From the Guidelines
Proton pump inhibitors (PPIs) like omeprazole increase the risk of Clostridioides difficile infections by reducing stomach acid, which normally helps protect against pathogens. To manage this risk, PPIs should only be used when clearly indicated, at the lowest effective dose, and for the shortest duration necessary. For patients requiring long-term PPI therapy, periodic reassessment is essential to determine if continued use is necessary. Those at higher risk for C. diff (elderly patients, immunocompromised individuals, those with prior C. diff infections, or patients in healthcare facilities) should be monitored more closely. If C. diff infection develops while on a PPI, consider discontinuing or reducing the PPI if possible while treating the infection with appropriate antibiotics (typically oral vancomycin 125 mg four times daily for 10-14 days, or fidaxomicin 200 mg twice daily for 10 days for initial episodes) 1. For recurrent C. diff infections, antibiotic therapy may need to be extended or alternative approaches like fecal microbiota transplantation considered. Preventive measures include strict hand hygiene, contact precautions for infected patients, and antimicrobial stewardship to reduce unnecessary antibiotic use, which is another major risk factor for C. diff infections.
Some key points to consider:
- The clinical association between PPI use and CDI is well-established, with a significant increase in risk of CDI with PPI use 1.
- Stewardship activities to discontinue unneeded PPIs are strongly warranted 1.
- Antibiotic therapy is the first choice for CDI treatment, and specific antibiotic therapy guideline recommendations should be based on the severity of the disease 1.
- Fecal microbiota transplantation (FMT) is a viable alternative treatment approach for recurrent CDI, with high efficacy rates reported in the literature 1.
- Preventive measures, such as strict hand hygiene and contact precautions, are essential to reduce the transmission of C. diff infections 1.
It is essential to weigh the benefits and risks of PPI use and to consider alternative treatments for patients at high risk of C. diff infections. By prioritizing the management of PPI use and implementing preventive measures, we can reduce the risk of C. diff infections and improve patient outcomes.
From the FDA Drug Label
Published observational studies suggest that PPI therapy like omeprazole may be associated with an increased risk of Clostridium difficile-associated diarrhea, especially in hospitalized patients. Treatment with proton pump inhibitors may lead to slightly increased risk of gastrointestinal infections such as Salmonella and Campylobacter and, in hospitalized patients, possibly also Clostridium difficile.
Proton Pump Inhibitors (PPIs) and C diff Infections: The use of PPIs, such as omeprazole, may be associated with an increased risk of Clostridium difficile (C diff)-associated diarrhea, particularly in hospitalized patients.
- Key Points:
- PPI therapy may increase the risk of C diff-associated diarrhea.
- Hospitalized patients are at higher risk.
- Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated. 2
From the Research
Risks of C diff Infections with Proton Pump Inhibitors
- The use of proton pump inhibitors (PPIs) has been associated with an increased risk of Clostridium difficile (C diff) infections in some studies 3, 4, 5.
- A systematic review and meta-analysis found that PPI use was associated with a 70% increase in the risk of C diff infection 5.
- However, other studies have found no association between PPI use and C diff infection, suggesting that the relationship may be more complex 3, 6.
- A murine model study found that omeprazole, a type of PPI, did not promote C diff colonization in mice 6.
Management Strategies for C diff Infections
- The management of C diff infections typically involves discontinuing the use of PPIs and other medications that may be contributing to the infection 7.
- Antibiotic treatment is often necessary to treat C diff infections, and hospitalization may be required in severe cases 3.
- Strategies to prevent C diff infections include careful consideration of PPI prescriptions, avoidance of unnecessary antibiotic use, and implementation of infection control measures in healthcare settings 4, 7.
Factors that Increase the Risk of C diff Infections
- Advanced age, black race, and increased comorbidities have been identified as risk factors for C diff infection recurrence 3.
- The use of antibiotics, particularly clindamycin, has been shown to increase the risk of C diff infection 6.
- PPI use has been associated with an increased risk of community-associated C diff infection, with the risk remaining elevated up to 1 year after PPI treatment has ended 4.