From the Guidelines
Protonix (pantoprazole) should not be stopped solely for the treatment of Clostridioides difficile (C. difficile) infection, as there is insufficient evidence to support discontinuation of proton pump inhibitors (PPIs) as a measure for preventing CDI [ 1 ].
Key Considerations
- The decision to discontinue PPIs should be based on the individual patient's need for the medication, rather than the presence of CDI [ 1 ].
- Stewardship activities to discontinue unneeded PPIs are strongly warranted [ 1 ].
- The primary treatment for CDI is antibiotic therapy, and the choice of antibiotic should be based on the severity of the disease [ 1 ].
Management of CDI
- Discontinue therapy with the inciting antibiotic agent(s) as soon as possible, as this may influence the risk of CDI recurrence [ 1 ].
- Consider empirical antibiotic therapy for CDI in situations where a substantial delay in laboratory confirmation is expected, or for fulminant CDI [ 1 ].
Treatment Options
- Fidaxomicin, vancomycin, and metronidazole are recommended treatment options for CDI, depending on the severity of the disease [ 1 ].
- Bezlotoxumab may be considered as an adjunctive treatment for patients with CDI recurrence [ 1 ].
From the FDA Drug Label
5.3 Clostridium difficile-Associated Diarrhea Published observational studies suggest that PPI therapy like pantoprazole sodium may be associated with an increased risk of Clostridium difficile associated diarrhea, especially in hospitalized patients. Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated.
The FDA drug label suggests an association between PPI therapy, such as pantoprazole, and an increased risk of Clostridium difficile-associated diarrhea.
- To manage this risk, patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated.
- However, the label does not explicitly state that pantoprazole should be stopped in patients with C. difficile infection.
- Considering the potential association between PPI therapy and C. difficile-associated diarrhea, it may be prudent to discontinue pantoprazole in patients with C. difficile infection, especially if the diarrhea does not improve, as a conservative clinical decision 2.
From the Research
Association between Protonix (Pantoprazole) and C. difficile Infection
- The use of proton pump inhibitors (PPIs), such as pantoprazole, has been associated with an increased risk of Clostridium difficile infection (CDI) 3, 4, 5, 6.
- Studies have shown that continuous PPI use is associated with a higher risk of CDI recurrence 3, 4.
- The risk of CDI recurrence remains elevated even after PPI use is stopped, with one study showing an increased risk up to 1 year after PPI treatment had ended 5.
Considerations for Stopping Protonix (Pantoprazole) in Patients with C. difficile Infection
- The decision to stop PPIs in patients with CDI should be individualized, taking into account the patient's underlying medical conditions and the potential benefits and risks of PPI use 3, 7.
- One study suggested that the cessation of unnecessary PPI use should be considered at the time of CDI diagnosis 3.
- Another study recommended that clinicians should consider treating C. difficile infection in patients with vancomycin instead of metronidazole, and that PPIs may be discontinued in patients with CDI if they are not necessary 7.
Evidence Summary
- Multiple studies have demonstrated a significant association between PPI use and the risk of CDI, including initial and recurrent infections 4, 5, 6.
- A systematic review and meta-analysis found that PPI use was associated with a significantly increased risk of CDI in both adult and pediatric patients 6.
- The evidence suggests that stopping PPIs, such as pantoprazole, may be beneficial in reducing the risk of CDI recurrence in patients with C. difficile infection 3, 4, 5, 6.