To the Editor: There is an increasing incidence of community-acquired Clostridium difficile infection (CDI) among patients regarded as low risk because they were not exposed to antimicrobial therapy.1 In his Clinical Crossroads article discussing CDI, Dr Kelly2 did not mention the potential role of the excess use of proton pump inhibitors (PPIs) in hospitals and in the community.
The inhibition of gastric acid secretion by PPIs could be an important mechanism in the increasing incidence of CDI because it is thought to suppress a fundamental physiologic defense mechanism against ingested bacteria and spores. The vegetative form of C difficile has been shown to survive in gastric contents with a raised pH,3 which could explain why patients using PPIs may be prone to colonization with C difficile. This is supported by the experimental finding that the risk of acquiring active CDI and the severity of the resulting colitis are similar when animals are exposed to either PPIs or antibiotics.4 However, it is unclear whether giving PPIs to patients who are also taking antibiotics could further increase the susceptibility to CDI; more well-designed epidemiologic studies are needed to assess this hypothesis.
Up to 70% of patients using PPIs have no appropriate indication for gastric acid suppression, and being treated with antimicrobials is not an appropriate indication for PPIs.5 Until it is known whether avoidance of PPIs can protect against C difficile, we recommend being much more conservative in their use, especially in combination with broad-spectrum antibiotics.
Financial Disclosures: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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