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Letters to the Editor
|
Proton pump inhibitors
Confirmed association with C difficile
From Mr N. J. Oxley, MRPharmS, and others
The Clostridium difficile outbreak at Stoke Mandeville has been in the
news recently. This problem is not unique and has affected wards at our
own hospital. For the past year we have been looking at a pharmacy-proposed
link between the overuse of proton pump inhibitors (PPIs) and the subsequent
emergence of C difficile infection, as well as trying various methods
of prevention and treatment. A quick literature search will find many
references to C difficile outbreak in patients treated with antibiotics1 but not many find a strong with patients also on PPIs, with the exception
of the work done by Cunningham et al.2
We now have complete data for five patients (and incomplete data for
two more) who were admitted to the elderly care wards and were taking
a PPI, and who subsequently developed C difficile-associated diarrhoea.
These patients were treated for at least three days with a broad-spectrum
antibiotic (cefalosporins in four patients and ciprofloxacin in the fifth).
Microbiologically confirmed C difficile-associated diarrhoea presented
within three days of starting antibiotic treatment. In all cases the
C difficile was treated with oral vancomycin 125mg qds for 10 days. In
those previously treated with cefalosporins the diarrhoea settled but
the ciprofloxacin-associated case did not. However, the four resolved
cases relapsed within 48 hours of completing the course of vancomycin.
The patients were then treated with metronidazole 400mg tds with limited
response. On pharmacy advice, the PPIs were stopped in all five patients.
In the four cefalosporin-induced cases the C difficile then resolved
with a further course of metronidazole or vancomycin and did not relapse
again. The remaining patient who developed C difficile diarrhoea after
being given ciprofloxacin, eventually required additional treatment with
intravenous immunoglobulin. Although our data are, admittedly, limited,
the general feeling is that since antibiotic therapy is a well-known
risk factor for developing C difficile diarrhoea, the explosion in PPI
use has helped to compound the problem and may be why the C difficile
rates have risen in recent years, despite a step-up in hygiene and modification
to the antibiotic policy to help reduce infection rates. In-house data
relating to C difficile cases in the hospital show that over 50 per cent
are taking a PPI, which is consistently above the basal prescribing rate.
We do not mean to suggest that patients on a PPI alone are going to develop
C difficile but we have loosely concluded that patients on a PPI and
subsequent antibiotic therapy are “sitting ducks” for C difficile
infection, which is likely to be difficult to eradicate. Since pharmacy
has started actively challenging PPI use (leading to at least a temporary
cessation of the PPI wherever possible, especially in elderly care),
we have noticed a hospital-wide drop in C difficile infection rates.
Neil Oxley
Lead Pharmacist for Elderly Care
John Horncastle
Clinical Pharmacist
Lesley Davidson
Principal Clinical Pharmacist
Richard Ellis
Consultant Microbiologist
South Tyneside NHS Foundation Trust
References
1. Dial S, Alrasadi K, Manoukian C, Huang A, Menzies D. Risk of Clostridium
difficile diarrhoea among hospital inpatients prescribed proton pump
inhibitors: cohort and case-control studies. Canadian Medical Association
Journal 2004;171:33–8.
2. Cunningham R, Dale B, Undy B, Gaunt N. Proton Pump inhibitors as
a risk factor for Clostridium difficile diarrhoea. Journal of Hospital
Infection 2003;54:243–5. |
The
Pharmaceutical Journal