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Dickson RP. The microbiome and critical illness. THE LANCET. RESPIRATORY MEDICINE 2016; 4:59-72. [PMID: 26700442 PMCID: PMC4752077 DOI: 10.1016/s2213-2600(15)00427-0] [Citation(s) in RCA: 270] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 10/10/2015] [Accepted: 10/13/2015] [Indexed: 12/12/2022]
Abstract
The central role of the microbiome in critical illness is supported by a half century of experimental and clinical study. The physiological effects of critical illness and the clinical interventions of intensive care substantially alter the microbiome. In turn, the microbiome predicts patients' susceptibility to disease, and manipulation of the microbiome has prevented or modulated critical illness in animal models and clinical trials. This Review surveys the microbial ecology of critically ill patients, presents the facts and unanswered questions surrounding gut-derived sepsis, and explores the radically altered ecosystem of the injured alveolus. The revolution in culture-independent microbiology has provided the tools needed to target the microbiome rationally for the prevention and treatment of critical illness, holding great promise to improve the acute and chronic outcomes of the critically ill.
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Affiliation(s)
- Robert P Dickson
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
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152
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Benmassaoud A, McDonald EG, Lee TC. Potential harms of proton pump inhibitor therapy: rare adverse effects of commonly used drugs. CMAJ 2015; 188:657-662. [PMID: 26598371 DOI: 10.1503/cmaj.150570] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Amine Benmassaoud
- Division of General Internal Medicine (Benmassaoud, McDonald, Lee), Department of Medicine, McGill University Health Centre; McGill Centre for Quality Improvement (McDonald, Lee), Montréal, Que
| | - Emily G McDonald
- Division of General Internal Medicine (Benmassaoud, McDonald, Lee), Department of Medicine, McGill University Health Centre; McGill Centre for Quality Improvement (McDonald, Lee), Montréal, Que
| | - Todd C Lee
- Division of General Internal Medicine (Benmassaoud, McDonald, Lee), Department of Medicine, McGill University Health Centre; McGill Centre for Quality Improvement (McDonald, Lee), Montréal, Que.
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153
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Garg SK, Gurusamy KS. Laparoscopic fundoplication surgery versus medical management for gastro-oesophageal reflux disease (GORD) in adults. Cochrane Database Syst Rev 2015; 2015:CD003243. [PMID: 26544951 PMCID: PMC8278567 DOI: 10.1002/14651858.cd003243.pub3] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Gastro-oesophageal reflux disease (GORD) is a common condition with 3% to 33% of people from different parts of the world suffering from GORD. There is considerable uncertainty about whether people with GORD should receive an operation or medical treatment for controlling the condition. OBJECTIVES To assess the benefits and harms of laparoscopic fundoplication versus medical treatment for people with gastro-oesophageal reflux disease. SEARCH METHODS We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group (UGPD) Trials Register (June 2015), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 6, 2015), Ovid MEDLINE (1966 to June 2015), and EMBASE (1980 to June 2015) to identify randomised controlled trials. We also searched the references of included trials to identify further trials. SELECTION CRITERIA We considered only randomised controlled trials (RCT) comparing laparoscopic fundoplication with medical treatment in people with GORD irrespective of language, blinding, or publication status for inclusion in the review. DATA COLLECTION AND ANALYSIS Two review authors independently identified trials and independently extracted data. We calculated the risk ratio (RR) or standardised mean difference (SMD) with 