Proton pump inhibitors (PPIs): potential link with Clostridioides difficile infection and pneumonia
This is second in a series of PPI blogs
Key points
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Clostridioides difficile infection (CDI) has been associated with PPI use.
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The NHSGGC guideline on Management of Suspected or Proven Clostridioides difficile Infection (CDI) in Adults advises stopping gastric acid suppression (e.g. PPIs) where possible.
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In recent years there have been reports of a link between PPI use and pneumonia, however, evidence is conflicting and therefore there are no NHSGGC guidelines for the management of PPIs in patients with pneumonia.
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Report suspected side effects via the MHRA Yellow Card scheme. Refer to Yellow Card Reporting – An update for healthcare professionals for further information on reporting.
Adverse effects
Clostridioides difficile infection (CDI)
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PPIs are thought to increase the risk of CDI by raising the gastric pH which may increase the growth of pathogenic gut flora.
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A review paper published in 2021, highlighted the statistically significant association between PPI use and CDI.
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A systematic review and meta-analysis of observational studies published in 2021, reviewed the link between CDI recurrence and PPI use. This demonstrated an increase in the rate of recurrence (24%) in those taking a PPI versus those who were not (18%) with users of PPIs having approximately 69% higher odds of recurrent CDI compared to non-users.
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Current NHSGGC advice is if a patient has suspected or proven CDI, the PPI (and other gastric acid suppressors) should be reviewed and if possible should be stopped, to minimise the risk of further episodes. This depends on the indication for the PPI and consideration of the risks vs benefits.
Pneumonia
- In recent years there has been discussion around a possible link between pneumonia and PPI use, however, there are limited clinical trials assessing the link and data is often conflicting. Although a systematic review and meta-analysis of observational studies published in 2020 suggested there was a possible link between PPI use and the risk of community-acquired pneumonia, it concluded that randomised controlled studies were needed to assess whether the observed epidemiologic association is a causal effect or a result of unmeasured/residual confounding.
Patient Scenario - CDI
A 56-year-old male presents to hospital with a history of loose stools, dehydration, abdominal pain and pyrexia. He has a history of hypertension and gastro-oesophageal reflux disease (GORD); his medication history includes ramipril 10mg daily, plus lansoprazole 30mg daily. Bloods requested show an elevated white cell count (16.2 x 109/L) and creatinine of 154 micromol/L. Stool cultures are positive for C. Difficile toxin.
What could be done in this patient?
- The patient should be managed as per the NHSGGC Suspected or Proven Clostridioides Difficile Infection Management in Adults guideline
- Medications which may exacerbate dehydration and/or precipitate kidney injury should be withheld where possible, until fluid status has improved
- The long-term need for the PPI should be reviewed with a view to stopping, only if safe and appropriate to do so
For further information, refer to the other blog in the PPI series:
General overview of oral Proton Pump Inhibitors (PPIs)
Proton Pump Inhibitors (PPIs): Adverse Effects Reported by the MHRA
Published: 04/01/2023. Medicines Update blogs are correct at the time of publishing.