Recurrent C Diff and PPI’s – Case Study

A 69 year old male has a past medical history of hypertension, heartburn, CHF, CAD and osteoarthritis.   This gentleman had been in and out of the hospital several times over the previous year for a variety of reasons including CHF, femur fracture, and pneumonia.  About 6 months ago, he had been diagnosed with a spell of heartburn and placed on Protonix 40 mg daily.  Heartburn was greatly improved with the addition of Protonix.

Current medications included:

  • Aspirin 81 mg daily
  • Enalapril 5 mg daily
  • Metoprolol 12.5 mg twice daily
  • Acetaminophen as needed
  • Bumetanide 1 mg daily
  • Protonix 40 mg daily

About 4 months ago he was treated with Metronidazole for Clostridium Difficle (C Diff).  The infection (or at least the symptoms) did resolve.  Just recently he again started to develop symptoms of loose stools and was diagnosed with recurrent C Diff.  My focus in this case is the PPI.  We’ve got a great reason to get rid of the PPI in this case.

A couple questions that are guiding my thinking here with regards to the CDiff and PPI’s.

1. When was the PPI started, when did the C Diff happen?  It seems we’ve got some correlation there.

2. If the PPI is discontinued, what GI risk will be encountered? The patient is only on low dose aspirin which could increase GI risk (no NSAIDs, Warfarin etc).  The diagnosis of heartburn doesn’t indicate to me a long history of GI problems where long term PPI maybe necessary. (I.e. if this patient had recurrent GI bleeding, Barrett’s etc. they would obviously be at higher risk and have a greater need for PPI therapy.)

Written By Eric Christianson

September 2, 2015

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