Administration of proton pump inhibitors in critically ill medical patients is associated with increased risk of developing Clostridium difficile–associated diarrhea

Hospitalized patients on proton pump inhibitors for stress ulcer prophylaxis have a higher risk of Clostridioides difficile infection compared with those on histamine-2 receptor antagonists

BACKGROUND

Previous studies on Clostridioides difficile infection (CDI) in proton pump inhibitor (PPI) users generally enrolled a heterogeneous population and did not include a control group of histamine H2 receptor antagonists (H2RAs) users or adjust for confounding variables, such as previous antibiotics. It is uncertain whether hospitalized patients using PPIs for stress ulcer prophylaxis (SUP) are at a higher risk of CDI compared with those using H2RAs. This study aimed to compare the association between CDI and the usage of antisecretory drugs (ASDs): PPIs and H2RAs, for SUP among hospitalized patients, and the impact of the duration of their use on CDI.

METHODS

In this nationwide population-based cohort study using the Taiwan National Health Insurance Database, hospitalized patients using ASDs for SUP were identified between 2017 and 2018. A total of 63,266 and 69,269 individuals were included in the PPI and H2RA groups, respectively. The primary endpoint was a 90-day monitoring of CDI occurrence.

FINDINGS

The incidences of CDI were 1.6/10,000 and 0.5/10,000 person-days in the PPIs and H2RAs groups, respectively. After adjusting for confounding factors, the risk of infection in the PPIs group remained significantly higher than in the H2RAs group (hazard ratio (HR), 2.49; 95% confidence interval (CI), 1.63-3.81). In the subgroup analysis, during hospitalization, the risk of CDI for patients using high-risk antibiotics or admitted to the intensive care unit (ICU), as well as patients with immunodeficiency, using PPIs for SUP, was higher than using H2RAs. Furthermore, the risk of CDI was higher in patients using ASDs for durations >14 days than in those using them for <7 days (adjusted HR, 3.66; 95% CI, 2.34-5.75).

CONCLUSIONS

The risk of occurrence CDI for hospitalized patients using PPIs for SUP was higher than using H2RAs. It is recommended not to exceed 14 days of any gastric ASDs for SUP during hospitalization, especially for patients who have used high-risk antibiotics, have been admitted to the ICU, or have immunodeficiency.

Incidence, timing, and risk factors for development of gastrointestinal bleeding in acute traumatic spinal cord injury: A systematic review

CONTEXT

Current guidelines recommend four weeks of stress ulcer prophylaxis following traumatic spinal cord injury.

OBJECTIVES

Assess the current literature on the incidence, timing, and risk factors for gastrointestinal bleeding/clinically important gastrointestinal bleeding in the acute setting following a traumatic spinal cord injury and whether the use of stress ulcer prophylaxis has been shown to reduce the rates of gastrointestinal bleeding.

METHODS

A systematic review was performed in PubMed, Embase, Web of Science, and Cochrane Library following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

RESULTS

A total of 24 articles met the inclusion/exclusion criteria. The average rate of gastrointestinal bleeding among all studies was 5.5% (95% CI = 5.4-5.6%; n = 26,576). The average rate of clinically important gastrointestinal bleeding was 1.8% (95% CI = 1.79-1.82%; n = 3,857). The mean time since injury to when gastrointestinal bleeding occurred ranged from 5 to 22.5 days. For clinically important gastrointestinal bleeding the average time was 16 days or less. Those with cervical injuries had a higher incidence of clinically important gastrointestinal bleeding compared to those with non-cervical injuries (2.7% vs. 0.7%). No study found any difference in the use of stress ulcer prophylaxis in participants with or without gastrointestinal bleeding.

CONCLUSIONS

The overall incidence of clinically important gastrointestinal bleeding among studies was found to be low. Individuals with non-cervical injury were not found to be at high risk of clinically important gastrointestinal bleeding. There was also insufficient evidence to indicate that use of stress ulcer prophylaxis reduces the rate of gastrointestinal bleeding in those with traumatic spinal cord injury.

Proton pump inhibitors for gastrointestinal bleeding prophylaxis in critically ill patients: A systematic review protocol

BACKGROUND

Proton pump inhibitors (PPIs) are the most commonly prescribed drugs for preventing upper gastrointestinal bleeding in critically ill patients. However, concerns have arisen about the possible harms of using PPIs, including potentially increased risk of pneumonia, Clostridioides difficile infection, and more seriously, an increased risk of death in the most severely ill patients. Triggered by the REVISE trial, which is a forthcoming large randomized trial comparing pantoprazole to placebo in invasively mechanically ventilated patients, we will conduct this systematic review to evaluate the efficacy and safety of PPIs versus no prophylaxis for critically ill patients.

METHODS

We will systematically search randomized trials that compared gastrointestinal bleeding prophylaxis with PPIs versus placebo or no prophylaxis in adults in the intensive care unit (ICU). Pairs of reviewers will independently screen the literature, and for those eligible trials, extract data and assess risk of bias. We will perform meta-analyses using a random-effects model, and calculate relative risks for dichotomous outcomes and mean differences for continuous outcomes, and the associated 95% confidence intervals. We will conduct subgroup analysis to explore whether the impact of PPIs on mortality differs in more and less severely ill patients. We will assess certainty of evidence using the GRADE approach.

DISCUSSION

This systematic review will provide the most up-to-date evidence regarding the merits and limitations of stress ulcer prophylaxis with PPIs in critically ill patients in contemporary practice.

Guidelines for Antibiotics Prescription in Critically Ill Patients

How to cite this article: Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, et al. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024;28(S2):S104-S216.

Proton-Pump Inhibitors to Prevent Gastrointestinal Bleeding - An Updated Meta-Analysis

BACKGROUND

The goal of this systematic review was to examine the efficacy and safety of proton-pump inhibitors for stress ulcer prophylaxis in critically ill patients.

METHODS

We included randomized trials comparing proton-pump inhibitors versus placebo or no prophylaxis in critically ill adults, performed meta-analyses, and assessed certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations approach. To explore the effect of proton-pump inhibitors on mortality based on disease severity, a subgroup analysis was conducted combining within-trial subgroup data from the two largest trials and assessed credibility using the Instrument for Assessing the Credibility of Effect Modification Analyses.

RESULTS

Twelve trials that enrolled 9533 patients were included. Proton-pump inhibitors were associated with a reduced incidence of clinically important upper gastrointestinal bleeding (relative risk [RR], 0.51 [95% confidence interval (CI), 0.34 to 0.76]; high certainty evidence). Proton-pump inhibitors may have little or no effect on mortality (RR, 0.99 [95% CI, 0.93 to 1.05]; low certainty). Within-trial subgroup analysis with intermediate credibility suggested that the effect of proton-pump inhibitors on mortality may differ based on disease severity. Subgroup results raise the possibility that proton-pump inhibitors may decrease 90-day mortality in less severely ill patients (RR, 0.89; 95% CI, 0.80 to 0.98) and may increase mortality in more severely ill patients (RR, 1.08; 95% CI, 0.96 to 1.20]. Proton-pump inhibitors may have no effect on pneumonia and little or no effect on Clostridioides difficile infection (low certainty).

CONCLUSIONS

High certainty evidence supports the association of proton-pump inhibitors with decreased upper gastrointestinal bleeding. Proton-pump inhibitors may have little or no effect on mortality, although a decrease in mortality in less severely ill patients and an increase in mortality in more severely ill patients remain possible. (PROSPERO number CRD42023461695.).

Clinical characteristics and outcomes of Clostridioides difficile infection in the intensive care unit: a KASID multi-centre study

BACKGROUND

Despite the growing clinical and economic burden of Clostridioides difficile infection (CDI), data on CDI in the intensive care unit (ICU) in the Asia-Pacific region are lacking.

METHODS

This retrospective study analysed 191 patients who were treated with CDI in the ICUs of three hospitals in South Korea from January 2017 to May 2021. Backward-stepwise multiple logistic regression was used to identify factors influencing the treatment response and mortality.

