Home' Australian Pharmacist : Australian Pharmacist May 2012 Contents 420 Australian Pharmacist May 2012 I © Pharmaceutical Society of Australia Ltd.
take antibiotics daily.1 Antibiotics, such
as fluoroquinolones, have been proven
to reduce the risk of infection by 84%.1,5
However, frequent antibiotic use is
discouraged, as bacterial resistance
It is recommended that prescribers review
the indication for use of the PPI and
evaluate its necessity.23 If possible, the PPI
therapy should be ceased three months
before travelling.39 This virtually reduces
the risk of developing traveller’s diarrhoea
to that of an individual who is not taking
a PPI.12 Alternatively, if the patient cannot
stop taking acid suppressive therapy
it is recommended they switch to a H2
antagonist.24 Some studies have proven
there is decreased risk in developing
traveller’s diarrhoea when on an H2
antagonist compared to a PPI.24,26
In today’s society, GIT symptoms are
becoming more problematic.40 Often, PPIs
provide effective relief of these symptoms,
and are therefore, a popular choice for
patients.40 Upon reviewing the literature
it has become apparent that the use of
PPIs while travelling increases the risk
of developing traveller’s diarrhoea.1
Two possible mechanisms exist for this
increased risk, acid suppression and
inhibition of PgP in the gut. The increased
risk for this commonly used drug class
presents a significant health issue for
any traveller who requires ongoing PPI
therapy.1,2 At this time it would seem
prudent to warn PPI users of the increased
risk of traveller’s diarrhoea, particularly
those travelling to Southeast Asia, Africa,
South America and the Middle East, and of
possible ways to minimise this risk.
1. Ericsson C. Travellers’ diarrhoea. Int J Antimicrob Ag 2003; 21:
2. Leggat P, Goldsmith J. Travellers’ diarrhoea: Health advice for
travellers. Travel Med Infect Dis 2004; 2: 17-22.
3. Dial MS. Proton pump inhibitors and enteric infections. Am J
Gastroentrol 2009; 104 (Suppl): S10-6.
4. Pauli-Magnus C, Rekersbrink S, Klotz U, Fromm MF. Interaction
of omeprazole, lansoprazole and pantoprazole with
p-glycoprotein. Naunyn-Schmiedeberg’s Arch Pharmacol 2000;
364: 551-7 .
5. Ericsson C. Travellers with pre-existing medical conditions. Int J
Antimicrob Ag 2003; 21: 181-8 .
6. Seif S Al-Abri, Nick J Beeching, Fred J Nye. Traveller’s diarrhoea.
Lancet Infect Dis 2005; 5: 349–60 .
7. Ang J, Mathur A. Traveller’s diarrhoea: Updates for
paediatricians. Paediatr Ann 2008; 37: 814-820.
8. Shah N, DuPont HL, Ramsey DJ. Global etiology of travelers’
diarrhea: systematic review from 1973 to the present. Am J
Trop Med Hyg 2009; 80: 609-14 .
9. de la Cabada Bauche J, DuPont HL. New developments in
traveler’s diarrhea. Gastroenterol Hepatol 2011; 7: 88-95.
10. Yates J. Traveler’s diarrhea. Am Fam Physician 2005; 71: 2095-
11. Farthing MJG. Diarrhoea: a significant worldwide problem. Int J
Antimicrob Ag 2000; 14: 65-9 .
12. Sheen E, Triadafilopoulos G. Adverse effects of long term
proton pump inhibitor therapy. Dig Dis Sci 2011; 56: 931-950.
13. Lodato F, Azzaroli F, Turco L, et al. Adverse effects of proton
pump inhibitors. Best Pract Res Cl Ga 2010; 24: 193-201.
14. Leonard J, Marshall JK, Moayyedi P. Systematic review of the risk
of enteric infection in patients taking acid suppression. Am J
Gastroenterol 2007; 102: 2047–56.
15. Cook GC. Infective gastroenteritis and its relationship to
reduced gastric acidity. Scand J Gastroenterol 1985; 111
16. Cunningham R, Dale B, Undy B, Gaunt N. Proton pump
inhibitors as a risk factor for Clostridium difficile diarrhoea. J
Hosp Infect 2003; 54: 243–5.