95% confidence intervals (CI) using both fixed-effect and random-effects models with RevMan 5 based on available case analysis. MAIN RESULTS Four studies met the inclusion criteria for the review, and provided information on one or more outcomes for the review. A total of 1160 participants in the four RCTs were either randomly assigned to laparoscopic fundoplication (589 participants) or medical treatment with proton pump inhibitors (571 participants). All the trials included participants who had had reflux symptoms for at least six months and had received long-term acid suppressive therapy. All the trials included only participants who could undergo surgery if randomised to the surgery arm. All of the trials were at high risk of bias. The overall quality of evidence was low or very low. None of the trials reported long-term health-related quality of life (HRQoL) or GORD-specific quality of life (QoL).The difference between laparoscopic fundoplication and medical treatment was imprecise for overall short-term HRQOL (SMD 0.14, 95% CI -0.02 to 0.30; participants = 605; studies = 3), medium-term HRQOL (SMD 0.03, 95% CI -0.19 to 0.24; participants = 323; studies = 2), medium-term GORD-specific QoL (SMD 0.28, 95% CI -0.27 to 0.84; participants = 994; studies = 3), proportion of people with adverse events (surgery: 7/43 (adjusted proportion = 14.0%); medical: 0/40 (0.0%); RR 13.98, 95% CI 0.82 to 237.07; participants = 83; studies = 1), long-term dysphagia (surgery: 27/118 (adjusted proportion = 22.9%); medical: 28/110 (25.5%); RR 0.90, 95% CI 0.57 to 1.42; participants = 228; studies = 1), and long-term reflux symptoms (surgery: 29/118 (adjusted proportion = 24.6%); medical: 41/115 (35.7%); RR 0.69, 95% CI 0.46 to 1.03; participants = 233; studies = 1).The short-term GORD-specific QoL was better in the laparoscopic fundoplication group than in the medical treatment group (SMD 0.58, 95% CI 0.46 to 0.70; participants = 1160; studies = 4).The proportion of people with serious adverse events (surgery: 60/331 (adjusted proportion = 18.1%); medical: 38/306 (12.4%); RR 1.46, 95% CI 1.01 to 2.11; participants = 637; studies = 2), short-term dysphagia (surgery: 44/331 (adjusted proportion = 12.9%); medical: 11/306 (3.6%); RR 3.58, 95% CI 1.91 to 6.71; participants = 637; studies = 2), and medium-term dysphagia (surgery: 29/288 (adjusted proportion = 10.2%); medical: 5/266 (1.9%); RR 5.36, 95% CI 2.1 to 13.64; participants = 554; studies = 1) was higher in the laparoscopic fundoplication group than in the medical treatment group.The proportion of people with heartburn at short term (surgery: 29/288 (adjusted proportion = 10.0%); medical: 59/266 (22.2%); RR 0.45, 95% CI 0.30 to 0.69; participants = 554; studies = 1), medium term (surgery: 12/288 (adjusted proportion = 4.2%); medical: 59/266 (22.2%); RR 0.19, 95% CI 0.10 to 0.34; participants = 554; studies = 1), long term (surgery: 46/111 (adjusted proportion = 41.2%); medical: 78/106 (73.6%); RR 0.56, 95% CI 0.44 to 0.72); participants = 217; studies = 1) and those with reflux symptoms at short-term (surgery: 6/288 (adjusted proportion = 2.0%); medical: 53/266 (19.9%); RR 0.10, 95% CI 0.05 to 0.24; participants = 554; studies = 1) and medium term (surgery: 6/288 (adjusted proportion = 2.1%); medical: 37/266 (13.9%); RR 0.15, 95% CI 0.06 to 0.35; participants = 554; studies = 1) was less in the laparoscopic fundoplication group than in the medical treatment group. AUTHORS' CONCLUSIONS There is considerable uncertainty in the balance of benefits versus harms of laparoscopic fundoplication compared to long-term medical treatment with proton pump inhibitors. Further RCTs of laparoscopic fundoplication versus medical management in patients with GORD should be conducted with outcome-assessor blinding and should include all participants in the analysis. Such trials should include long-term patient-orientated outcomes such as treatment-related adverse events (including severity), quality of life, and also report on the social and economic impact of the adverse events and symptoms.