RESULTS

Fifty-eight patients (30.4%) were considered immunocompromised. The mean Charlson comorbidity index was 5.65 ± 2.39 (10-year survival rate: 21%), the APACHE II score was 20.86 ± 7.78 (mortality rate: 40%), the ATLAS score was 5.45 ± 1.59 (cure rate: 75%), and the SOFA score was 7.97 ± 4.03 (mortality rate: 21.5%). Fifty-eight (30.4%) of the CDI cases were severe and 40 (20.9%) were fulminant. Oral vancomycin or oral metronidazole was the most frequently first-line treatments (N = 57; 32.6%). The 10-day response rate was 59.7% and the eight-week overall mortality rate was 41.4%. Fulminant CDI (OR 0.230; 95% CI 0.085-0.623) and each one-unit increment in the SOFA score (OR 0.848; 95% CI 0.759-0.947) were associated with treatment failure. High APACHE II (OR 0.355; 95% CI 0.143-0.880) and SOFA (OR 0.164; 95% CI 0.061-0.441) scores were associated with higher mortality.

CONCLUSIONS

High-risk patients in the ICU had a higher mortality rate and a lower cure rate of CDI. Further research is required to provide more accurate prediction scoring systems and better clinical outcomes.

Appropriateness of proton pump inhibitors use in noncritically ill hospitalized children in a tertiary hospital in Saudi Arabia

Background

Studies assessing the appropriate use of proton pump inhibitors (PPIs) for hospitalized noncritically ill pediatric patients are lacking. Therefore, this study aimed to assess the suitability of PPI prescriptions in noncritically ill pediatric patients.

Methods

This cross sectional retrospective study was conducted at a maternity hospital in Qassim, Saudi Arabia from November 2020 to January 2021. All noncritically ill hospitalized children aged 14 years and below who received PPIs were included. The endpoints included the number and percentage of patients who appropriately received PPIs in general and in each age category. The collected data were analyzed using Microsoft Excel (version 2208, Microsoft Corp., Redmond, WA, USA).

Results

In total, 332 medical records were screened, of which 246 were included. Of all patients, 49.2% were children and 50.8% were infants, with the average age at admission being 5.39 ± 5.4 years years. More than half of the patients were female, and the average weight of patients was 19.8 kg. Omeprazole was appropriately used in 95 (38.5%) patients. Based on age groups, omeprazole was appropriately used in 66.3% of children and 38.4% of infants.

Conclusion

The use of omeprazole in noncritically ill pediatrics was only deemed appropriate in 38.6% of the study population. This result indicates that this medication was overused in the institution. Additional research is required to confirm this on a nationwide scale.

The impact of pharmacist intervention on the intravenous-to-oral switch therapy of proton pump inhibitors in cardiovascular surgery

BACKGROUND

The prescriptions of proton pump inhibitors (PPIs) have been widely concerned due to both huge increase in medical costs and possible long-term adverse events (AEs) caused by the improper route of drug administration. The aim of this study was to assess the effectiveness of pharmacist interventions on the clinical outcome and safety of switching from intravenous (IV) to oral PPIs therapy.

PATIENTS AND METHODS

A retrospective, single-center, pre- intervention (early -stage)- and intervention (later -stage) study was performed in a Chinese hospital.

RESULTS

A total of 1736 patients were included in the study. After 12 months of interventions, significant improvements in the number of rational IV to oral switch in patients with oral switch indications were found. The median duration of oral therapy was increased, while the duration of PPIs therapy was decreased. Pharmacist interventions led to significant reductions in mean PPI costs, mean total drug costs, mean hospitalization costs, and the risk for long-term adverse events.

CONCLUSION

This study provides important evidence on the beneficial effect of pharmacist interventions on promoting an optimal IV to oral switch of PPIs and substantial cost saving by shortening the duration of IV PPIs therapy and reducing the risk for long-term AEs.

Effect of electroacupuncture on the repair of stress ulcer injury in neurocritical patients: A randomized clinical trial

BACKGROUND

Stress ulcer (SU) is one of the main causes of prolonged hospital stay, poor prognosis, and increased mortality in critically ill patients. This study aimed to investigate the effect of electroacupuncture (EA) on SU in patients with severe neurological diseases and explore its possible mechanisms.

METHODS

Taking patients with SU in adult neurocritical care as the research object, they were randomly divided into the EA group and the control group. Through the perioperative EA intervention, the following indicators were documented: main observation indicator (the effective rate of SU treatment), secondary observation indicators (gastric juice pH, gastric juice occult blood test, and stool occult blood test), related mechanisms [repair factors trefoil factor family 2 (TFF2), vascular endothelial growth factor (VEGF), and heat shock protein 70 (HSP70)], complications during hospitalization, and intensive care unit (ICU) stay time.

RESULTS

Compared with the control treatment, EA increased the effective rate of SU treatment (85.4% for the EA group, 57.5% for the control group, risk difference: 27.9% (95% CI: 8.3%-45.1%); P < 0.01). EA increased the success rate of gastric juice pH treatment on days 1, 2, and 3 (P < 0.01 for day 1, P < 0.05 for days 2 and 3). EA lowered the positive rate of gastric occult blood test on days 1 and 3 (all P-values < 0.05) and the positive rate of fecal occult blood test on day 3 (P < 0.05). EA also reduced the ICU stay time (P < 0.01) and total hospitalization time (P < 0.05). Compared with day 0, all serum repair factors (VEGF, HSP70, and TFF2) of both groups significantly increased on days 1, 3, and 5 (all P-values < 0.01). Compared with the control group, VEGF in the EA group was increased on days 3 and 5 (all P-values < 0.01); HSP70 was increased on days 1, 3, and 5 (P < 0.05 for day 1, P < 0.01 for days 3 and 5); and TFF2 was increased on days 1, 3, and 5 (all P-values < 0.01).

CONCLUSION

Electroacupuncture promoted the repair of SU damage in severe neurological disease, and its effect was related to enhancing the expression of gastric mucosal repair factors.

CLINICAL TRIAL REGISTRATION

[https://www.chictr.org.cn/showprojen.aspx?proj=127012], identifier [ChiCTR2100046701].

Association of Vitamin B12 deficiency with long-term PPIs use: A cohort study

Background

Proton Pump inhibitors are widely used among the majority of the world's population as acid-suppressing medications. Proton Pump Inhibitors have been reported to cause intestinal damage and adverse gut microbiota changes affecting several mechanisms, including malabsorption, etc.

Aim

In order to gain a deeper understanding, we conducted a cohort analysis to assess the prevalence & association of Vitamin B12 deficiency in patients on long-term use of PPIs.

Methods

This single-center cohort study was conducted at the Department of Internal Medicine, KRL hospital in Islamabad, Pakistan from May 2021 to May 2022. Rao soft calculator with a 95% confidence interval and 5% error margin was used to find the estimated sample size. Vitamin B₁₂ levels were analyzed using the Cobas e411 analyzer. Chi-square test, odds ratio, and t-tests were used for analysis.

Results

Among the 1225 participants, more than half of the men (55.10%) had low levels of vitamin B12. Vit B12 levels were observed to be significantly lower in Omeprazole patients than in Pantoprazole patients. A vitamin B12 deficiency is 0.5 times more likely in patients taking PPIs. There is a substantial difference between the early and final levels of B12 indicated by the t-test.

Conclusion

According to our findings, long-term usage of PPIs is linked to an increased risk of vitamin B12 insufficiency specifically in men falling under the ages of 18 and 40.

•

Increased focus and precision have been achieved by single-centered approach.

•

Over 1200 people were enrolled during the course of the year-long data collection period, which have contributed to the study's overall authenticity.

•

It is possible that this large-scale investigation may serve to clarify the link between PPIs and VIT B12 deficiency during this period of uncertainty.

Prophylactic acid suppressants in patients with primary neurologic injury: A systematic review and meta-analysis of randomized controlled trials

PURPOSE

Neurocritical care patients are at risk of stress-induced gastrointestinal ulceration. We performed a systematic review and meta-analysis of stress ulcer prophylaxis (SUP) in critically ill adults admitted with a primary neurologic injury.

