Electronic letters to:

Research:
Sandra Dial, Khalid Alrasadi, Chantal Manoukian, Allen Huang, and Dick Menzies
Risk of Clostridium difficile diarrhea among hospital inpatients prescribed proton pump inhibitors: cohort and case–control studies
CMAJ 2004; 171: 33-38 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read eLetter] PPIs and C. Difficile - Balanced Response
Nigel Flook   (9 August 2004)

PPIs and C. Difficile - Balanced Response 9 August 2004
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Nigel Flook
University of Alberta

Send letter to journal:
Re: PPIs and C. Difficile - Balanced Response

nflook{at}shaw.ca Nigel Flook

The Board of the Canadian Society of Primary Care Gastroenterology has reviewed the article written by Dr. Dial and associates and published July 6, 2004 in the CMAJ. This article has special interest for physicians who treat hospitalized patients in Canada because of the frequency with which PPIs are used in this population and the dangers of Clostridium difficile associated diarrhoea.

The authors conclude the use of PPIs increases the risk of Clostridium difficile associated diarrhoea. We believe the authors’ discussion overstates the strength of the evidence and leaves the reader with the inaccurate impression that this biologically plausible association has been proven by the study to have a causative association.

We are concerned that failing to bring a balanced perspective to the weight of this evidence could have unfortunate consequences. If the potential association is accepted as proven based on this article, it could shift attention from the most important risk factor for Clostridium difficile associated diarrhoea and from other effective opportunities to prevent this serious disease. The use of antibiotics (particularly broad- spectrum antibiotics and protocols using multiple antibiotics) is the main risk factor for Clostridium difficile associated diarrhoea. Avoiding the unnecessary use of antibiotics remains the most important opportunity to prevent Clostridium difficile associated diarrhoea.

We would not want this article to turn attention away from attempts to control the spread of Clostridium difficile outbreaks by improved hygiene on hospital wards. More frequent and effective cleaning of bathrooms and careful hand washing after caring for patients has the potential to prevent contamination of patients with Clostridium difficile spores. Another strategy that has great potential to prevent this serious disease would recommend the use of bedside commodes dedicated to the personal use of any patient who develop diarrhoea when taking antibiotics.

The possible association between PPI use and Clostridium difficile associated diarrhoea must be recognized in perspective. It should not overshadow important issues in relation to better hygiene or more appropriate antibiotic use and this article should not be taken as the final word on this issue. In our opinion more study is needed before we will know whether this information should alter the present indications for prescribing PPIs to hospitalized patients. It would be unfortunate if patients were to suffer unnecessarily after being denied the use of PPIs based on an inappropriate response to this study.

As clinicians let us strive for appropriate prescribing of all medications including antibiotics and PPIs. As we lobby for cleaner hospitals we must all remember to wash our hands!

Canadian Association of Primary Care Gastroenterology,

Nigel Flook, Alan Kaplan, Brian Craig, Garth Noad, Elliot Mintz, Jamal Serrar, Morgan Govender, Liisa Jaakkimainen, Richard McCammon, Robert Woodland

Conflict of Interest:

Honoraria and Consultancies – Medical Education Program Development Astra Zeneca Abbott Novartis Solvay Glaxo Smith Merck Frosst Janssen Ortho Sanofi-Synthelabo