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Lynne V McFarland
Diarrhoea associated with antibiotic use
BMJ 2007; 335: 54-55 [Full text]
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[Read Rapid Response] An “Antacid policy” to reduce the incidence of Clostridium difficile infection
Jecko Thachil   (27 September 2007)

An “Antacid policy” to reduce the incidence of Clostridium difficile infection 27 September 2007
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Jecko Thachil,
Specialist Registrar
Royal Liverpool University Hospital L7 8XP

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Re: An “Antacid policy” to reduce the incidence of Clostridium difficile infection

The inappropriate and excess use of antibiotics is well established in the causation of C.difficile infection. But at the same time it is important to bear in mind the contribution of acid-suppressive therapy (AST) to this increasing problem. It has recently been shown that these drugs, particularly proton pump inhibitors, are associated with an increased risk of community-acquired C difficile [1]. The ability of the vegetative form of C. difficile to survive in gastric contents with an elevated pH has been suggested as a potential mechanism [2]. It is therefore important that a drug which may alter the helpful gastric milieu is intelligently used in the same manner as the antimicrobials. However, AST is commonly misused in hospitals, with as many as 71% of patients in general medicine wards receiving some sort of AST without an appropriate indication [3].

In one study of 357 patients who received stress ulcer prophylaxis during their intensive care unit (ICU) stay, 80% continued on gastric acid suppressants on transfer from the ICU, with 60% of the therapy being inappropriate [4]. Out of these 25% of the patients were discharged from the hospital with inappropriate prescription of gastric acid suppressants. Focussing on just medical inpatient stay, 54% of patients (from a total of 213) were described antacids on discharge compared to the 29% who were taking them prior to admission [5]. The authors concluded that only 10% of these patients were found to have accepted indications. The problem is not unique to hospital practice and the family physicians have also shown to contribute [6].

It is helpful thus to have a hospital “antacid policy” where the judicious use of gastric acid suppressant therapy is advised to accompany the antimicrobial protocol and thus limit C.difficile infection. There is also the need for the increased awareness among general practitioners about the appropriate use of these “apparently safe” drugs. Consideration could also be made to withholding them while the patients receive broad spectrum antibiotics.

References

1. Dial S, Delaney JAC, Barkun AN, et al. Use of gastric acid- suppressive agents and the risk of community-acquired Clostridium difficile-associated disease. JAMA 2005; 294:2989-95

2. Jump RL, Pultz MJ, Donskey CJ. Vegetative Clostridium difficile survives in room air on moist surfaces and in gastric contents with reduced acidity: a potential mechanism to explain the association between proton pump inhibitors and C. difficile-associated diarrhoea? Antimicrob Agents Chemother. 2007; 51: 2883-7.

3. Grube RR, May DB. Stress ulcer prophylaxis in hospitalized patients not in intensive care units. Am J Health Syst Pharm. 2007; 64: 1396-400.

4. Wohlt PD, Hansen LA, Fish JT. Inappropriate continuation of stress ulcer prophylactic therapy after discharge. Ann Pharmacother. 2007; 41: 1611-6.

5. Pham CQ, Regal RE, Bostwick TR, Knauf KS. Acid suppressive therapy use on an inpatient internal medicine service. Ann Pharmacother. 2006; 40: 1261-6.

6. Scagliarini R, Magnani E, Pratico A, Bocchini R, Sambo P, Pazzi P. Inadequate use of acid-suppressive therapy in hospitalized patients and its implications for general practice. Dig Dis Sci. 2005; 50: 2307-11.

Competing interests: None declared