Proton Pump Inhibitors Use and Risk of Clostridium difficile Infection in Hospitalized Patients

Abstract

Introduction: Proton pump inhibitors are a common class of medications used to treat gastroesopheageal reflux and acid peptic diseases. Widely used and highly effective,proton pump inhibitors (PPIs) are associated with a number of adverse effects including an increased risk of gastrointestinal infections such as clostridium difficile infection (CDI).In this study we seek to compare the rates of hospital acquired CDI among patients taking PPIs and those not taking PPIs. Methods: After obtaining institutional review board approval, we conducted a retrospective review of all patients admitted to Johnson City Medical Center from January 1, 2013 until May 31, 2014 in order to determine the total number of patients diagnosed with CDI during this time.We classified CDI as present on admission if the diagnosis was made within 72 hours of admission. Clostridium difficile infection diagnosed after 72 hours was classified as hospital acquired.For the purpose of our study we analyzed the cohort of hospital acquired CDI and compared the rate of CDI among PPI users and non-PPI users. We then performed a chart review of the hospital acquired CDI patients to determine the magnitude of risk CDI in PPI users compared to non-PPI users. Categorical data will be compared using Chi square with Yates' correction or Fisher's exact for data entry points less than five. Results: There were a total of 41,663 admissions to Johnson City Medical Center from January 1, 2013 until May 31, 2014. During this time there were 349 diagnoses of CDI, of which 80 were not present on admission. Sixty-five patients who received PPIs in the hospital were diagnosed with nosocomial CDI (0.37%),compared to just 15 patients who did not receive PPI therapy in the hospital (0.06%).This data suggest that PPI use in the hospitalized patient is associated with a 6-fold increase in the risk of nosocomial CDI (P < 0.0001).CDI accounted for nearly $900,000 during the review period, of which $722,737 was spend on CDI in patients taking PPIs. Conclusion: The association between PPI use and risk of CDI is well described, however most studies show that the risk is small with an odds ratio of 2 or less.Our data indicate that the risk of nosocomial CDI in PPI users may be as high as 6 fold compared to non-PPI users. Given the significant morbidity, mortality and cost of treating nosocomial CDI,the indications, risks and benefits of PPI therapy should be carefully weighed and discussed with each patient, particularly in the hospital setting.