NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update

PPIs and Clostridium Difficile (July 2014)

Clostridium difficile infection (CDI) is one of the important healthcare associated infection in Scottish hospitals. It is life-threatening (reported mortality rate 10 - 30%) and has the potential for person to person spread within healthcare settings. Particularly at risk are patients who are aged > 65 years, frail, immunocompromised or who have chronic obstructive pulmonary disease or cardiovascular disease. Across Scotland, rates of CDI have levelled off after a period of significant decreases but there is a need for new strategies to address the burden of CDI that still remains.


PPIs have been identified as a risk factor for CDI but, historically, the evidence has been conflicting. Four recently published meta-analyses provide further evidence that the use of PPIs can increase the risk of CDI and its recurrence, albeit there is general agreement with regards the low quality of available evidence. The recently published CDI guidelines from Health Protection Scotland, suggest that consideration should be given to stopping or reviewing the need for PPIs in patients with or at high risk of CDI.


There is also evidence that PPIs may be linked to other adverse clinical outcomes, while a number of studies (from the UK and the US) suggest that between 60-86% of PPIs may be being used inappropriately.


A significant amount of work has been undertaken in recent years in primary care to ensure PPI therapy is reviewed regularly. There is also guidance available on prescribing PPIS for patients discharged from hospital.


This additional information reminds prescribers of the need for ongoing review of patients prescribed PPIs to consider whether doses can be decreased or therapy stopped rather than continued indefinitely.