Proton Pump Inhibitors Not a Major Risk Factor for Hospital-acquired Clostridium difficile Infection in Young, African American Males

Abstract

Introduction: Clostridium difficile infection (CDI) is the leading cause of healthcare-associated infections. Due to its increased morbidity and mortality, there is great need to identify associated demographics and risk factors. National epidemiology reveals a predominance of elderly, Caucasian females. Proton pump inhibitors (PPIs) have been associated with a 1.4-2.75x increased risk of CDI. The exact relationship between hospital-acquired CDI (HA-CDI) and PPIs is unclear. We performed a retrospective analysis to (1) Examine CDI epidemiology at Hahnemann University Hospital compared to national epidemiology and (2) Investigate the association between PPIs as a risk factor for HA-CDI.Figure: Demographic and PPI characteristics of the CDI cases and controls.Methods: We conducted a case-control study of HA-CDI from 08/2014 to 04/2017. Cases (n=229) were defined as confrmed diagnosis 72 hrs post-admission. Controls (n=454) were frequency matched in a 2:1 ratio based on age and length of stay. PPI was classified into 4 categories: dosage (20mg, 40mg), frequency (QD, BID), delivery (PO, IV) and duration (10 days). Student's T-test, Wilcoxon rank sum test, Chisquared test were used to compare risk factors between cases and controls. Results: HA-CDI cases had a mean age of 60 with male predominance (54%, n=123) vs. females (46%, n=106), and by race, 56% (n=120) African American and 36% (n=77) Caucasian. In our sample (cases & controls), 48% (n=328) were on a PPI with the combined majority 73% (n=239) on 40mg daily vs. 25% (n=83) on 40mg BID. PPIs were administered orally in 61% (n=200) vs. IV in 38% (n=123) of all combined patients with the majority exposed for 10+ days (59%, n=190). There were no statistically significant differences between cases and controls in PPI use, dosage, route of administration or duration. Conclusion: National CDI epidemiology reveals a predominance of elderly (51.9% age >65), Caucasian (78.6%) and female (59%) patients. In contrast, our CDI epidemiology showed a predominance of younger, African American males. PPIs are theorized to increase the risk of CDI due to increased gastric pH which may prevent protective flora from actively suppressing the germination of Clostridium difficile spores and toxin synthesis. However, given that there was no significant association detected between PPI and CDI in our sample, we must consider alternative risk factors that may uniquely predispose our distinct cohort to CDI. The relationship between PPI and CDI in unique demographic cohorts such as ours needs to be further explored in future studies.