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Do PPIs Increase Risk for Community-Acquired C. difficile Infection?

A new study says yes, but some caveats apply.

Rates of Clostridium difficile–associated disease (CDAD) are rising sharply, with an increasing number of cases in patients lacking the usual risk factors of antibiotic use and hospitalization. Some studies have suggested that the use of proton-pump inhibitors (PPIs) may pose a heretofore unrecognized risk for outpatient infection.

From 1994 through 2004, a total of 317 outpatients who were registered in a giant British primary care database received prescriptions for oral vancomycin (whose only medical indication is treatment for CDAD). Almost half the patients had no record of receiving other antibiotics within 3 months of receiving vancomycin. Compared with age-matched controls from the same database, these patients were three times as likely to have used PPIs within 3 months of receiving vancomycin, and eight times as likely to have used other antibiotics; rates of H₂-blocker use were similar in the two groups.

Comment: In this study, an unusual technique helped to uncover a link between PPI use and CDAD. The validity of the link rests on the assumption that British physicians do not mistakenly use oral vancomycin for other problems; further, because most guidelines suggest that oral vancomycin be reserved for refractory CDAD, the link may apply only to severe cases. As an editorialist points out, the pathogenesis of CDAD is so complicated, with so many unknown steps between asymptomatic carriage of the infecting organism and disease, that it is no surprise that the role of PPIs has been difficult to sort out.

— Abigail Zuger, MD

Published in Journal Watch General Medicine October 24, 2006

Citation(s):

Dial S et al. Proton pump inhibitor use and risk of community-acquired Clostridium difficile-associated disease defined by prescription for oral vancomycin therapy. CMAJ 2006 Sep 26; 175:745-8.

• Original article (Subscription may be required)
• Medline abstract (Free)

Cunningham R. Proton pump inhibitors and the risk of Clostridum difficile-associated disease: Further evidence from the community. CMAJ 2006 Sep 26; 175:757-8.

• Original article (Subscription may be required)
• Medline abstract (Free)