MATERIALS AND METHODS

We included randomized controlled trials (RCTs) comparing SUP with histamine-2-receptor antagonists (H2RAs) or proton pump inhibitors (PPIs) to placebo/no prophylaxis, as well as to each other. The primary outcome was in-ICU gastrointestinal bleeding (GIB). Predefined secondary outcomes were all-cause 30-day mortality, ICU length of stay (LOS), nosocomial pneumonia, and other complications.

RESULTS

We identified 14 relevant trials enrolling 1036 neurocritical care patients; 11 trials enrolling 930 patients were included in the meta-analysis. H2RAs resulted in a lower incidence of GIB as compared to placebo or no prophylaxis (Risk ratio [RR] 0.42, 95% CI 0.30-0.58; p < 0.001); PPIs with a lower risk of GIB compared to placebo/no prophylaxis (RR 0.37, 95% CI 0.23-0.59; p < 0.001). No significant difference was observed in GIB comparing PPIs with H2RAs (RR 0.53, 95% CI 0.26-1.06; p = 0.07; I² = 0%).

CONCLUSIONS

In neurocritical care patients, the overall high or unclear risk of bias of individual trials, the low event rates, and modest sample sizes preclude strong clinical inferences about the utility of SUP.

Stress Ulcer Prophylaxis for Critical Asthma

BACKGROUND

Children hospitalized for critical asthma (CA) in the pediatric ICU (PICU) are commonly prescribed stress ulcer prophylaxis (SUP) to mitigate risk of gastrointestinal (GI) bleeding. We sought to describe trends for SUP prescribing and explore for differences in rates of GI bleeding, gastritis, and SUP-related complications for those with and without SUP exposure.

METHODS

We performed a retrospective, multicenter cohort study using the Pediatric Hospital Information System registry among 42 children's hospitals from 2010 to 2019 including children 3 to 17 years of age admitted to the PICU for CA. Primary outcomes were chronologic and regional variation in SUP prescribing assessed by Joinpoint regression and Pearson's correlation. Rates of GI bleeding, gastritis, enteric ulceration, and SUP-related complications (C. difficile colitis, necrotizing enterocolitis, and thrombocytopenia) were compared for those with and without SUP exposure.

RESULTS

Of 30 177 children studied, 10 387 (34.4%) received SUP. No episodes of GI bleeding were recorded. One subject developed gastric ulceration and 32 (0.1%) gastritis. Linear trends for SUP were observed with rates increasing from 25.5% in 2010 to 42.1% in 2019 (+1.9% annually). Prescribing varied by institution (range: 5.5% to 97.2%) without correlation to admission volumes. Extremely rare rates of SUP-related complications were noted.

CONCLUSIONS

Although children hospitalized for CA routinely receive SUP, no episodes of GI bleeding were noted over a 10-year period. SUP solely for corticosteroid exposure may be unwarranted. We advocate for a targeted approach to SUP considering alternative risk factors for GI bleeding.

Pre-hospitalization proton pump inhibitor use and clinical outcomes in COVID-19

INTRODUCTION

Severe acute respiratory syndrome coronavirus-2 may escape the inactivation by gastric acid because of hypochlorhydria caused by proton pump inhibitors (PPIs), which could predispose the patients to severe COVID-19.

METHODS

We studied the association between prehospitalization PPI exposure and clinical outcomes among hospitalized COVID-19 patients.

RESULTS

A total of 295 hospitalized COVID-19 patients were included in the study. 15.6% of hospitalized COVID-19 patients were on PPIs at home. Mortality among PPI-users was 2.3 times higher than non-users, along with 2.3 times higher risk of acute respiratory distress syndrome after adjusting for confounding variables.

CONCLUSION

We found that prehospitalization PPI-exposure is independently associated with worse clinical outcomes, including mortality in COVID-19 patients, regardless of the presence of cardiovascular comorbidities.

A Nomogram for Individualized Prediction of Stress-Related Gastrointestinal Bleeding in Critically Ill Patients with Primary Intracerebral Hemorrhage

PURPOSE

To establish and validate a nomogram model for predicting stress-related gastrointestinal bleeding in critically ill patients with primary intracerebral hemorrhage.

PATIENTS AND METHODS

From January 2018 to March 2021, we conducted a hospital-based study by screening eligible patients with acute intracerebral hemorrhage. Univariate and multivariate logistic regression analyses were performed to determine the predictors for stress-related gastrointestinal bleeding in patients with primary intracerebral hemorrhage. The nomogram was constructed on the basis of multivariate logistic model and was internally validated by bootstrap resampling. The discriminative performance of the nomogram was evaluated using the calibration and concordance index (C-index), which was equal to the area under the curve of receiver-operating characteristics. Hosmer-Lemeshow test was performed to check the model's goodness of fit. A decision curve analysis was used to assess its clinical utility.

RESULTS

A total of 410 patients were enrolled in this study. Stress-related gastrointestinal bleeding occurred in 115 patients (28.0%). Multivariate analysis demonstrated that gastric pH at admission [odds ratio (OR): 0.52, 95% confidence interval (CI): 0.41-0.66, P < 0.001], ICH volume (OR: 1.03, 95% CI: 1.02-1.05, P < 0.001) and sepsis (OR: 2.56, 95% CI: 1.54-4.25, P < 0.001) were independent predictors for stress-related gastrointestinal bleeding in critically ill patients with ICH. The nomogram including gastric pH at admission, ICH volume and sepsis presented good discrimination with C-index of 0.770 (95% CI: 0.716 to 0.822), which was confirmed to be 0.764 through bootstrapping validation. The calibration plot showed good agreement between the predicted and observed outcomes. The Hosmer-Lemeshow test showed a goodness-of-fit (Chi-Square = 8.085, DF = 8, P = 0.425). Decision curve analysis demonstrated that the nomogram was clinically beneficial.

CONCLUSION

The proposed nomogram based on gastric pH at admission, ICH volume and sepsis can accurately predict the risk of stress-related gastrointestinal bleeding in critically ill patients with primary intracerebral hemorrhage.

Are Proton Pump Inhibitors More Effective Than Histamine-2-Receptor Antagonists for Stress Ulcer Prophylaxis in Critically Ill Patients? A Systematic Review and Meta-Analysis of Cohort Studies

BACKGROUND

Histamine-2-receptor antagonists (H₂RAs) have been largely replaced by proton pump inhibitors (PPIs) for stress ulcer prophylaxis (SUP) despite the inconclusive evidence concerning comparative effectiveness.

OBJECTIVE

To compare the effectiveness of PPIs and H₂RAs on SUP in real-world setting.

METHODS

PubMed, Embase, and the Cochrane Library were searched from inception to September 19, 2021. We included cohort studies comparing PPIs with H₂RAs in critically ill adult patients and explicitly reporting the outcome of gastrointestinal (GI) bleeding or mortality. Newcastle-Ottawa Scale was used to assess potential risk of bias. We conducted a random-effects meta-analysis and only the studies with adjusted effect estimates were pooled. The Grading of Recommendations Assessment, Development, and Evaluation system was used to assess the overall quality of the evidence.

RESULTS

Thirteen cohort studies (N = 145 149) were eligible and 11 of them available for full texts were of low to moderate risk of bias. Meta-analysis of adjusted effect estimates indicated that PPIs were associated with a significantly higher risk of GI bleeding, compared with H₂RAs (8 studies, odds ratio [OR] = 1.98, 95% confidence interval [CI] = 1.30-3.01, low certainty). Post hoc pooling analysis also suggested that PPIs were associated with a slightly higher risk of mortality in comparison with H₂RAs (7 studies, OR = 1.27, 95% CI = 1.13-1.42, low certainty).

CONCLUSION AND RELEVANCE

The systematic review of cohort studies showed that PPIs were associated with higher risks of GI bleeding and mortality, although the certainty of evidence was low. Overall, we suggest not excluding H₂RAs for SUP, while further studies are essential for elucidating the risk stratification, optimal regimen, and specific duration.

The efficacy and safety of acid suppressants for gastrointestinal bleeding prophylaxis in cardiac care unit patients

BACKGROUND AND AIM

Concerns regarding adverse events associated with proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) for gastrointestinal bleeding (GIB) prophylaxis in the intensive care unit have increased in recent years. Few studies have focused on acid suppressant use in the cardiac care unit (CCU) setting exclusively. We performed a cohort study to determine the efficacy and safety of acid suppressants for GIB prophylaxis in CCU patients.

