Gastric Acid Suppression Therapy Ups Risk of Recurrent C. difficile

By Reuters Staff

March 30, 2017

NEW YORK (Reuters Health) - Withholding proton pump inhibitors (PPIs) or histamine 2 receptor blockers (H2Bs) in the setting of active or recent Clostridium difficile infection may help prevent a recurrent bout of CDI, researchers say.

In a meta-analytic review, they found that use of gastric acid suppression therapy was associated with about a 50% increased risk of recurrent CDI.

Gastric acid suppression has been associated with an increased risk of primary CDI, but the risk of recurrent CDI in patients taking gastric acid suppressant medications is unclear, note Dr. Sahil Khanna of the Division of Gastroenterology at the Mayo Clinic in Rochester, Minnesota and colleagues.

They reviewed 16 observational studies involving a total of 7703 patients with CDI, including 1525 (19.8%) who developed recurrent CDI.

The rate of recurrent CDI was higher in patients with vs without gastric acid suppression (22.1% vs 17.3%; odds ratio, 1.52; 95% CI, 1.20 to 1.94; P<0.001). Subgroup analyses of studies adjusting for age and multiple potential confounders confirmed an increased risk of recurrent CDI with gastric acid suppression (OR, 1.38; 95% CI: 1.08 to 1.76; P=0.02).

“There was significant heterogeneity among the studies, most likely owing to the diverse patient populations included and methodologic differences between the studies. Subgroup analyses separating case-control and cohort studies and the type of gastric acid suppressant used (PPIs and H2Bs vs PPIs) did not identify a cause of the heterogeneity,” Dr. Khanna and colleagues note in their report online March 27 in JAMA Internal Medicine.

“It may be reasonable to stop gastric acid suppressants in patients with C. difficile infection; limiting unnecessary use of these medications may help to decrease both recurrent C. difficile infection and health care costs,” they conclude.

Each year in the United States, nearly half a million people develop Clostridium difficile infections and about one in five will develop a recurrent C diff infection. “Therefore, identification of modifiable risk factors for incident and recurrent C. difficile infection is a public health priority, say Dr. Scott R. Bauer and Dr. Patrick O’Malley in an editor's note.

“Because patients who take gastric acid suppressants are different from, and most likely sicker than, those who do not take gastric acid suppressants . . . it is reassuring that the observed association was relatively robust when restricted to cohort studies and studies that adjusted for confounders,” they point out. “However, an unbiased assessment without the risk of unmeasured confounding would require randomized clinical trials of gastric acid suppressant continuation vs withdrawal among patients with C. difficile colitis who are also using chronic gastric acid suppressants.”

“In the meantime, these findings support a strategy of withholding gastric acid suppression therapy in the setting of active or recent C. difficile infection,” they conclude.


JAMA Intern Med 2017.


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