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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.
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
Competing interests: No competing interests