METHODS

This retrospective cohort study included adults who were admitted directly to the CCU for more than 2 days from January 1, 2014, to April 30, 2019. The Crusade score was calculated to evaluate the risk of GIB. The primary outcomes were clinically important gastrointestinal bleeding (CIGIB), hospital-acquired pneumonia (HAP), and in-hospital mortality.

RESULTS

Of the 3318 patients enrolled, 2284 (68.8%) patients received PPIs, 515 (15.5%) received H2RAs, and 519 (15.7%) received no acid suppressants. After adjusting for potential confounders, utilization of PPIs (2.69, 95% confidence interval [0.62-11.73]) and H2RAs (1.41, 95% confidence interval [0.19-10.36]) were not associated with a lower risk of CIGIB than the control. Sensitivity analyses revealed that PPI use was an independent risk factor for in-hospital mortality in patients over 75 years old, with an adjusted odds ratio of 4.08 (1.14-14.63). PPIs increased the risk of HAP in patients over 75 years old and in those with heart failure, with adjusted odds ratios of 2.38 (1.06-5.34) and 2.88 (1.34-7.28), respectively.

CONCLUSIONS

Proton pump inhibitors and H2RAs for GIB prophylaxis in CCU patients were not associated with a lower risk of CIGIB than the controls. PPI therapy is associated with increased risks of HAP and in-hospital mortality in patients over 75 years old. PPIs may increase the risk of HAP in patients with heart failure.

Critical Care Management of the Patient with Clostridioides difficile

OBJECTIVES

To review published clinical evidence on management of Clostridioides difficile infection in critically ill patients.

DATA SOURCES

We obtained relevant studies from a PubMed literature review and bibliographies of reviewed articles.

STUDY SELECTION

We selected English-language studies addressing aspects of C. difficile infection relevant to critical care clinicians including epidemiology, risk factors, diagnosis, treatment, and prevention, with a focus on high-quality clinical evidence.

DATA EXTRACTION

We reviewed potentially relevant studies and abstracted information on study design, methods, patient selection, and results of relevant studies. This is a synthetic (i.e., not systematic) review.

DATA SYNTHESIS

C. difficile infection is the most common healthcare-associated infection in the United States. Antibiotics are the most significant C. difficile infection risk factor, and among antibiotics, cephalosporins, clindamycin, carbapenems, fluoroquinolones, and piperacillin-tazobactam confer the highest risk. Age, diabetes mellitus, inflammatory bowel disease, and end-stage renal disease are risk factors for C. difficile infection development and mortality. C. difficile infection diagnosis is based on testing appropriately selected patients with diarrhea or on clinical suspicion for patients with ileus. Patients with fulminant disease (C. difficile infection with hypotension, shock, ileus, or megacolon) should be treated with oral vancomycin and IV metronidazole, as well as rectal vancomycin in case of ileus. Patients who do not respond to initial therapy should be considered for fecal microbiota transplant or surgery. Proper infection prevention practices decrease C. difficile infection risk.

CONCLUSIONS

Strong clinical evidence supports limiting antibiotics when possible to decrease C. difficile infection risk. For patients with fulminant C. difficile infection, oral vancomycin reduces mortality, and adjunctive therapies (including IV metronidazole) and interventions (including fecal microbiota transplant) may benefit select patients. Several important questions remain regarding fulminant C. difficile infection management, including which patients benefit from fecal microbiota transplant or surgery.

Comparative risk of Clostridium difficile infection between proton pump inhibitors and histamine-2 receptor antagonists: A 15-year hospital cohort study using a common data model

BACKGROUNDS AND AIM

There are potential concerns regarding infectious complications including Clostridium difficile infections (CDIs) among patients taking gastric acid suppressants. Furthermore, it is speculated that the stronger acid suppression by proton pump inhibitors (PPIs) potentially enhance infectious complications. This study aimed to compare the risk of CDI between PPIs and histamine-2 receptor antagonists (H2RAs).

METHODS

Using the long-term database of the Kangdong Sacred Heart Hospital, converted to the Observational Medical Outcomes Partnership Common Data Model, we identified outpatients treated with PPIs and H2RAs for ≥ 7 days from January 1, 2004 through December 31, 2018. We conducted Cox regression analysis to examine the hazard ratio (HR) of CDI after propensity score matching.

RESULTS

During a median follow-up period of 1.2 years (interquartile range, 0.2-3.2 years), the initial CDI occurrence differed significantly between matched cohorts of patients taking PPIs and H2RAs [PPIs vs H2RAs, 88/31 095 person years vs 47/32 836 person years; HR, 2.22; 95% confidence interval (CI) 1.29-3.96; P = 0.005]. Almost 50% of all events occurred within 1 year of drug exposure. The risk of CDIs was significantly greater among groups receiving PPIs or H2RAs than in matched controls (PPIs vs control: HR, 2.65; 95% CI 1.28-5.79; P = 0.011; and H2RAs vs control: HR 2.43; 95% CI 1.09-5.68; P = 0.034].

CONCLUSION

In long-term hospital cohort, outpatient-based PPIs were associated with greater risk of CDI than H2RAs. It is necessary to be cautioned about complication of CDI in patients taking long-term PPI therapy.

Adherence to a stress ulcer prophylaxis protocol by critically ill patients: a prospective cohort study

OBJECTIVE

To evaluate adherence to the stress ulcer prophylaxis protocol in critically ill patients at a tertiary university hospital.

METHODS

In this prospective cohort study, we included all adult patients admitted to the medical and surgical intensive care units of an academic tertiary hospital. Our sole exclusion criterion was upper gastrointestinal bleeding at intensive care unit admission. We collected baseline variables and stress ulcer prophylaxis indications according to the institutional protocol and use of prophylaxis. Our primary outcome was adherence to the stress ulcer prophylaxis protocol. Secondary outcomes were appropriate use of stress ulcer prophylaxis, upper gastrointestinal bleeding incidence and factors associated with appropriate use of stress ulcer prophylaxis.

RESULTS

Two hundred thirty-four patients were enrolled from July 2nd through July 31st, 2018. Patients were 52 ± 20 years old, 125 (53%) were surgical patients, and the mean SAPS 3 was 52 ± 20. In the longitudinal follow-up, 1499 patient-days were studied; 1069 patient-days had stress ulcer prophylaxis indications, and 777 patient-days contained prophylaxis use (73% stress ulcer prophylaxis protocol adherence). Of the 430 patient-days without stress ulcer prophylaxis indications, 242 involved prophylaxis (56% inappropriate stress ulcer prophylaxis use). The overall appropriate use of stress ulcer prophylaxis was 64%. Factors associated with proper stress ulcer prophylaxis prescription were mechanical ventilation OR 2.13 (95%CI 1.64 - 2.75) and coagulopathy OR 2.77 (95%CI 1.66 - 4.60). The upper gastrointestinal bleeding incidence was 12.8%.

CONCLUSION

Adherence to the stress ulcer prophylaxis protocol was low and inappropriate use of stress ulcer prophylaxis was frequent in this cohort of critically ill patients.

Clostridioides difficile infections in the intensive care unit: a monocentric cohort study

Introduction

Patient-level data from Clostridioides difficile infections (CDI) treated in an intensive care setting is limited, despite the growing medical and financial burden of CDI.

Methods

We retrospectively analyzed data from 100 medical intensive care unit patients at the University Hospital Cologne with respect to demography, diagnostics, severity scores, treatment, and outcome. To analyze factors influencing response to treatment and death, a backward-stepwise multiple logistic regression model was applied.

Results

Patients had significant comorbidities including 26% being immunocompromised. The mean Charlson Comorbidity Index was 6.3 (10-year survival rate of 2.25%). At the time of diagnosis, the APACHE II was 17.4±6.3 (predicted mortality rate of 25%), and the ATLAS score was 5.2±1.9 (predicted cure rate of 75%). Overall, 47% of CDI cases were severe, 35% were complicated, and 23% were both. At least one concomitant antibiotic was given to 74% of patients. The cure rate after 10 and 90 days was 56% and 51%, respectively. Each unit increment in APACHE II score was associated with poorer treatment response (OR 0.931; 95% CI 0.872–0.995; p = 0.034). Age above 65 years was associated with death (OR 2.533; 95% CI 1.031–6.221; p = 0.043), and overall mortality at 90 days was 56%.