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Affiliation(s)
- Sushil K Garg
- University of MinnesotaDepartment of MedicineMinneapolisMNUSA
| | - Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
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154
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Dwyer LL, Lau DT, Shega JW. Medications That Older Adults in Hospice Care in the United States Take, 2007. J Am Geriatr Soc 2015; 63:2282-9. [DOI: 10.1111/jgs.13795] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Lisa L. Dwyer
- National Center for Health Statistics; Centers for Disease Control and Prevention; Hyattsville Maryland
| | - Denys T. Lau
- National Center for Health Statistics; Centers for Disease Control and Prevention; Hyattsville Maryland
- College of Pharmacy; University of Illinois at Chicago; Chicago Illinois
- Milken Institute; School of Public Health; George Washington University; Washington District of Columbia
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155
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Meli M, Raffa MP, Malta R, Morreale I, Aprea L, D’Alessandro N. The use of proton pump inhibitors in an Italian hospital: focus on oncologic and critical non-ICU patients. Int J Clin Pharm 2015; 37:1152-61. [DOI: 10.1007/s11096-015-0178-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 07/30/2015] [Indexed: 01/17/2023]
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156
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Buckley MS, Park AS, Anderson CS, Barletta JF, Bikin DS, Gerkin RD, O'Malley CW, Wicks LM, Garcia-Orr R, Kane-Gill SL. Impact of a clinical pharmacist stress ulcer prophylaxis management program on inappropriate use in hospitalized patients. Am J Med 2015; 128:905-13. [PMID: 25820164 DOI: 10.1016/j.amjmed.2015.02.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 01/02/2015] [Accepted: 02/26/2015] [Indexed: 12/29/2022]
Abstract
PURPOSE Appropriate utilization of stress ulcer prophylaxis should be limited to high-risk, intensive care unit (ICU) patients. However, inappropriate stress ulcer prophylaxis use among all hospitalized patients remains a concern. The purpose of this study was to evaluate the clinical and economic impact of a novel pharmacist-managed stress ulcer prophylaxis program in ICU and general ward patients. METHODS This retrospective, pre- and poststudy design was conducted in adult ICU and general ward patients at a large academic medical center between January 1, 2011 and January 31, 2012 to compare the rates of inappropriate stress ulcer prophylaxis before and after the implementation of a pharmacist-led stress ulcer prophylaxis management program. RESULTS A total of 1134 unique patients consisting of 16,415 patient days were evaluated. The relative reduction in the rate of inappropriate stress ulcer prophylaxis days after program implementation in ICU and general ward patients was 58.3% and 83.5%, respectively (P < .001). The rates of ICU patients inappropriately continued on stress ulcer prophylaxis upon hospital discharge in the pre- and postimplementation groups were 29.9% and 3.6%, respectively (P < .001), whereas general ward patients significantly decreased from 36.2% to 5.4% in the pre- and postimplementation groups, respectively (P < .001). Total inpatient costs associated with all stress ulcer prophylaxis administered was $20,052.70 in the pre- and $3280.49 in the postimplementation group (P < .001), resulting in an estimated cost savings of > $200,000 annually. No differences in clinical outcomes were observed. CONCLUSIONS The implementation of a pharmacist-managed stress ulcer prophylaxis program was associated with a decrease in inappropriate acid suppression rates during hospitalization and upon discharge, as well as significant cost savings.
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Affiliation(s)
| | - Andrew S Park
- Banner-University Medical Center Phoenix, Phoenix, Ariz
| | | | | | - Dale S Bikin
- Banner-University Medical Center Phoenix, Phoenix, Ariz
| | | | | | - Laura M Wicks
- Banner-University Medical Center Phoenix, Phoenix, Ariz
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157
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William JH, Nelson R, Hayman N, Mukamal KJ, Danziger J. Proton-pump inhibitor use is associated with lower urinary magnesium excretion. Nephrology (Carlton) 2015; 19:798-801. [PMID: 25142949 DOI: 10.1111/nep.12330] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2014] [Indexed: 02/06/2023]
Abstract
AIMS Although multiple recent studies have confirmed an association between chronic proton-pump inhibitor (PPI) use and hypomagnesaemia, the physiologic explanation for this association remains uncertain. To address this, we investigated the association of PPI use with urinary magnesium excretion. METHODS We measured 24-hour urine magnesium excretion in collections performed for nephrolithiasis evaluation in 278 consecutive ambulatory patients and determined PPI use from contemporaneous medical records. RESULTS There were 50 (18%) PPI users at the time of urine collection. The mean daily urinary magnesium was 84.6 ± 42.8 mg in PPI users, compared with 101.2 ± 41.1 mg in non-PPI users (P = 0.01). In adjusted analyses, PPI use was associated with 10.54 ± 5.30 mg/day lower daily urinary magnesium excretion (P = 0.05). Diuretic use did not significantly modify the effect of PPI on urinary magnesium. As a control, PPI use was not associated with other urinary indicators of nutritional intake. CONCLUSIONS Our findings suggest that PPI use is associated with lower 24-hour urine magnesium excretion. Whether this reflects decreased intestinal uptake due to PPI exposure, or residual confounding due to decreased magnesium intake, requires further study.
