Proton Pump Inhibitors in Patients with Colitis or C. difficile Infection

Risk Association Between PPIs and C. difficile

The American College of Gastroenterology recommends that proton pump inhibitors (PPIs) be avoided in patients with C. difficile infection (CDI) or colitis when possible, as they are associated with an increased risk of CDI and may worsen existing infection 1
Current guidelines recommend stewardship activities to discontinue unneeded PPIs in patients at high risk for CDI, with a strength of evidence based on case-control studies showing an odds ratio of 2.5 for PPI use and CDI 1, 2

For patients with active CDI, the Infectious Diseases Society of America recommends discontinuing PPIs if not medically necessary, and using the lowest effective dose for the shortest duration possible if PPI therapy must be continued 1, 2
For patients with a history of CDI or at high risk, the American College of Gastroenterology recommends evaluating the necessity of PPI therapy, considering H2 receptor antagonists as an alternative, and monitoring closely for signs of CDI recurrence 1, 2

In patients with CDI who require continued antibiotic therapy for other infections, the Society for Healthcare Epidemiology of America recommends using antibiotics less frequently implicated with CDI, such as parenteral aminoglycosides, sulfonamides, macrolides, vancomycin, or tetracycline/tigecycline 1, 2
The European Society of Clinical Microbiology and Infectious Diseases notes that pseudomembrane formation in C. difficile infection requires neutrophils, so may not be seen if the patient is neutropenic 4
The American College of Gastroenterology advises that in patients with severe C. difficile infection, PPI discontinuation alone is unlikely to be sufficient treatment, and appropriate antibiotic therapy with oral vancomycin or fidaxomicin is necessary 3, 4