Conclusions

CDI affects a high-risk population, in whom predictive scoring tools are not accurate, and outcomes are poor despite intensive treatment. Further research in this field is warranted to improve prediction scoring and patient outcomes.

Electronic supplementary material

The online version of this article (10.1007/s15010-020-01413-8) contains supplementary material, which is available to authorized users.

Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: systematic review and network meta-analysis

OBJECTIVE

To determine, in critically ill patients, the relative impact of proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), sucralfate, or no gastrointestinal bleeding prophylaxis (or stress ulcer prophylaxis) on outcomes important to patients.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials, trial registers, and grey literature up to March 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES AND METHODS

We included randomised controlled trials that compared gastrointestinal bleeding prophylaxis with PPIs, H2RAs, or sucralfate versus one another or placebo or no prophylaxis in adult critically ill patients. Two reviewers independently screened studies for eligibility, extracted data, and assessed risk of bias. A parallel guideline committee (BMJ Rapid Recommendation) provided critical oversight of the systematic review, including identifying outcomes important to patients. We performed random-effects pairwise and network meta-analyses and used GRADE to assess certainty of evidence for each outcome. When results differed between low risk and high risk of bias studies, we used the former as best estimates.

RESULTS

Seventy two trials including 12 660 patients proved eligible. For patients at highest risk (>8%) or high risk (4-8%) of bleeding, both PPIs and H2RAs probably reduce clinically important gastrointestinal bleeding compared with placebo or no prophylaxis (odds ratio for PPIs 0.61 (95% confidence interval 0.42 to 0.89), 3.3% fewer for highest risk and 2.3% fewer for high risk patients, moderate certainty; odds ratio for H2RAs 0.46 (0.27 to 0.79), 4.6% fewer for highest risk and 3.1% fewer for high risk patients, moderate certainty). Both may increase the risk of pneumonia compared with no prophylaxis (odds ratio for PPIs 1.39 (0.98 to 2.10), 5.0% more, low certainty; odds ratio for H2RAs 1.26 (0.89 to 1.85), 3.4% more, low certainty). It is likely that neither affect mortality (PPIs 1.06 (0.90 to 1.28), 1.3% more, moderate certainty; H2RAs 0.96 (0.79 to 1.19), 0.9% fewer, moderate certainty). Otherwise, results provided no support for any affect on mortality, Clostridium difficile infection, length of intensive care stay, length of hospital stay, or duration of mechanical ventilation (varying certainty of evidence).

CONCLUSIONS

For higher risk critically ill patients, PPIs and H2RAs likely result in important reductions in gastrointestinal bleeding compared with no prophylaxis; for patients at low risk, the reduction in bleeding may be unimportant. Both PPIs and H2RAs may result in important increases in pneumonia. Variable quality evidence suggested no important effects of interventions on mortality or other in-hospital morbidity outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019126656.

Stress ulcer prophylaxis with proton pump inhibitors or histamine 2 receptor antagonists in critically ill adults - a meta-analysis of randomized controlled trials with trial sequential analysis

Background

Proton pump inhibitors (PPI) and histamine 2 receptor antagonists (H2RA) have been widely used as stress ulcer prophylaxis (SUP) in critically ill patients, however, its efficacy and safety remain unclear. This study aimed to assess the effect of SUP on clinical outcomes in critically ill adults.

Methods

Literature search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane database of clinical trials for randomized controlled trials (RCTs) that investigated SUP, with PPI or H2RA, versus placebo or no prophylaxis in critically ill patients from database inception through 1 June 2019. Study selection, data extraction and quality assessment were performed in duplicate. The primary outcomes were clinically important gastrointestinal (GI) bleeding and overt GI bleeding. Conventional meta-analysis with random-effects model and trial sequential analysis (TSA) were performed.

Results

Twenty-nine RCTs were identified, of which four RCTs were judged as low risk of bias. Overall, SUP could reduce the incident of clinically important GI bleeding [relative risk (RR) = 0.58; 95% confidence intervals (CI): 0.42–0.81] and overt GI bleeding (RR = 0.48; 95% CI: 0.36–0.63), these results were confirmed by the sub-analysis of trials with low risk of bias, TSA indicated a firm evidence on its beneficial effects on the overt GI bleeding (TSA-adjusted CI: 0.31–0.75), but lack of sufficient evidence on the clinically important GI bleeding (TSA-adjusted CI: 0.23–1.51). Among patients who received enteral nutrition (EN), SUP was associated with a decreased risk of clinically important GI bleeding (RR = 0.61; 95% CI: 0.44–0.85; TSA-adjusted CI: 0.16–2.38) and overt GI bleeding (RR = 0.64; 95% CI: 0.42–0.96; TSA-adjusted CI: 0.12–3.35), but these benefits disappeared after adjustment with TSA. Among patients who did not receive EN, SUP had only benefits in reducing the risk of overt GI bleeding (RR = 0.37; 95% CI: 0.25–0.55; TSA-adjusted CI: 0.22–0.63), but not the clinically important GI bleeding (RR = 0.27; 95% CI: 0.04–2.09).

Conclusions

SUP has benefits on the overt GI bleeding in critically ill patients who did not receive EN, however, its benefits on clinically important GI bleeding still needs more evidence to confirm.

Stress Ulcer Prophylaxis in Neurocritical Care

Stress ulcer prophylaxis (SUP) with acid-suppressive drug therapy is widely utilized in critically ill patients following neurologic injury for the prevention of clinically important stress-related gastrointestinal bleeding (CIB). Data supporting SUP, however, largely originates from studies conducted during an era where practices were vastly different than what is considered routine by today's standard. This is particularly true in neurocritical care patients. In fact, the routine provision of SUP has been challenged due to an increasing prevalence of adverse drug events with acid-suppressive therapy and the perception that CIB rates are sparse. This narrative review will discuss current controversies with SUP as they apply to neurocritical care patients. Specifically, the pathophysiology, prevalence, and risk factors for CIB along with the comparative efficacy, safety, and cost-effectiveness of acid-suppressive therapy will be described.

Stress ulcer prophylaxis in children with status asthmaticus receiving systemic corticosteroids: a descriptive study assessing frequency of clinically important bleeding

Objective: To determine the frequency of clinically important bleeding (CIB) among children hospitalized for status asthmaticus with and without exposure to stress ulcer prophylaxis (SUP).Methods: We performed a single-center, retrospective cohort in 217 children admitted for asthma exacerbation aged 5-18 years from May 2015 to May 2017. We assessed cohorts with and without exposure to SUP to determine if differences in frequency of CIB exist. Study outcomes included frequency of CIB, gastrointestinal complications (occult bleeding, macroscopic bleeding, gastric perforation, and acquired gastritis), and SUP-related adverse events (ventilator associated pneumonia, C. difficile colitis, necrotizing enterocolitis, and acute thrombocytopenia).Results: Ninety-two (42%) children received SUP of which 82 were admitted to the pediatric intensive care unit (PICU). There were no differences in asthma severity or known risk factors for CIB in children with and without SUP in the PICU subcohort. We observed no CIB or SUP-related adverse events. Two subjects acquired gastritis in the no-SUP cohort and one additional subject experienced occult gastrointestinal bleeding with spontaneous symptom resolution.Conclusion: Children admitted for status asthmaticus with and without SUP had no observed incidence of CIB. In this specific population, we propose a prerequisite assessment for the presence of known stress ulcer related gastrointestinal bleeding risk factors prior to the blanket administration of SUP.

