Proton pump inhibitors and Clostridium difficile

Clinical bottom line

Reduction of PPI use may be an additional strategy to reduce the incidence of this infection.

Reference

R Cunningham et al. Proton pump inhibitors as a risk factor for Clostridium difficile diarrhoea. Journal of Hospital Infection 2003 54: 243-245.

Study

In this case-control study the cases were 277 inpatients found to be positive for Clostridium difficile in 1999. Cases were identified from laboratory and infection control team records. After exclusions for various bowel disorders and missing case notes, there were 170 cases available. Controls were identified from patients records, and matched by age, sex, month of admission and admitting physician.

Results

Clostridium difficile diarrhoea was associated with a higher rates of PPI use (odds ratio 2.5; 95% CI 1.5 to 4.2), antibiotics (2.8; 1.5 to 5.2), and cytotoxic chemotherapy (4.2; 1.5 to 12). Combinations of these circumstances gave rise to very high rates using logistic regression analysis (Table 1).

Table 1: Combinations of therapy associated with Clostridium difficile diarrhoea.

PPI	Antibiotic	Cytotoxic therapy	Odds ratio (95% CI)
Yes	Yes	No	5 (2 to 13)
No	Yes	Yes	17 (3 to 113)
Yes	No	Yes	20 (3 to 130)
Yes	Yes	Yes	43 (6 to 330)

Comment

The estimated cost of a case of Clostridium difficile diarrhoea in hospital usually to an older and sicker patient, is about £5000, and prolongs length of stay by 21 days. Reduction of PPI use may be an additional strategy to reduce the incidence of this infection, as vegatative cells are highly susceptible to acid.