrences with fidaxomicin. Consider fidaxomicin for recurrence (conditional, moderate). Do not use faecal microbiota transplantation routinely (strong, low), though it may be reasonable once treatment is over and the child is no longer immunosuppressed. Do not use probiotics routinely for prevention or treatment (conditional, low), because of documented invasive infections from probiotics in children with cancer, nor bezlotoxumab (conditional, moderate). Two new good practice statements: isolate according to local policy, and minimise systemic antibiotics, especially after a previous episode.
Why: Isolation limits spread of C. difficile to other children; the exact rules differ by country and hospital.
“In pediatric patients with cancer and HCT recipients experiencing CDI, follow infection control practices including isolation according to jurisdictional policies.”
International panel (Pediatric Oncology Group of Ontario), eClinicalMedicine 2024 · Good practice statement
Why: Exposure to antibiotics is a known risk factor for C. difficile in children with cancer.
“In pediatric patients with cancer and HCT recipients, especially those who have experienced CDI, minimize systemic antibacterial administration where feasible.”
International panel (Pediatric Oncology Group of Ontario), eClinicalMedicine 2024 · Good practice statement
Why: There are no trials in children having cancer treatment, and probiotics have caused bloodstream and fungal infections in such children.
“We suggest that probiotics not be used routinely for the prevention of CDI in pediatric patients with cancer and HCT recipients”
International panel (Pediatric Oncology Group of Ontario), eClinicalMedicine 2024 · conditional recommendation, low quality evidence
Why: The trials found similar cure and relapse rates with the two.
“Use either oral metronidazole or oral vancomycin for the treatment of non-severe CDI in pediatric patients with cancer and HCT recipients”
International panel (Pediatric Oncology Group of Ontario), eClinicalMedicine 2024 · strong recommendation, low quality evidence
Why: Vancomycin cured more severe cases than metronidazole; fidaxomicin, tested in a trial that included children with cancer, cured more at follow-up and halved relapses compared with vancomycin.
“Use either oral vancomycin or oral fidaxomicin for the treatment of severe CDI in pediatric patients with cancer and HCT recipients”
International panel (Pediatric Oncology Group of Ontario), eClinicalMedicine 2024 · strong recommendation, low quality evidence
Why: Fidaxomicin reduces further relapses, though it has not been tested specifically in recurrent infection.
“Consider fidaxomicin for the treatment of recurrent CDI in pediatric patients with cancer and HCT recipients”
International panel (Pediatric Oncology Group of Ontario), eClinicalMedicine 2024 · conditional recommendation, moderate quality evidence
Why: Its benefit in children is uncertain, the products vary, and the safety concern is highest while the child is neutropenic or immunosuppressed.
“Do not use FMT routinely for the treatment of CDI in pediatric patients with cancer and HCT recipients”
International panel (Pediatric Oncology Group of Ontario), eClinicalMedicine 2024 · strong recommendation, low quality evidence
Why: Bezlotoxumab did not help in the trial of children with cancer and needs a drip; probiotics carry the infection risk above.
“We suggest that monoclonal antibodies not be used routinely for the treatment of CDI in pediatric patients with cancer and HCT recipients”
International panel (Pediatric Oncology Group of Ontario), eClinicalMedicine 2024 · conditional recommendation, moderate quality evidence
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
The 2024 international paediatric guideline (Patel et al.), endorsed by the Children's Oncology Group, is the only guideline written for children with cancer and transplant recipients: oral metronidazole or vancomycin for non-severe infection, oral vancomycin or fidaxomicin for severe infection, fidaxomicin considered for recurrence, isolation and antibiotic stewardship, and no routine probiotics, faecal transplant or bezlotoxumab. Its evidence is mostly from adult trials, which is why most grades are low; adult guidelines (IDSA and SHEA 2021) were not read here beyond their abstract, so no comparison with them is made on this page.
International panel (Pediatric Oncology Group of Ontario), eClinicalMedicine 2024 · Children's Oncology Group 2024
Where it differs: Uses faecal transplant for recurrent infection once the child has finished cancer treatment and is no longer immunosuppressed.
Evidence: The guideline's strong recommendation is against routine use during treatment; its rationale says faecal transplant may be a reasonable option once patients have completed therapy and are no longer immunosuppressed. No paediatric oncology trial supports it.
International panel (Pediatric Oncology Group of Ontario), eClinicalMedicine 2024
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Oral metronidazole or vancomycin for non-severe infection | strong recommendation, low quality evidence | International panel (Pediatric Oncology Group of Ontario), eClinicalMedicine 2024 |
| Oral vancomycin or fidaxomicin for severe infection | strong recommendation, low quality evidence | International panel (Pediatric Oncology Group of Ontario), eClinicalMedicine 2024 |
| Fidaxomicin for recurrence | conditional recommendation, moderate quality evidence | International panel (Pediatric Oncology Group of Ontario), eClinicalMedicine 2024 |
| No routine faecal microbiota transplantation | strong recommendation, low quality evidence | International panel (Pediatric Oncology Group of Ontario), eClinicalMedicine 2024 |
| No routine probiotics for prevention | conditional recommendation, low quality evidence | International panel (Pediatric Oncology Group of Ontario), eClinicalMedicine 2024 |
| No routine probiotics for treatment “We suggest that probiotics not be used routinely for the treatment of CDI in pediatric patients with cancer and HCT recipients” | conditional recommendation, low quality evidence | International panel (Pediatric Oncology Group of Ontario), eClinicalMedicine 2024 |
| No routine monoclonal antibodies (bezlotoxumab) | conditional recommendation, moderate quality evidence | International panel (Pediatric Oncology Group of Ontario), eClinicalMedicine 2024 |
Shares Fever and neutropenia in children with cancer or after stem cell transplant, Allogeneic stem cell transplantation, Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.
Shares Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.
Shares Allogeneic stem cell transplantation, Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.
Shares Allogeneic stem cell transplantation, Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.
Shares Fever and neutropenia in children with cancer or after stem cell transplant, Allogeneic stem cell transplantation, Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.
Shares Allogeneic stem cell transplantation, Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.
Shares Allogeneic stem cell transplantation, Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.
Shares Allogeneic stem cell transplantation, Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.