Fidaxomicin Compared With Oral Vancomycin for the Treatment of Severe Clostridium difficile-Associated Diarrhea: A Retrospective Review

Purpose: The most recent published guidelines on Clostridium difficile-associated diarrhea (CDAD) developed by the Infectious Diseases Society of America (IDSA) were released in 2017 and outline its treatment based on severity of the disease and recurrence; however, a clear first-line agent has not been recommended specifically for severe CDAD. Methods: This retrospective chart review was approved by the institutional review board and consisted of three community hospitals and one academic medical center. To be included, patients need to meet criteria for severe CDAD and receive at least 72 hours of therapy. Patients received either oral vancomycin or fidaxomicin, in addition to other therapies for CDAD, and differences in outcomes such as cost obtained from a common charge center, rates of recurrence, time to recurrence as measured at time of positive to negative polymerase chain reaction (PCR) test, and mortality were assessed. Results: Of the 147 patients, 74 patients received fidaxomicin and 73 patients received oral vancomycin. The average hospitalization cost for patients receiving fidaxomicin was $129,338.69 and for patients receiving vancomycin was $153,563.81 (P = .26). Recurrence rates were lower with fidaxomicin compared with vancomycin (6.8% vs 17.6%; P = .047), and time to recurrence was longer with fidaxomicin versus vancomycin, but not statistically significant (96.8 ± 45.9 days vs 63.2 ± 66.9 days; P = .321). Mortality, length of stay in the intensive care unit, and overall length of stay were similar between the two therapies. Conclusions: In the treatment of severe CDAD, recurrence rates were lower and time to recurrence was higher with fidaxomicin compared with oral vancomycin. A clear financial benefit has yet to translate from these known findings.

Gastrointestinal Tract Dysfunction With Critical Illness: Clinical Assessment and Management

The gut is the site of digestion and absorption as well as serving as an endocrine and immune organ. All of these functions may be affected by critical illness. This review will discuss secondary effects of critical illness on the gut in terms of gastrointestinal function that is clinically observable and discuss consequences of gut dysfunction with critical illness to patient outcome. Because there is little evidence-based medicine in the veterinary field, much of our understanding of gut dysfunction with critical illness comes from animal models or from the human medical field. We can extrapolate some of these conclusions and recommendations to companion animals, particularly in dogs, who have similar gastrointestinal physiology to people. Additionally, the evidence regarding gut dysfunction in veterinary patients will be explored. By recognizing signs of dysfunction early and taking preventative measures, we may be able to increase success with treatment of critical illnesses.

Global burden of Clostridium difficile infections: a systematic review and meta-analysis

Background

Clostridium difficile is a leading cause of morbidity and mortality in several countries. However, there are limited evidence characterizing its role as a global public health problem. We conducted a systematic review to provide a comprehensive overview of C. difficile infections (CDI) rates.

Methods

Seven databases were searched (January 2016) to identify studies and surveillance reports published between 2005 and 2015 reporting CDI incidence rates. CDI incidence rates for health care facility-associated (HCF), hospital onset-health care facility-associated, medical or general intensive care unit (ICU), internal medicine (IM), long-term care facility (LTCF), and community-associated (CA) were extracted and standardized. Meta-analysis was conducted using a random effects model.

Results

229 publications, with data from 41 countries, were included. The overall rate of HCF-CDI was 2.24 (95% confidence interval CI = 1.66-3.03) per 1000 admissions/y and 3.54 (95%CI = 3.19-3.92) per 10 000 patient-days/y. Estimated rates for CDI with onset in ICU or IM wards were 11.08 (95%CI = 7.19-17.08) and 10.80 (95%CI = 3.15-37.06) per 1000 admission/y, respectively. Rates for CA-CDI were lower: 0.55 (95%CI = 0.13-2.37) per 1000 admissions/y. CDI rates were generally higher in North America and among the elderly but similar rates were identified in other regions and age groups.

Conclusions

Our review highlights the widespread burden of disease of C. difficile, evidence gaps, and the need for sustainable surveillance of CDI in the health care setting and the community.

Constipation in a cohort prospective in adult critically ill patients: How much occurs and why?

OBJECTIVE

To assess the incidence and factors associated with constipation in adult critical care patients.

DESIGN

Prospective cohort study.

SETTING

Intensive care unit (ICU) of a high-complexity hospital from November 2015 to October 2016.

PATIENTS

Adults who were hospitalized for at least 72h in the ICU were followed from their admission to the ICU until their departure.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In the 157 patients followed up, the incidence of constipation was 75.8%. The univariate analysis showed that constipated patients were younger, used more sedation and showed more respiratory and postoperative causes for hospitalization, while non-constipated patients were hospitalized more for gastrointestinal reasons. The use of vasoactive substances, mechanical ventilation and haemodialysis was similar between the constipated and non-constipated patients. Multivariate analysis, days of use of docusate+bisacodyl (HR: .79; 95% CI: .65-.96) of omeprazole or ranitidine (HR: .80; 95%CI: .73-.88) and lactulose (HR: .87; 95%CI: .76-.99) were independent protection factors for constipation.

CONCLUSION

Constipation has a high incidence among adult critical care patients. Days of drug use acting on the digestive tract (lactulose, docusate+bisacodyl and omeprazole and/or ranitidine) are able to prevent this outcome.

[Clostridium difficile in the intensive care unit]

Clostridium difficile infections (CDI) are encountered in about 1-2% of patients in the intensive care unit (ICU) and pose a special challenge to those who provide care. Only little data regarding severity and management of CDI in ICU patients in Europe are available. Extrapolation of results from one patient population to another is often difficult. The comorbidities of those patients often limit the application of general recommendations concerning diagnosis and therapy. In addition, there are a relevant percentage of patients (10-20%) with asymptomatic C. difficile colonization. The relevance for the patient and for the risk of patient to patient infection is not yet fully understood. Based on available data, we give an overview of current challenges in the diagnosis, assessment of disease course, primary management options, and alternatives in special cases and treatment failures of CDI. We also discuss prevention of new CDI in the intensive care unit.

Effect of sucralfate on gastric permeability in an ex vivo model of stress-related mucosal disease in dogs

BACKGROUND

Sucralfate is a gastroprotectant with no known systemic effects. The efficacy of sucralfate for prevention and treatment of stress-related mucosal diseases (SRMD) in dogs is unknown.

HYPOTHESIS/OBJECTIVES

To develop a canine ex vivo model of SRMD and to determine the effect of sucralfate on mucosal barrier function in this model.

ANIMALS

Gastric antral mucosa was collected immediately postmortem from 29 random-source apparently healthy dogs euthanized at a local animal control facility.

METHODS

Randomized experimental trial. Sucralfate (100 mg/mL) was applied to ex vivo canine gastric mucosa concurrent with and after acid injury. Barrier function was assessed by measurement of transepithelial electrical resistance (TER) and radiolabeled mannitol flux.

RESULTS

Application of acidified Ringers solution to the mucosal side of gastric antrum caused a reduction in gastric barrier function, and washout of acidified Ringers solution allowed recovery of barrier function (TER: 34.0 ± 2.8% of control at maximum injury, 71.3 ± 5.5% at recovery, P < .001). Sucralfate application at the time of injury or after injury significantly hastened recovery of barrier function (TER: 118.0 ± 15.2% of control at maximum injury, P < .001 and 111.0 ± 15.5% at recovery, P = .35).

CONCLUSIONS AND CLINICAL IMPORTANCE

Sucralfate appeared effective at restoring defects in gastric barrier function induced by acid and accelerating repair of tissues subjected to acid in this model, suggesting that sucralfate could have utility for the treatment and prevention of SRMD in dogs.

Inpatient Proton Pump Inhibitor Administration and Hospital-Acquired Clostridium difficile Infection: Evidence and Possible Mechanism

The incidence of Clostridium difficile infection continues to increase globally. Particularly concerning are hospital-acquired cases that attribute significant morbidity, mortality, and expenditures to the health care system. Proton pump inhibitors, which are widely prescribed and generally considered to have minimal adverse effects, have recently come under scrutiny for positive associations with C. difficile infection development. This article will specifically review the current state of evidence demonstrating a positive association between nosocomial proton pump inhibitor administration and the incidence of hospital-acquired C. difficile infection. In addition, the article delivers state-of-the-art knowledge relative to mechanisms by which proton pump inhibitor exposure may propagate the manifestation of C. difficile infection.

