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Warning over PPI scrips after link to C difficile

GPs should be more cautious in their prescribing of proton pump inhibitors (PPIs) because the treatment could more than triple the risk of Clostridium difficile infection, experts have said. This followed analysis of the General Practice Research Database that identified 317 patients treated with oral vancomycin were indicative of infection with community-acquired C dificile. Comparison with 3,167 control patients showed that those who had been prescribed PPIs in the 90 days prior to the Cdificile infection index date were three and-a-half times more likely to develop infection than those who had not taken the drugs.

Antibiotic use in the 90 days before clostridium infection was associated with an eight-fold Increased risk of C difficile infection.
Renalfailure,inflammatory bowel disease and cancer, and a previous diagnosis of MRSA infection were also linked to community-acquired C difficile. Dr Richard Cunningham, a microbiologist from Derriford Hospital in Plymouth, Devon, said: 'GPs should be sure that patients have a clinical indication for PPIs before prescribing them. 'It is widely accepted that PPIs are effective with few side effects, but that they are sometimes prescribed generously.'

In guidance issued in July 2004, NICE estimated that prescribing of PPIs according to its guidance could reduce use of PPIs by at least 15 per cent.

NICE guidance on PPls

Gastro-oesophageal reflux disease: full-dose PPls for one to two months, then dosage stepped down to lowest dose and return to self-care. Peptic ulcer disease: Helicobactor-pylori eradication if tests show infection. Non-ulcer dyspepsia: lowest dose of H2 blocker that controls symptoms as needed. Uninvestigated dyspepsia: test and treat for H pylori, or PPl treatment.

C difficile specialist Dr Jon Brazier, from the Public Health Laboratory at the University of Wales in Cardiff, explained that higher doses of PPIs increased stomach pH, thereby allowing ingested C difficile spores to colonise the small intestine. 'That may upset the gut flora and so allow C difficile to grow,' he said.

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