January 2006
Bad combinations
How stomach-acid medications and antibiotics increase infection risk
Here are new reasons to take potent medications only when truly necessary: Overuse of certain antibiotics has led to a virulent, drug-resistant strain of Clostridium difficile bacteria, or C. difficile for short, which can cause potentially life-threatening diarrhea and colitis; public health authorities worry the particularly nasty bug may be spreading from hospitals into the community; and provocative new research suggests that some heartburn drugs may increase the risk of catching the infection.
Outbreaks of that worrisome strain occurred in eight U.S. health-care facilities between 2000 and 2003, medical epidemiologists report in the Dec. 8, 2005, issue of The New England Journal of Medicine. Moreover, the number of hospital infections with any strain of C. difficile nearly doubled between 1996 and 2003, the U.S. Centers for Disease Control reported in an early-released study appearing in the March 2006 issue of Emerging Infectious Diseases. C. difficile is a fecal bacteria that can be spread from patient to patient by health-care workers who fail to wash their hands (or stethoscope and blood-pressure cuff) between bedside visits, or even by sharing a bathroom with an infected person. Patients receiving antibiotics are at high risk because the drug knocks out beneficial intestinal bacteria, allowing the bad bug to move in and produce toxins. The severely ill and the very old risk life-threatening drug-resistant infection, though antibiotic treatment with metronidazole (Flagyl) or vancomycin (Vancocin) still works.
Now the bacterium--including virulent strains--has surfaced outside of hospitals in at least four U.S. states--New Hampshire, New Jersey, Ohio, and Pennsylvania--striking dozens of young, otherwise healthy people in 2005, the CDC reported in the Jan. 4, 2006, Journal of the American Medical Association. Whether that signals an important shift toward community-acquired disease is "still too early to tell," says L. Clifford McDonald, M.D., a medical epidemiologist at the CDC.
Other preliminary research suggests that commonly used proton pump inhibitors, or PPIs (AcipHex, Nexium, Prevacid, Protonix, and Prilosec, which is also available over-the-counter as Prilosec OTC and as generic omeprazole) may up the risk of catching the infection. Researchers at McGill University in Montreal analyzed a database of 1,233 cases of community-acquired C. difficile infection matched with 12,330 uninfected "control" cases recorded between 1994 and 2004 in the United Kingdom.
Overall, the rate of infection was still relatively low in 2004 at 22 cases per 100,000, but the rate was three times higher among people who had taken PPIs compared with those who didn't use drugs, according to an analysis in the Dec. 21, 2005, issue of JAMA. The infection rate among those who took another class of heartburn drugs known as H2 blockers (Axid, Pepcid, Tagamet, and Zantac, all of which are available in nonprescription or generic versions) was lower, but still twice that of nondrug users.
Sandra Dial, M.D., the lead investigator, explains that because these drugs suppress stomach acid, more spore-forming bacteria may survive to eventually colonize the intestinal tract. Follow-up studies are under way.
WHAT YOU CAN DO
Experts we consulted noted that C. difficile disease acquired outside of the hospital currently appears to be rare, and that only further study will suggest how important a risk factor reducing stomach acid may be. Here are steps that can help protect you and your family against Clostridium difficile infections at home and in the hospital:
For more information about drug-resistant infections, see our October 2005 report.
How stomach-acid medications and antibiotics increase infection risk
Here are new reasons to take potent medications only when truly necessary: Overuse of certain antibiotics has led to a virulent, drug-resistant strain of Clostridium difficile bacteria, or C. difficile for short, which can cause potentially life-threatening diarrhea and colitis; public health authorities worry the particularly nasty bug may be spreading from hospitals into the community; and provocative new research suggests that some heartburn drugs may increase the risk of catching the infection.