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Affiliation(s)
- Jeffrey H William
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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158
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Hong MT, Monye LC, Seifert CF. Acid Suppressive Therapy for Stress Ulcer Prophylaxis in Noncritically Ill Patients. Ann Pharmacother 2015; 49:1004-8. [PMID: 26139638 DOI: 10.1177/1060028015592014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The current literature discourages the use of acid suppressive therapy (AST) for stress ulcer prophylaxis (SUP) in noncritically ill patients. However, several sources indicate that the majority of noncritically ill patients are given AST for SUP while there may only be a small proportion of high-risk patients who need SUP therapy. There is a new scoring system to aid practitioners in stratifying the risk of stress ulcer-related gastrointestinal bleeding in noncritically ill patients developed by Herzig et al and appropriately prescribe AST for SUP in this population. OBJECTIVE Our primary objective was to determine the current usage of AST in noncritically ill patients at a tertiary teaching hospital and use the new scoring system to identify non-intensive care unit patients who were inappropriately given AST. METHODS We retrospectively determined the percentage of noncritically ill patients who were given AST on medical floors between January 2010 and December 2012. After identifying these patients, we randomly selected a sample and retrospectively collected data from their medical record to determine the gastrointestinal bleeding risk score to determine if the patient was appropriately given AST. RESULTS Of the 42 600 admissions, 22 949 (53.7%) noncritically ill patients were given AST. A total of 442 patients were randomly selected for data collection and 156 patients were excluded. Gastrointestinal bleeding risk score was calculated in 286 patients. This new risk stratification tool identified 253 (88.5%) patients to have a low (≤7) and low-medium risk score (8-9). CONCLUSIONS A large percentage of noncritically ill patients were given AST during their hospital stay; 88.5% of these medications were given inappropriately to patients who were at extremely low risk of gastrointestinal bleeding. Using the above information and the AST prescribing patterns at our institution, we estimate a potential inpatient medication cost savings of $114 622 for the study period.
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Affiliation(s)
- Minh T Hong
- Medical Center Hospital, Odessa, TX, USA Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Leslie C Monye
- Medical Center Hospital, Odessa, TX, USA Texas Tech University Health Sciences Center, Lubbock, TX, USA
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159
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Cheungpasitporn W, Thongprayoon C, Kittanamongkolchai W, Srivali N, Edmonds PJ, Ungprasert P, O'Corragain OA, Korpaisarn S, Erickson SB. Proton pump inhibitors linked to hypomagnesemia: a systematic review and meta-analysis of observational studies. Ren Fail 2015; 37:1237-41. [PMID: 26108134 DOI: 10.3109/0886022x.2015.1057800] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The reported risk of hypomagnesemia in patients with proton pump inhibitor (PPI) use is conflicting. The objective of this meta-analysis was to assess the association between the use of PPIs and the risk of hypomagnesemia. METHODS A literature search of observational studies was performed using MEDLINE, EMBASE and Cochrane Database of Systematic Reviews from inception through September 2014. Studies that reported odd ratios or hazard ratios comparing the risk of hypomagnesemia in patients with PPI use were included. Pooled risk ratios (RRs) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method. RESULTS Nine observational studies (three cohort studies, five cross-sectional studies and a case-control study) with a total of 109,798 patients were identified and included in the data analysis. The pooled RR of hypomagnesemia in patients with PPI use was 1.43 (95% CI, 1.08-1.88). The association between the use of PPIs and hypomagnesemia remained significant after the sensitivity analysis including only studies with high quality score (Newcastle-Ottawa scale score ≥ 8) with a pooled RR of 1.63 (95% CI, 1.14-2.23). CONCLUSIONS Our study demonstrates a statistically significant increased risk of hypomagnesemia in patients with PPI use. The finding of this meta-analysis of observational studies suggests that PPI use is associated with hypomagnesemia and may impact clinical management of patients who are taking PPIs and at risk for hypomagnesemia related cardiovascular events.
