Blog | Friday, September 27, 2013

C. diff infection? Think of the effect of proton pump inhibitors

Following up on last year’s MMWR that reported that “nearly 75% of all Clostridium difficile infections (CDI) related to U.S. health care have their onset outside of hospitals,” CDC researchers have released a new study in JAMA Internal Medicine looking specifically at the epidemiology of community-associated CDI. The study used data from the Emerging Infections Program, which began to actively collect CDI data in 10 states starting in 2009. This report uses data from 984 patients collected over 29 months with true community-onset CDI, as they excluded community-onset, healthcare facility associated infections.

Somewhat surprisingly, 36% of patients had not received antibiotics and 18% had no outpatient health care exposure. Not surprisingly, 31% of those who had not been exposed to antibiotics had been exposed to PPIs. I highlighted the risk of CDI from PPIs in my ICPIC talk when I discussed this meta-analysis by Kwok and colleagues. In this CDC study, those patients lacking significant outpatient healthcare exposure were also more likely to be exposed to infants and household members with active outpatient health care exposure suggesting a potential route of transmission. I agree with the authors' primary conclusion that a reduction of outpatient PPI use may be necessary to reduce the risk of CDI. As Mike Edmonds, MD, FACP, pointed out four years ago, PPIs are also associated with HAP, VAP, and SBP, so there are many reasons to be concerned about PPIs.

There is an excellent accompanying editorial by some guy named Kent Sepkowitz, who discusses the “PPI-zation” of the U.S. and the difficulties facing any public health initiative targeting PPIs. For one, PPIs are the third most utilized drug in the U.S. and they are addictive since discontinuation is associated with withdrawal symptoms. For another, unlike antibiotics, PPIs are widely available over the counter and supported by huge advertising campaigns. Looks like PPIs are here to stay.

Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.