Restarting Dexlansoprazole After Prior Clostridioides difficile Infection: Evidence‑Based Guidance

1. Risk Assessment

2. Indication and Stewardship

3. Duration and Dose Considerations

4. Monitoring and Early Detection

5. Additional Patient‑Specific Risk Factors

6. Prophylaxis Recommendations

7. Importance of Early Treatment

Proton Pump Inhibitors in Patients with C. difficile Infection

Risk Association Between PPIs and C. difficile

• PPIs have been epidemiologically associated with an increased risk of C. difficile infection, according to the Infectious Diseases Society of America (IDSA) 6, 7

Guidelines on PPI Use in CDI Patients

• The IDSA/SHEA guidelines acknowledge the epidemiologic association between PPI use and CDI, and note that unnecessary PPIs should always be discontinued as part of good stewardship practice 6, 8
• The World Society of Emergency Surgery (WSES) guidelines state that stewardship activities to discontinue unneeded PPIs are strongly warranted 7, 9

Decision-Making Algorithm for PPI Use in CDI Patients

• The European Society of Cardiology recommends evaluating the necessity of PPI therapy, and discontinuing the PPI if no clear indication exists 6, 7, 9, 10
• For patients with legitimate PPI indications, the European Heart Journal suggests considering the risk-benefit ratio carefully, using the minimum effective dose required to treat symptoms, and considering temporary discontinuation during acute CDI treatment if clinically feasible 9, 10

Important Clinical Considerations

• The World Journal of Emergency Surgery recommends discontinuing the inciting antibiotic agent(s) as soon as possible when treating CDI, and considering using antimicrobials less frequently implicated with CDI if continued antibiotic therapy is required 6, 7, 9
• The Infectious Diseases Society of America (IDSA) recommends avoiding continued PPIs without a clear indication in patients with CDI 6, 10

Management of Patients at Risk of C. difficile Infection Taking PPIs

Risk Association Between PPIs and C. difficile

• Multiple meta-analyses have demonstrated a significant association between PPI use and increased risk of C. difficile infection (CDI), with odds ratios ranging from 1.69 to 2.34, according to the Clinical Infectious Diseases guideline 11
• Minimize the duration of antibiotic therapy to reduce CDI risk, as recommended by the Clinical Infectious Diseases guideline 11
• The risk of CDI increases with the number of antibiotics prescribed - compared to patients receiving only 1 antibiotic, the adjusted hazard ratios for those receiving 2, 3-4, or ≥5 antibiotics were 2.5, 3.3, and 9.6, respectively, as reported by the Clinical Infectious Diseases guideline 11
• The number needed to harm is higher for the general population (range: 899-3925) compared to hospitalized patients not on antibiotics (range: 202-367) or hospitalized patients on antibiotics (range: 28-50), according to the Clinical Infectious Diseases guideline 11