Current practices and unmet needs in the management of Clostridioides difficile infection in pediatric inflammatory bowel disease: A national survey.

OBJECTIVES

Children with inflammatory bowel disease (IBD) are at increased risk for Clostridioides difficile infection (CDI), which is associated with worse clinical outcomes. We aimed to assess current diagnostic and therapeutic practices for CDI among Italian pediatric IBD centers.

METHODS

A nationwide survey was conducted in 2025 using a structured 28-item questionnaire distributed to all pediatric IBD centers in Italy. Items addressed diagnostic strategies, treatment approaches, recurrence management, and immunosuppressive therapy handling in children with IBD and CDI.

RESULTS

Twenty-seven centers responded (response rate, 90%). Diagnostic approaches varied: toxin enzyme immunoassays (EIA) were indicated by 21/27 centers (78%), glutamate dehydrogenase (GDH) testing by 19/27 (70%), and nucleic acid amplification tests (NAAT) by 13/27 (48%). Routine CDI testing at IBD diagnosis was indicated by 12/27 centers (44%), whereas 23/27 (85%) reported testing during IBD flares. For a first non-severe episode, vancomycin and metronidazole were equally identified as preferred first-line options (18/27; 66% each). Oral vancomycin was the preferred treatment for recurrent CDI (26/27; 96%). Third or subsequent recurrences prompted consideration of fidaxomicin (19/27; 70%), fecal microbiota transplantation (6/27; 22%), and bezlotoxumab (2/27; 7%). In fulminant CDI, 7/27 centers (26%) indicated adding fidaxomicin to standard therapy. In acute severe colitis with concomitant CDI at diagnosis, 18/27 centers (67%) described a cautious approach to biologic initiation.

CONCLUSIONS

This nationwide survey highlights substantial unmet needs in CDI management in pediatric IBD, including variability in diagnostic strategies, lack of consensus on first-line therapy, and uncertainty regarding immunosuppressive management, supporting the need for evidence-based pediatric-specific guidelines.