The Effect of Proton Pump Inhibitors on Nosocomial Clostridium Difficile: A Literature Review

Magee, Michelle, and Joyce PhD. RN Conley



The objective of this literature review is to examine what association exists between Proton Pump Inhibitor (PPI) therapy and the development of Clostridium difficile infection (CDI). PPIs are widely used for gastric ulcer prophylaxis in the inpatient setting.



What is the effect of PPI therapy on incidence of nosocomial Clostridium difficile among hospitalized adults, compared to patients who do not receive PPIs?



The Ovid Medline, CINAHL, and PubMed databases were searched using the headings “Clostridium difficile” and “Proton Pump Inhibitors”. The search was limited to humans and the last five years. Articles focused on nursing homes, community acquired CDI and adults with CDI diagnosis prior to hospitalization were excluded. Four articles were applicable for this review. A fifth article was found as a reference in another article, and a sixth landmark study published in 2004 was also included.



There are no guidelines for best practice with regards to preventative PPI use found in the Cochrane Review or SUMSearch.



The studies analyzed were either case control or cohort; one was a systemic review. Five out of 6 studies found a statiscally significant link between PPI use and CDI. Because there are multiple risks associated with CDI (such as poor infection control practices, long hospital stays, renal impairment, age, and co-morbidities), it is difficult to control for every factor. However, overuse of broad spectrum antibiotics is the most consistent causative factor for CDI. The one article that did not find an association between PPI use and CDI did not control for antibiotic exposure, and was carried out during a CDI epidemic.



There is convincing evidence to discontinue PPI prophylaxis and recommend PPI stewardship in the hospital setting where there is no medical indication for PPI therapy.