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Affiliation(s)
| | - Charat Thongprayoon
- a Division of Nephrology and Hypertension , Mayo Clinic , Rochester , MN , USA
| | | | - Narat Srivali
- b Division of Pulmonary and Critical Care Medicine , Mayo Clinic , Rochester , MN , USA
| | - Peter J Edmonds
- c Department of Medicine , SUNY Upstate Medical University , Syracuse , NY , USA
| | | | | | - Sira Korpaisarn
- f Department of Medicine , MetroWest Medical Center , Framingham , MA , USA
| | - Stephen B Erickson
- a Division of Nephrology and Hypertension , Mayo Clinic , Rochester , MN , USA
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160
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Kim EH, Lee YC, Chang YW, Park JJ, Chun HJ, Jung HY, Kim HS, Jeong HY, Seol SY, Han SW, Choi MG, Park SH, Lee OJ, Jung JT, Lee DH, Jung HC, Lee ST, Kim JG, Youn SJ, Kim HY, Lee SW. Efficacy of Lafutidine Versus Famotidine in Patients with Reflux Esophagitis: A Multi-Center, Randomized, Double-Blind, Non-inferiority Phase III Trial. Dig Dis Sci 2015; 60:1724-32. [PMID: 25532503 DOI: 10.1007/s10620-014-3489-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 12/08/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND There has been no study on the efficacy of lafutidine for patients with reflux esophagitis in Korea. AIM To evaluate the efficacy of a new-generation histamine-2 receptor antagonist, lafutidine, in comparison with famotidine in patients with reflux esophagitis. METHODS This was a randomized, double-blind, non-inferiority trial enrolling patients with erosive esophagitis. The efficacy and safety of 20 mg lafutidine (treatment group) were compared with those of 40 mg famotidine (control group) and 20 mg omeprazole (reference group). The primary endpoint was the complete healing rates of reflux esophagitis on endoscopy after 8 weeks of treatment. The non-inferiority margin was assumed to be -15 %. RESULTS The healing rates of reflux esophagitis on endoscopy after 8 weeks of treatment were 70.14 % (101/144) in the lafutidine, 63.45 % (92/145) in the famotidine, and 85.71 % (126/147) in the omeprazole group. The difference in healing rates between the lafutidine and famotidine groups was 6.69 % (95 % confidence interval = [-4.14 to 17.52]). In addition, lafutidine was superior to famotidine in clinical improvement (53.73 % vs. 39.55 %, P = 0.0200). CONCLUSIONS Lafutidine was non-inferior to famotidine in healing of reflux esophagitis. Lafutidine, however, was superior to famotidine in terms of symptom relief of reflux esophagitis.
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Affiliation(s)
- Eun Hye Kim
- Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea,
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161
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Shin S. Evaluation of costs accrued through inadvertent continuation of hospital-initiated proton pump inhibitor therapy for stress ulcer prophylaxis beyond hospital discharge: a retrospective chart review. Ther Clin Risk Manag 2015; 11:649-57. [PMID: 26005351 PMCID: PMC4420549 DOI: 10.2147/tcrm.s81759] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Background Stress ulcers and related upper gastrointestinal bleeding are well-known complications in intensive care unit (ICU) patients. Proton pump inhibitor (PPI)-based stress ulcer prophylaxis (SUP) has been widely prescribed in noncritically ill patients who are at low risk for clinically significant bleeding, which is then injudiciously continued after hospital discharge. This study aimed to evaluate the incidence of inappropriate prescribing of PPI-based preventative therapy in ICU versus non-ICU patients that subsequently continued postdischarge, and to estimate the costs incurred by the unwarranted outpatient continuation of PPI therapy. Methods A retrospective review of patient data at a major teaching hospital in Korea was performed. During the 4-year study period, adult patients who were newly initiated on PPI-based SUP during hospital admission and subsequently discharged on a PPI without a medical indication for such therapy were captured for data analysis. The incidence rates of inappropriate prescribing of PPIs were compared between ICU and non-ICU patients, and the costs associated with such therapy were also examined. Results A total of 4,410 patients, more than half of the inpatient-initiated PPI users, were deemed to have been inadvertently prescribed a PPI at discharge in the absence of a medical need for acid suppression. The incidence of inappropriate outpatient continuation of the prophylaxis was higher among ICU patients compared with non-ICU patients (57.7% versus 52.2%, respectively; P=0.001). The total expenditure accrued through the continuation of nonindicated PPI therapy was approximately US$40,175. Conclusion This study confirmed that excess usage of PPIs for SUP has spread to low-risk, non-ICU patients. The overuse of unwarranted PPI therapy can incur large health care expenditure, as well as clinical complications with minimal therapeutic benefits. Educating clinicians regarding SUP guidelines and the adverse effects of long-term use of acid suppression can improve the cost effectiveness of PPI therapy.