Successful Fecal Microbiota Transplantation in a Patient with Severe Complicated Clostridium difficile Infection after Liver Transplantation

Clostridium difficile infection (CDI) represents one of the most common healthcare-associated infections. Due to increasing numbers of recurrences and therapy failures, CDI has become a major disease burden. Studies have shown that fecal microbiota transplantation (FMT) can both be a safe and highly efficacious therapy for patients with therapy-refractory CDI. However, patients undergoing solid organ transplantation are at high risk for CDI due to long-term immunosuppression, previous antibiotic therapy, and proton pump inhibitor use. Additionally, these patients may be especially prone to adverse events related to FMT. Here, we report a successful FMT in a patient with severe therapy-refractory CDI after liver transplantation.

Acid-Suppressive Therapy and Risk of Infections: Pros and Cons

This narrative review summarises the benefits, risks and appropriate use of acid-suppressing drugs (ASDs), proton pump inhibitors and histamine-2 receptor antagonists, advocating a rationale balanced and individualised approach aimed to minimise any serious adverse consequences. It focuses on current controversies on the potential of ASDs to contribute to infections-bacterial, parasitic, fungal, protozoan and viral, particularly in the elderly, comprehensively and critically discusses the growing body of observational literature linking ASD use to a variety of enteric, respiratory, skin and systemic infectious diseases and complications (Clostridium difficile diarrhoea, pneumonia, spontaneous bacterial peritonitis, septicaemia and other). The proposed pathogenic mechanisms of ASD-associated infections (related and unrelated to the inhibition of gastric acid secretion, alterations of the gut microbiome and immunity), and drug-drug interactions are also described. Both probiotics use and correcting vitamin D status may have a significant protective effect decreasing the incidence of ASD-associated infections, especially in the elderly. Despite the limitations of the existing data, the importance of individualised therapy and caution in long-term ASD use considering the balance of benefits and potential harms, factors that may predispose to and actions that may prevent/attenuate adverse effects is evident. A six-step practical algorithm for ASD therapy based on the best available evidence is presented.

The impact of pharmaceutical interventions on the rational use of proton pump inhibitors in a Chinese hospital

BACKGROUND

The prescriptions of proton pump inhibitors (PPIs) have raised concern due to both huge increase in medical expenditure and the possible long-term adverse events caused by them; therefore, an approach to taper off the irrational use of PPIs by patients is clinically warranted. The aim of this study was to evaluate the impact of pharmaceutical interventions on the rational use of PPIs.

PATIENTS AND METHODS

A single-center, pre- to post-intervention study (pharmaceutical interventions group and control group) was performed in a Chinese hospital. Pharmaceutical interventions were performed in the post-intervention group, including educative group activities, real-time monitoring of clinical records and making recommendations to doctors on PPI prescriptions based on the criteria set at the beginning of the study. The number of patients with rational indication, the accuracy rate of administration route, the duration of therapy and the changes in total PPI costs, mean PPI costs, mean total drug costs and mean hospitalization costs were the main outcome measures.

RESULTS

A total of 285 patients were included in the study. After 6 months of interventions, significant improvements in the number of patients with rational indication were found (96.5% in the pharmaceutical interventions group vs 71.8% in the control group, P<0.01). The accuracy rate of administration route was increased (99.3% vs 73.2%, P<0.05), while the duration of therapy was decreased (7.9±0.5 vs 14.3±0.8, P<0.01). Pharmaceutical interventions led to significant reductions in mean PPIs costs, mean total drug costs and mean hospitalization costs (P<0.001).

CONCLUSION

This study provides important evidence on the beneficial effect of pharmaceutical interventions on enhancing the rational use of PPIs and substantial cost saving by increasing the number of patients with rational indication and reducing the risk for long-term adverse events.

Proton pump inhibitors therapy and risk of Clostridium difficile infection: Systematic review and meta-analysis

AIM

To perform a systematic review and meta-analysis on proton pump inhibitors (PPIs) therapy and the risk of Clostridium difficile infection (CDI).

METHODS

We conducted a systematic search of MEDLINE/PubMed and seven other databases through January 1990 to March 2017 for published studies that evaluated the association between PPIs and CDI. Adult case-control and cohort studies providing information on the association between PPI therapy and the development of CDI were included. Pooled odds ratios (ORs) estimates with 95% confidence intervals (CIs) were calculated using the random effect. Heterogeneity was assessed by I² test and Cochran’s Q statistic. Potential publication bias was evaluated via funnel plot, and quality of studies by the Newcastle-Otawa Quality Assessment Scale (NOS).

RESULTS

Fifty-six studies (40 case-control and 16 cohort) involving 356683 patients met the inclusion criteria and were analyzed. Both the overall pooled estimates and subgroup analyses showed increased risk for CDI despite substantial statistical heterogeneity among studies. Meta-analysis of all studies combined showed a significant association between PPI users and the risk of CDI (pooled OR = 1.99, CI: 1.73-2.30, P < 0.001) as compared with non-users. The association remained significant in subgroup analyses: by design-case-control (OR = 2.00, CI: 1.68-2.38, P < 0.0001), and cohort (OR = 1.98, CI: 1.51-2.59, P < 0.0001); adjusted (OR = 1.95, CI: 1.67-2.27, P < 0.0001) and unadjusted (OR = 2.02, CI: 1.41-2.91, P < 0.0001); unicenter (OR = 2.18, CI: 1.72-2.75, P < 0.0001) and multicenter (OR = 1.82, CI: 1.51-2.19, P < 0.0001); age ≥ 65 years (OR = 1.93, CI: 1.40-2.68, P < 0.0001) and < 65 years (OR = 2.06, CI: 1.11-3.81, P < 0.01). No significant differences were found in subgroup analyses (test for heterogeneity): P = 0.93 for case-control vs cohort, P = 0.85 for adjusted vs unadjusted, P = 0.24 for unicenter vs multicenter, P = 0.86 for age ≥ 65 years and < 65 years. There was significant heterogeneity across studies (I² = 85.4%, P < 0.001) as well as evidence of publication bias (funnel plot asymmetry test, P = 0.002).

CONCLUSION

This meta-analysis provides further evidence that PPI use is associated with an increased risk for development of CDI. Further high-quality, prospective studies are needed to assess whether this association is causal.

Risk of Clostridium difficile Infection with the Use of a Proton Pump Inhibitor for Stress Ulcer Prophylaxis in Critically Ill Patients

Background/Aims

Proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) are commonly prescribed for stress ulcer prophylaxis (SUP) in critically ill patients. Several studies have suggested that the use of PPIs is a potential risk factor for Clostridium difficile infection (CDI). We compared the incidences of CDI in the PPI group and H2RA group for SUP in critically ill patients.

Methods

From August 2005 to July 2012, the incidences of CDI were retrospectively analyzed in patients who were admitted directly to intensive care units and stayed for more than 3 days. SUP-related CDI was defined as a CDI diagnosed during the SUP period. Patient clinical data were analyzed to identify potential risk factors for SUP-related CDI.

Results

Of the 1,005 patients enrolled (444 patients received PPI and 561 received H2RA), 38 (3.8%) were diagnosed with SUP-related CDI. The incidence of SUP-related CDI was considerably higher in patients who received PPI than in those who received H2RA (6.7% vs 1.8%). PPI use for SUP (odds ratio [OR], 3.3; confidence interval [CI], 1.5 to 7.1; p=0.003) and diabetes mellitus (OR, 2.3; CI, 1.2 to 4.7; p=0.019) were independent risk factors for SUP-related CDI.

Conclusions

PPI therapy is associated with a higher risk of SUP-related CDI than H2RA therapy in critically ill patients.

Pantoprazole or Placebo for Stress Ulcer Prophylaxis (POP-UP): Randomized Double-Blind Exploratory Study

OBJECTIVES

Pantoprazole is frequently administered to critically ill patients for prophylaxis against gastrointestinal bleeding. However, comparison to placebo has been inadequately evaluated, and pantoprazole has the potential to cause harm. Our objective was to evaluate benefit or harm associated with pantoprazole administration.

DESIGN

Prospective randomized double-blind parallel-group study.

SETTING

University-affiliated mixed medical-surgical ICU.

PATIENTS

Mechanically ventilated critically ill patients suitable for enteral nutrition.

INTERVENTIONS

We randomly assigned patients to receive either daily IV placebo or pantoprazole.

