Dr. Ted Steiner (biography and disclosures)
What I did before
Clostridium difficile infection (CDI) most commonly arises following antibiotic use in hospitalized patients. Isolation of suspected cases and hand hygiene are two of the most important means of prevention, but despite our best efforts CDI remains a huge problem. Even after successful treatment with metronidazole or vancomycin, anywhere from 20-35% of patient will relapse, but the risk factors for relapse differ among studies. One important risk factor is continuation of other antibiotics, which prevents repopulation of the gut with normal bacteria. The role of other medications, including proton pump inhibitor (PPIs), has been less clear. PPIs are very effective at preventing gastrointestinal bleeding in hospitalized patients, and C. difficile spores are acid resistant. How important are PPIs as a risk factor for initial or recurrent CDI?
What changed my practice
Several recent publications specifically examined the role of acid suppression in CDI. Most striking was the study by Howell et al1 that found an incremental increase in the risk of initial CDI with increasing acid suppression (H2 receptor antagonists (H2RA), once-daily PPIs, or more frequent PPIs). A second study by Linsky et al2 found that administration of PPIs within 14 days of diagnosis was an independent risk factor for CDI recurrence, with an adjusted HR of 1.42 (higher in elderly patients). There is also accumulating evidence that PPIs are commonly used in inpatients for indications other than those recommended in published guidelines.
What I do now
PPIs remain the drug of choice for several indications, including treatment of bleeding ulcers or GERD, and stress ulcer prophylaxis in selected high-risk patients. These include patients on NSAIDs plus anticoagulants, corticosteroids, or a history of NSAID-induced ulcers; patients with severe head or spinal trauma; burn patients; and ICU patients with coagulopathy. However, PPIs are frequently used for routine ulcer prophylaxis in patients who do not meet these criteria, in the absence of clear evidence of a benefit versus other forms of ulcer prophylaxis (such as H2 blockers) in these settings. Moreover, many patients started on PPIs in hospital are frequently continued on these medications after discharge, even after CDI is diagnosed.
Based on recent literature, my current practice is to carefully consider whether PPIs or H2 blockers are truly indicated in inpatients, and to stop them if they are not. In patients with CDI infection, I try to discontinue anti-secretory therapy whenever possible. With all prescribed medications, physicians need to carefully consider the potential harm to patients when they write their orders, and be aware of medical evidence that shifts the balance in favor of drug avoidance. While PPIs have a long track record of efficacy and safety, the increasing incidence and severity of CDI may shift the risk/benefit ratio of these drugs.
References: (Note: Article requests require a login ID with CPSBC or UBC)
1. Howell MD, Novack V, Grgurich P, Soulliard D, Novack L, Pencina M, Talmor D. Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection. Arch Intern Med. 2010 May 10;170(9):784-90. PubMed PMID: 20458086. (View article with CPSBC or UBC)
2. Linsky A, Gupta K, Lawler EV, Fonda JR, Hermos JA. Proton pump inhibitors and risk for recurrent Clostridium difficile infection. Arch Intern Med. 2010 May 10;170(9):772-8. (View article with CPSBC or UBC)
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Thank you
Timely article as we have been reviewing in our ED c. difficile hygiene management. Thank you. I will be more “aware” of my PPI prescribing based on this article.
Good advice. It is easy to forget the hazards of medication.
Good idea to look at cost/benefit ratio of PPI’s initially as inpatient, on discharge fm hospital, as well as on review post discharge.
Good advice, it is an issue I am not aware.
I look after hospitalized cancer patients with complications during and after chemotherapy or radiation. Many of these patients are needing steroids, antibiotics, and PPI’s. So far I haven’t had a patient with a GI bleed complicating their course. I would be reluctant to substitue H2 blockers for PPI’s in this patient population. Cl diff diarrhea does occur, but seems quite manageable in my experience to date. Seems to respond to metronidazole quite promptly. I will try to stop PPI’s on discharge, and replace with H2 blockers, after the acute illness.
I agree PPI has been overprescribed for a longtime. I have been telling my patients who take PPI daily for occasional heartburn to stop the daily use. Sometime successful other times not. As PPI and antibiotic are 2 of the commonest prescribed medications we are bound to run into this C diff scenerio more often. Excellent advice
thank you, I deal with CDI all the time in the hospital, will look carefully at the need of PPIs now.
Good reminder. Sometimes in the ICU setting, when a patient has a mortality risk with bleeding ulcers, one has to balance the risk of bleeding and risk of developing C. Diff problems.
Have been aware that PPI use is associated with susceptibility to gastroenteritis but not to C. Deficile specifically. Thanks for the information.
as in the daily practice we, as health care provider, have come across so many cases of G-I problem that PPI and H2 inkibitor have been great demand to start on our patients. However there is some grey areas for the use of these drugs, base on symptomatic vs actual pathological indication. the possibility of increasing CDI would be another precaution in consideratio for using these anti-secretory med.for our patients.
Thank you. I have been quite suspicious of all the PPI promotion. Now a new worry.
Thank You.Good reasons for therapeutic rethink.
Thanks, with the recent media coverage of c.diff “outbreaks” the public is more aware and also aware of the relationship to antibiotics. This is a new issue for me and valuable information
Thank You. These study results are a reminder to thoughtfully consider the need for PPI and or H2 Blocker therapy in hospitalised patients, and whenever possible to discontinue these agent when CDI is confirmed.
Thank you. This will be another piece of information to pass on to patienet as I encourage them to do more behavioural modification and step down off PPI once symptoms have been successfully controlled.
Thank-you. Anything that we can do to help control and prevent CDI is useful.