17. Deshpande A, Pant C, Pasupuleti V, et al. Association between
proton pump inhibitor therapy and Clostridium difficile
infection in a meta-analysis. Clin Gastroenterol Hepatol. 2011
18. Bavishi C, Dupont HL. Systematic review: The use of proton
pump inhibitors and increased susceptibility to enteric
infection. Aliment Pharmacol Ther 2011; 34: 1269–81
19. Howell MD, Novack V, Grugurish P, et al. Iatrogenic gastric acid
suppression and the risk of nosocomial Clostridium difficile
infection. Arch Intern Med 2010; 170: 784-90 .
20. Dial S, Delaney JAC, Barkun AN, et al. Use of gastric acid-
suppressive agents and the risk of community- acquired
Clostridium difficile-associated diarrhea. JAMA 2005; 294:
21. Nerandzic MM, Pultz MJ, Donskey CJ. Examination of potential
mechanisms to explain the association between proton pump
inhibitors and Clostridium difficile infection. Antimicrob Agents
Ch. 2009; 53: 4133–7 .
22. Gurian L, Ward TT, Katon RM. Possible foodborne transmission
in a case of pseudomembranous colitis due to Clostridium
difficile: influence of gastrointestinal secretions on Clostridium
difficile infection. Gastroenterology 1982; 83: 465–9 .
23. Aseeri M, Schroeder T, Kramer J, Zackula R. Gastric acid
suppression by proton pump inhibitors as a risk factor for
Clostridium difficile associated diarrhea in hospitalized
patients. Am J Gastroenterol 2008; 103: 2308–13.
24. Kim JW, Lee KL, Jeong JB, Kim BG, Shin S, Kim JS, Jung HC, Song
IS. Proton pump inhibitors as a risk factor for recurrence of
Clostridium-difficile-associated diarrhea. World J Gastroenterol
2010; 16: 3573–7 .
25. Howden CW, Hunt RH. Relationship between gastric secretion
and infection. Gut 1987; 28: 96–107.
26. Thorens J, Froehlich F, Schwizer W, et al. Bacterial overgrowth
during treatment with omeprazole compared with cimetidine:
a prospective randomized double blinded study. Gut 1996;
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ingested microorganisms in man: studies in vivo and in vitro.
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29. Salix Pharmaceutical Inc. Xifaxan (rifaximin) Tablets, 550 mg
NDA 21–361. Briefing document for Gastrointestinal Drugs
Advisory Committee Meeting 16 Nov 2011.
30. Thiebaut F, Tsuruo T, Hamada H, Gottesman MM. Cellular
localization of the multi-drug-resistance gene product
p-glycoprotein in normal human tissues. P Natl Acad Sci USA
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31. Hunter J, Hirst BH, Simmons NL. Drug absorption limited by
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32. Augustijns PF, Bradshaw TP, Gan SL, Hendren RW, Thakker DR.
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34. De Lannoy IA, Silverman M. The MDR-1 gene product,
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35. Crowe A. The role of p-glycoprotein and breast cancer
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36. Collett A, Higgs NB, Gironella M, et al. Early molecular and
functional changes in colonic epithelium that precede
increased gut permeability during colitis development in
mdr1a(-/-) mice. Inflamm Bowel Dis 2008;14:620–31.
37. Siccardi D, Mumy KL, Wall DM, Bien JD, McCormick BA.
Salmonella enterica serovar Typhimurium modulates
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38. Farthing MJ. Traveller’s diarrhoea. Medicine 2003; 31: 35–40.
39. Schlenker C, Surawicz C. Emerging infections of the
gastrointestinal tract. Best Pract Res Cl Ga 2009; 23: 89–99 .
40. El-Dika S, Guyatt GH, Armstrong D, et al. The impact of illness
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Updating your knowledge
– enhancing your skills
Annual Consultant Pharmacy Seminar
Hyatt Regency Coolum
1–3 June 2012
ConPharm2012 strip ad-AJP-33x225mm.indd 1
5/02/2012 11:17:11 PM
PBA answers CPD questions
The Pharmacy Board of Australia
has published the answers to
frequently asked questions (FAQs)
about continuing professional
development (CPD) on its website. The
FAQs address issues such as meeting
annual requirements, absences from
practice, CPD activities / groups,
maintenance of CPD records for
audits, learning plans and the types
of activities interns can include
in their CPD records or portfolios.
The Board’s Policies, Codes and
Guidelines Committee was developed
the resources and incorporated
contributions from the staff of
the Australian Health Practitioner
Regulation Agency (AHPRA) and the
Australian Pharmacy Liaison Forum.
The FAQs are available online at: www.
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