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Proton pump inhibitors and the incidence of Clostridium difficile on the intensive care unit


Clostridium difficile associated disease (CDAD) is recognized as a major cause of morbidity and mortality among patients in hospital. There have been reported associations between the use of proton pump inhibitors (PPIs) and CDAD in community and hospital settings [1, 2]. The aim of this study was to investigate the effect of introducing PPI prophylaxis in critically ill patients on the incidence of CDAD.


Retrospective analysis of microbiology results of patients admitted to general and neurotrauma ICUs between February 2002 and September 2006. Prior to March 2004 the general ITU used PPIs for all patients as gastric acid prophylaxis, and the neurotrauma ITU used PPIs for only patients at high risk of GI ulceration. Following instigation of ventilator care bundles in March 2004 both units gave PPIs to all ventilated patients. The incidence of C. difficile toxin-positive samples and the number of doses of PPI used each month were compared for before and after this time period. The use of antibiotics was also compared between the two units over the time period to exclude this as a confounding variable.


We identified 92 C. difficile-positive faecal samples during the 57-month period from February 2002 to September 2006. This averaged 1.61 cases per month. The general ITU (ITU2) presented 49 cases (53.2%), and the neurotrauma ITU (ITU3) 43 cases (46.8%). In February 2002, PPI usage was infrequent in the ITU3, but more common in ITU2. The C. difficile rates were also higher in ITU2 than in ITU3. PPI usage increased in ITU3 until, on the instigation of the ventilator care bundle, PPIs were used for all patients from March 2004. Our preliminary data demonstrate an increase in C. difficile rates in ITU3, to meet the rates of ITU2, at the same time as PPI usage was increased (Figure 1). The ITUs back onto each other and share the same medical and nursing staff. Antibiotic usage was similar across both units with regards to cephalosporins, meropenem and pipracillin/tazobactam.

figure 1

Figure 1


C. difficile rates have remained relatively stable on the general ITU (ITU2) but showed a significant increase on the neurotrauma ITU (ITU3), concurrent with increased PPI usage. We believe this worthy of further investigation.


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Whitehead, I., Smith, J., Bellamy, R. et al. Proton pump inhibitors and the incidence of Clostridium difficile on the intensive care unit. Crit Care 11 (Suppl 2), P148 (2007).

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