Reply to Wiegand et al.: Proton pump inhibitor over-use and the ongoing battle to control Clostridium difficile infection in hospitals (original) (raw)

Letter to the Editor Reply to Wiegand et al.: Proton pump inhibitor over-use and the ongoing battle to control Clostridium difficile infection in hospitals Madam, Wiegand et al. highlighted the vast economic and clinical burden of C. difficile infection (CDI) in their systematic review of CDI-related mortality, length of stay, recurrence and related cost. 1 Mortality rates ranged from 2% to 42%, with the highest mortality being found in the UK and the lowest in France. Length of stay was on average 14 days longer for patients with C. difficile infection in the UK. Research has identified proton pump inhibitor (PPI) use as a potential risk factor for CDI, although the exact relationship remains unclear. In 2006, Dial et al. found that exposure to a PPI was associated with an increased risk of communityacquired C. difficile-associated disease (odds ratio: 3.5; 95% confidence interval: 2.3e5.2). 2 In 2010, recurrent CDI was linked to PPI exposure, with a study showing 42% increased risk of CDI recurrence when PPI use was continued throughout treatment of infection. 3 Following this they recommended that PPI therapy should be stopped during CDI. Further research by Howell et al. identified a doseeresponse relationship between level of iatrogenic gastric acid suppression and nosocomial CDI rates. 4 The UK guidelines on the indication for PPIs advise to avoid long-term use of PPIs except in specific circumstances and to use 'step-down' low-dose acid suppression therapy if long courses are required. 5 We have conducted a point prevalence study of the number of patients on PPIs across three medical wards at West Middlesex University Hospital in West London. Seventy-seven patients were included, reviewing PPI drug, dose, indication for therapy, duration of use and concurrent antibiotic use. The results revealed a high volume of PPI prescriptions, particularly on the non-acute wards. Forty-one of 77 (53%) patients were on regular PPI therapy, and no indication was stated or apparent in the majority of these cases (24/41, 59%). The majority of patients had commenced PPI therapy prior to admission (76%, 31/41); it was not possible to ascertain whether this was in primary or secondary care. Twenty-six percent of patients had been prescribed antibiotics concurrently during their admission.