MEASUREMENTS AND MAIN RESULTS

Major outcomes were clinically significant gastrointestinal bleeding, infective ventilator-associated complication or pneumonia, and Clostridium difficile infection; minor outcomes included overt bleeding, hemoglobin concentration profiles, and mortality. None of the 214 patients randomized had an episode of clinically significant gastrointestinal bleeding, three patients met the criteria for either an infective ventilator-associated complication or pneumonia (placebo: 1 vs pantoprazole: 2), and one patient was diagnosed with Clostridium difficile infection (0 vs 1). Administration of pantoprazole was not associated with any difference in rates of overt bleeding (6 vs 3; p = 0.50) or daily hemoglobin concentrations when adjusted for transfusion rates of packed red cells (p = 0.66). Mortality was similar between groups (log-rank p = 0.33: adjusted hazard ratio for pantoprazole: 1.68 [95% CI, 0.97-2.90]; p = 0.06).

CONCLUSIONS

We found no evidence of benefit or harm with the prophylactic administration of pantoprazole to mechanically ventilated critically ill patients anticipated to receive enteral nutrition. The practice of routine administration of acid-suppressive drugs to critically ill patients for stress ulcer prophylaxis warrants further evaluation.

Identification of Risk Factors Associated With Clostridium difficile Infection in Liver Transplantation Recipients: A Single-Center Analysis

Clostridium difficile remains the leading cause of health care-associated infectious diarrhea, and its incidence and severity are increasing in liver transplant recipients. Several known risk factors for C difficile infection (CDI) are inherently associated with liver transplantation, such as severe underlying illness, immunosuppression, abdominal surgery, and broad-spectrum antibiotic use. We conducted a single-center retrospective case control study to characterize risk factors for CDI among patients who received a liver transplant from January 2008 to December 2012. We also examined the associations of post-transplantation CDI with transplant outcomes. Cases were defined as having diarrhea with a positive test for C difficile by either toxin A/B enzyme immunoassay (EIA) or glutamate dehydrogenase EIA and polymerase chain reaction within 1 year after transplantation. Sixty-five consecutive patients were evaluated, of which 15 (23%) developed CDI. The median time from transplantation to CDI diagnosis was 65 days (interquartile range [IQR] 13-208) and more than one-half (53%) had severe infection. Risk factors that were associated with CDI among liver transplant recipients included: (1) previous history of CDI (20% vs 0%; P = .001); (2) exposure to proton-pump inhibitor therapy (93% vs 60%; P = .015); (3) antimicrobial therapy before transplantation (47% vs 18%; P = .039); (4) a prolonged length of stay before transplantation (1 day [IQR, 1-19] vs 1 day [IQR, 0-1]; P = .028); and (5) chronic kidney disease (53% vs 20%; P = .011). There was no significant differences in patient survivals at 6 months (93% vs 96%; P = .67) and 12 months (87% vs 94%; P = .35) among CDI case and control subjects, respectively.

Variables Associated with Adherence to Stress Ulcer Prophylaxis in Patients Admitted to the General Hospital Wards: A Prospective Study

Purpose: The dramatic increase in stress ulcer prophylaxis (SUP) prescribing patterns over the past several years has raised concerns regarding to their appropriate utilization. This prospective study attempted to evaluate the trend of adherence to stress ulcer prophylaxis from admission until discharge in non- Intensive care unit (ICU) setting. Additionally, we attempted to find those variables associated with appropriate SUP administration.

Methods: Data collection was performed prospectively to evaluate 195 randomly selected adult patients who received SUP or had indication for that in non-ICU wards of one of the largest referral center in Iran, during 6 months. Adherence was studied according to widely accepted American Society of Health system Pharmacists (ASHP) guideline. Univariate and multivariate logistic regression was also performed to detect associations related to misuse of SUP.

Results: We recognized total inappropriate use of SUP upon admission, during hospital stay and at discharge were somewhat identical at different time points (61%, 80% and 77.4% respectively). On the other hand, since small number of patients experienced SUP underutilization, unfortunately this was not possible to elucidate factors that may have effect on this flawed behavior. However, increasing age was identified to be significant variable in SUP overutilization.

Conclusion: This prospective study highlighted inappropriate overutilization of SUP within non-critically ill patients and found factors which predicted this behavior. Adherence during hospital stay was also calculated for the first time in this study, which was related to SUP adherence upon hospital admission.

Evaluation of Risk Factors for Clostridium difficile Infection in Hematopoietic Stem Cell Transplant Recipients

STUDY OBJECTIVES

The primary objective was to determine the impact of hematologic malignancies and/or conditioning regimens on the risk of developing Clostridium difficile infection (CDI) in patients undergoing hematopoietic stem cell transplantation (HSCT). Secondary objectives were to determine if traditional CDI risk factors applied to patients undergoing HSCT and to determine the presence of CDI markers of severity of illness among this patient population.

DESIGN

Single-center retrospective case-control study.

SETTING

Quaternary care academic medical center.

PATIENTS

A total of 105 patients who underwent HSCT between December 2009 and December 2014; of these patients, 35 developed an initial episode of CDI (HSCT/CDI group [cases]), and 70 did not (controls). Controls were matched in a 2:1 ratio to cases based on age (± 10 yrs) and date of HSCT (± 6 mo).

MEASUREMENTS AND MAIN RESULTS

Baseline characteristics of the two groups were well balanced regarding age, sex, race, ethnicity, and type of HSCT. No significant differences in conditioning regimen, hematologic malignancy, total body irradiation received for HSCT, use of antibiotics within 60 days of HSCT, or use of prophylactic antibiotics after HSCT were noted between the two groups. Patients in the control group were 10.57 (95% confidence interval 1.24-492.75) more likely to have received corticosteroids prior to HSCT than patients in the HSCT/CDI group (p=0.01). Use of proton pump inhibitors at the time of HSCT was greater among the control group than among patients in the HSCT/CDI group (97% vs 86%, p=0.048). No significant difference in mortality was noted between the groups at 3, 6, and 12 months after HSCT. Metronidazole was frequently prescribed for patients in the HSCT/CDI group (34 patients [97%]). Severe CDI was not common among patients within the HSCT/CDI group (13 patients [37%]); vancomycin was infrequently prescribed for these patients ([31%] 4/13 patients).

CONCLUSION

Hematologic malignancies and a conditioning regimen administered for HSCT were not significant risk factors for the development of CDI after HSCT. Use of corticosteroids prior to HSCT and use of proton pump inhibitors at the time of HSCT were associated with a significantly decreased risk of CDI.

Impact of a pharmacist-driven protocol to decrease proton pump inhibitor use in non-intensive care hospitalized adults

PURPOSE

Results of a pharmacist-driven protocol to decrease proton pump inhibitor (PPI) use in non-intensive care unit (ICU) hospitalized adults are presented.

METHODS

This concurrent preintervention and postintervention study included subjects at least 18 years of age receiving PPIs while hospitalized in general medical or surgical beds. Patients were identified for inclusion in the postintervention group using a daily list of hospitalized patients with active PPI orders. A pharmacist evaluated these subjects for PPI appropriateness, and then recommended discontinuing or changing PPIs to histamine H2-receptor antagonists. Per protocol, the pharmacist could change PPIs to H2-antagonists if prescribers did not respond to recommendations. Preintervention group patients were gathered retrospectively and treated as the retrospective control group. Patients were excluded if they had cumulative ICU or ICU step-down stays of at least two days, had predefined appropriate indications for PPIs, or were not evaluated within one day of PPI orders. The primary outcome was the rate of PPI use. Secondary objectives included rates of prescriber acceptance of pharmacist recommendations and hospital-onset Clostridium difficile infections (HO-CDI).

RESULTS

PPIs were discontinued in 66.0% (n = 62) of postintervention group patients compared to 41.1% (n = 39) of the preintervention group (absolute risk reduction, 24.9%; p = 0.001). In the postintervention group, 31.9% (n = 30) of recommendations were accepted, whereas 11.7% (n = 11) were rejected. No subjects in either group were diagnosed with HO-CDI during the study period.

CONCLUSION

The pharmacist-driven protocol described in this study decreased PPI use in non-ICU hospitalized adults.