Proton Pump Inhibitor Therapy Alleged Accomplice or Innocent Bystander in the Changing Epidemiology of Clostridium Difficile Associated Diarrhea?

Abstract

Purpose: Over the past decade there has been an increase in the number of hospital patients with Clostridium difficile-associated diarrhea (CDAD). It has become a major hospital acquired pathogen and understanding the potential risk factors for CDAD has become an important focus of research. One of the controversial associations commonly stated of increasing ones risk of acquiring CDAD is proton pump inhibitor (PPI) therapy (Am J Gastroenterol 2008; 103:2308-2313). This retrospective chart review study was done to evaluate the incidence of CDAD in hospitalized patients who were taking PPI therapy. Methods: An IRB approved retrospective case-control chart review study was conducted consisting of 209 randomly chosen hospitalized patients charts admitted between 1/01/05 to 7/01/08 that were found to have a discharge diagnosis of CDAD by ICD9 coding (008.45). Charts were then analyzed for inclusion criteria to determine if patients had a positive C.difficile cytotoxin assay performed during that admission, if PPI therapy was used continuously for at least three days prior to that positive cytotoxin stool assay, and whether the patients were over the age of eighteen. Exclusion criteria for the study consisted of having no prior history of CDAD within the past 6 months. In addition, a randomly chosen age and gender matched control group of 168 charts was obtained during the same time frame, with the only inclusion/exclusion criteria required be that the patient be above the age of eighteen, with no diarrhea symptoms while in the hospital and no positive C. difficle cytotoxin assays during admission. Results: Of the 209 hospitalized patient charts reviewed, 149 met the inclusion criteria for the study while 60 were excluded. Cases were not found to be more likely than controls to have acid suppressive therapy with PPI onboard while admitted to the hospital, 80 (53.7%) vs. 99 (58.9%) with a P=0.8081 by Cochran-Mantel-Haenszel analysis. Conclusion: This retrospective study further argues against the alleged risk factor association that PPI therapy will increase a hospitalized patient's chance for developing CDAD due to gastric acid suppression. Further randomized prospective studies should be sought to further clarify this discrepancy in correlation.