Clostridioides difficile infection (CDI), is a type of bacterial infection that causes diarrhea, abdominal pain, and sometimes life-threatening complications. CDI has been most associated with antibiotic use, which can disrupt the normal balance of gut bacteria and allow Clostridioides difficile bacteria (C. diff) to thrive and produce toxins.
C. diff can be present in a normal microbiome, but is suspected to thrive in a dysbiotic or unhealthy gut. A significant factor affecting the microbiome composition is the use of medication, especially exposure to antibiotics. Furthermore, the use of gastric acid suppressants, including proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs), as well as some non-steroidal ant-inflammatory drugs (NSAIDs), has been associated with CDI. Other risk factors include older age (over 65 years), chronic comorbidities such as inflammatory bowel disease and admission to hospitals and long-term care facilities.
A recent study investigating the effect of concurrent use was recently published in the Journal of Antimicrobial Chemotherapy. This large population-based study in Sweden compared 43,152 CDI patients with 355,172 matched controls and assessed the impact of recent and preceding use of antibiotics and PPIs on CDI and recurrent CDI risk. It was found that the odds of CDI were 17.51 times higher for those who used both antibiotics and PPIs in the past 30 days, compared with those who did not. Preceding (31 to 180 days) use of both resulted in odds that were 9.13 times higher. Recent antibiotic use did result in slightly higher odds of CDI recurrence, but little increased risk was seen if combined with PPIs. Certain antibiotics, such as macrolides, quinolones, and non-penicillin beta-lactams had the strongest association with CDI and recurrence.
The study suggests that both antibiotics and PPIs contribute to CDI risk, and that their combined use should be avoided or minimized. The study also highlights the need to reconsider the risk-benefit in use of these medication classes, which are often over-prescribed. PPIs are used as maintenance therapy in 10 – 30% of adults, often inappropriately.
“It is well known that antibiotics and PPIs are over-prescribed and are independent risk factors for C. diff infection. The results of this study shed new light on the compounded risk with
combined use of these agents. Continued emphasis of antibiotic stewardship is vitally important to decrease the burden of CDI. Additionally, these findings call on us to also prioritize the widespread problem of chronic PPI overuse. I encourage you to check out Deprescribing Guidelines and Algorithms – Deprescribing.org. There are many tools to aid in discontinuation of unnecessary PPIs,” shared Carrie Sorenson, PharmD; Quality Improvement Advisor with Great Plains QIN
Use these tools, developed by Great Plains QIN, to reduce CDI in your organization:
- Connecting the Dots – Antibiotic Stewardship, Immunization, Sepsis
- Decision Tree For Diarrhea Management
- CDI Chart Review Tool
Visit the CDC C. diff page for additional resources, trainings and fact sheets.
Reference: McKnights—cidrap.umn.edu
View our Focus 4 Health Series | Clostridium Difficile Infections (CDI)
Patient Safety – C. difficile | Recording
Risk and Detect | Recording
Spread | Recording
Prevent, Educate, Antibiotic Stewardship | Recording
Listen to our Podcast – Q-Tips For Your Ears!
C. difficile – What Everyone Needs to Know: What is C. diff, why is awareness of C. diff infections important and how can we prevent these infections to keep us safe? November is C. diff Awareness Month; knowing the signs and symptoms is key to improved health and better outcomes. Take a few minutes to listen and learn more.