1. Nilofar Rahman, MD RISK OF RECURRENCE OF CLOSTRIDIUM DIFFICILE INFECTION WITH PPI USE

2. CLOSTRIDIUM DIFFICILE ORGANISM  Identified in 1978  “J strain”  B1/NAP1/027 strain

3. INCIDENT RATES IF C. DIFF. INFECTION

4. EPIDEMIOLOGY OF C. DIFF INFECTION

5. RISK FACTORS FOR RECURRENCE OF CDI  Advanced age  Non- CDI targeted antibiotic exposure  Longer hospital stay  Inadequate antitoxin-antibody response  Concomitant use of PPIs

6. PATHOGENESIS OF C. DIFF INFECTION Antibiotic therapy Disruption of gut flora Toxin production C. Diff exposure

7. PROBABILITY OF RECURRENCE OF C. DIFF WITH VANC.(TOP) AND METRONIDAZOLE(BELOW)

8. STUDY DONE BY LINSKY ET AL. STUDY DESIGN 1549 Incident c. diff toxin 1408 treated with oral metronidazole or vancomycin 1166 treated within 3 d before or after index CDI 527 PPI exposure639 no PPI exposure

9. Study population

10. PRIMARY EXPOSURE AND OUTCOMES  Exposure measure : PPI within 14 days  Outcome measure: C. diff toxin in 15-90 after incident CDI  Covariates:  Age, sex  Comorbid conditions  CDI- targeted antibiotic  Non-CDI targeted antibiotic

11. RESULTS

12. ModelHazard ratio(95% CI)P value Unadjusted1.42(1.11-1.82)0.006 Adjusted1.42(1.10-1.83)0.008 Non-CDI antibiotic exposure 1.71(1.11-2.64)0.01 No antibiotic exposure 1.30(0.94-1.79)0.12 RESULTS CONTD..

13. Study done by Kim et al.

14. EXPOSURE VARIABLE AND STUDY DESIGN  Exposure variable: PPI use 3D prior to CDI Study design Recurrent group Non-recurrent group

15. RESULTS  Age > 65 (60%, P=0.02)  Fed via NGT (48.1%, P=0.04)  Low albumin ( 2.3+/- 0.5g/dl vs. 3.1 +/- 0.4g/dl)  PPI use (63% vs 39.8%, P=0.01) UNIVARIATE ANALYSIS

16. RISK FACTORSADJUSTED ODDS RATIO CI (95%)P VALUE Age>651.321.12-3.870.03 Concurrent PPI use1.851.35-4.910.028 Serum albumin<2.5g/dl 3.481.64-7.690.016 NGT1.250.91-2.650.068 MULTIVARIATE ANALYSIS

17. Since use of PPIs is a modifiable risk factor for recurrence it is appropriate to review, constantly, the use of PPIs in patients with CDI.

18. THANK YOU

19. REFERENCES