Outbreaks of that worrisome strain occurred in eight U.S. health-care facilities between 2000 and 2003, medical epidemiologists report in the Dec. 8, 2005, issue of The New England Journal of Medicine. Moreover, the number of hospital infections with any strain of C. difficile nearly doubled between 1996 and 2003, the U.S. Centers for Disease Control reported in an early-released study appearing in the March 2006 issue of Emerging Infectious Diseases. C. difficile is a fecal bacteria that can be spread from patient to patient by health-care workers who fail to wash their hands (or stethoscope and blood-pressure cuff) between bedside visits, or even by sharing a bathroom with an infected person. Patients receiving antibiotics are at high risk because the drug knocks out beneficial intestinal bacteria, allowing the bad bug to move in and produce toxins. The severely ill and the very old risk life-threatening drug-resistant infection, though antibiotic treatment with metronidazole (Flagyl) or vancomycin (Vancocin) still works.
Now the bacterium--including virulent strains--has surfaced outside of hospitals in at least four U.S. states--New Hampshire, New Jersey, Ohio, and Pennsylvania--striking dozens of young, otherwise healthy people in 2005, the CDC reported in the Jan. 4, 2006, Journal of the American Medical Association. Whether that signals an important shift toward community-acquired disease is "still too early to tell," says L. Clifford McDonald, M.D., a medical epidemiologist at the CDC.
Other preliminary research suggests that commonly used proton pump inhibitors, or PPIs (AcipHex, Nexium, Prevacid, Protonix, and Prilosec, which is also available over-the-counter as Prilosec OTC and as generic omeprazole) may up the risk of catching the infection. Researchers at McGill University in Montreal analyzed a database of 1,233 cases of community-acquired C. difficile infection matched with 12,330 uninfected "control" cases recorded between 1994 and 2004 in the United Kingdom.
Overall, the rate of infection was still relatively low in 2004 at 22 cases per 100,000, but the rate was three times higher among people who had taken PPIs compared with those who didn't use drugs, according to an analysis in the Dec. 21, 2005, issue of JAMA. The infection rate among those who took another class of heartburn drugs known as H2 blockers (Axid, Pepcid, Tagamet, and Zantac, all of which are available in nonprescription or generic versions) was lower, but still twice that of nondrug users.
Sandra Dial, M.D., the lead investigator, explains that because these drugs suppress stomach acid, more spore-forming bacteria may survive to eventually colonize the intestinal tract. Follow-up studies are under way.
WHAT YOU CAN DO
Experts we consulted noted that C. difficile disease acquired outside of the hospital currently appears to be rare, and that only further study will suggest how important a risk factor reducing stomach acid may be. Here are steps that can help protect you and your family against Clostridium difficile infections at home and in the hospital:
- Don't insist on antibiotics if your doctor says they're not necessary. Not only does overuse lead to drug-resistant bacteria,
but it also increases the risk of acquiring a C. difficile infection, particularly in hospitalized patients.
- Don't use PPIs and H2 blockers unless your doctor says they're necessary. Though research linking such strong heartburn medicine
with C. difficile infection is not yet conclusive, it makes sense to use simple antacids (Rolaids, Tums), which have not been
as well studied but theoretically should pose less potential risk for infection, if they're effective at relieving symptoms.
However, if you have gastroesophageal reflux disease you should know that the Agency for Healthcare Research and Quality,
part of the U.S. Department of Health and Human Services, recently concluded that PPIs are as effective as more costly surgery
for this condition and that PPIs were more effective than H2 blockers.
- Seek medical attention promptly for severe diarrhea and cramping that doesn't resolve after two or three days, especially
if you've been taking antibiotics or have recently been hospitalized.
- Insist on clean hands in hospitals and other health-care settings. Expect all people who touch you--including visitors--to
first wash their hands with soap and water (alcohol-based solutions are less effective against Clostridium difficile). If
you don't see them do that, politely ask whether they have. And of course, wash your own hands, especially if you have diarrhea.
- In choosing a hospital or nursing home, inquire about its procedures for controlling infection. If you're sharing a hospital
room with a patient who has severe diarrhea, ask for new arrangements.
- Consumers Union, publisher of Consumer Reports, has initiated a public campaign to require hospitals to reveal their infection rates to the public. For more information, go to the CU Web site at www.StopHospitalInfections.org .
For more information about drug-resistant infections, see our October 2005 report.
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