Proton-Pump Inhibitor Use and the Risk of Community-Associated Clostridium difficile Infection

Abstract

Background: Proton-pump inhibitors (PPIs) have been reported to increase the risk of community-associated Clostridium difficile infection (CDI), but the association remains disputed.

Methods: A nationwide cohort study among adults in Denmark, 2010-2013, linking register data on C. difficile testing, filled prescriptions, and patient characteristics. All incident episodes of community-associated CDI (ie, positive culture, molecular assay, or toxin test in individuals without previous hospitalization in the prior 12 weeks and without a positive test for C. difficile in the prior 8 weeks) were identified in the Danish National Microbiological Database. Self-controlled case-series analyses were used to estimate incidence rate ratios (IRRs) for community-associated CDI, comparing periods with and without exposure to PPIs. By design, models took fixed confounders such as chronic disease, genetics, and socioeconomic status into account; further, time-varying confounders, including hospital stay and antibiotic and corticosteroid use were adjusted for.

Results: 3583 episodes of community-associated CDI were identified, of which 964 occurred during current use of PPIs, 324 occurred 0-6 months after treatment cessation, 123 occurred 6-12 months after treatment cessation, and 2172 occurred during time periods without use of PPIs. The adjusted IRR was 2.03 (95% confidence interval, 1.74-2.36), comparing use of PPI with nonuse. The increased risk remained elevated in later time periods: 1.54 (1.31-1.80) for 0-6 months, 1.24 (1.00-1.53) for 6-12 months after current use.

Conclusions: Use of PPIs was associated with moderately increased risk of community-associated CDI. The risk remained elevated up to 1 year after PPI treatment had ended.

Keywords: C. difficile infection; epidemiology; proton-pump inhibitor; self-controlled case-series analysis.

Figure 1.

Flowchart of the selection of the study population. ^aDanish people at least 20 years of age in 2010–2013. Abbreviations: CDI, Clostridium difficile infection; PPI, proton-pump inhibitor; SCCS, self-controlled case-series.

Figure 2.

IRR of community-associated Clostridium difficile infection in users of proton-pump inhibitors. Abbreviations: CI, confidence interval; IRR, incidence rate ratio.

Figure 3.

IRR of community-associated Clostridium difficile infection in current users of proton-pump inhibitors according to age and gender. Abbreviations: CI, confidence interval; IRR, incidence rate ratio.