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Affiliation(s)
- Sooyoung Shin
- Ajou University College of Pharmacy, Yeongtong-gu, Suwon-si, Gyeonggi-do, South Korea
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162
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McDonald EG, Jones J, Green L, Jayaraman D, Lee TC. Reduction of inappropriate exit prescriptions for proton pump inhibitors: A before-after study using education paired with a web-based quality-improvement tool. J Hosp Med 2015; 10:281-6. [PMID: 25708942 DOI: 10.1002/jhm.2330] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 01/21/2015] [Accepted: 01/27/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are overprescribed despite concerns regarding associated adverse drug events. OBJECTIVE To reduce inappropriate PPI prescriptions using hospitalization as the point of contact to effect meaningful change. DESIGN Before-after study design. SETTING Forty-six-bed medical clinical teaching unit in a 417-bed university teaching hospital in Montreal, Canada. PATIENTS Four hundred sixty-four consecutively admitted patients in the preintervention control group, and 640 consecutively admitted patients in the intervention group. INTERVENTION A monthly educational intervention paired with a Web-based quality improvement tool. MEASUREMENTS We determined the proportion of patients admitted on PPIs, their indications, and appropriateness of use. We then compared the proportion of patients whose PPIs were discontinued at discharge before and after our intervention. RESULTS Forty-four percent of patients were already using a PPI prior to their hospitalization. In evaluated patients, only 54% of these patients had an evidence-based indication for ongoing use. The proportion of PPIs discontinued at hospital discharge increased from 7.7% per month in the 6 months prior to intervention, to 18.5% per month postintervention (P = 0.03). CONCLUSIONS Strategies to combat PPI overuse are needed to improve the overall quality of patient care. We significantly reduced discharge prescriptions for PPIs through the implementation of an educational initiative paired with a Web-based quality improvement tool. An active interventional strategy is likely required considering the increasingly recognized and preventable adverse events associated with PPI misuse.
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Affiliation(s)
- Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada; McGill Centre for Quality Improvement, Montreal, Canada
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163
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Changes in serum magnesium concentration after use of a proton pump inhibitor in patients undergoing percutaneous coronary intervention. Kidney Res Clin Pract 2015; 34:98-102. [PMID: 26484029 PMCID: PMC4570593 DOI: 10.1016/j.krcp.2015.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/19/2015] [Accepted: 03/14/2015] [Indexed: 01/11/2023] Open
Abstract
Background Although cross-sectional studies have suggested a relationship between proton pump inhibitor (PPI) use and hypomagnesemia, no large-scale cohort study has been conducted to date. Here, we examined the changes in serum magnesium levels in response to PPI use. We hypothesized that PPI use might change the serum magnesium concentration. Methods Of the 2,892 patients hospitalized for percutaneous coronary intervention between January 2007 and May 2012, 1,076 patients with normal baseline (1.6–2.5 mg/dL) and follow-up serum magnesium concentrations were enrolled. These patients were divided into two groups: the PPI group and the control group. Results The mean follow-up period was 9.51 ± 2.94 months. The incidence of hypomagnesemia (< 1.6 mg/dL) was 0.4% (3/834) in the PPI group and 0.4% (1/242) in the control group (P = 0.904). The change in magnesium levels did not differ between the two groups, and this result was maintained in the analysis of covariance after adjusting for confounding factors (P = 0.381). Moreover, magnesium levels did not significantly differ between the long-term (duration of use ≥ 12 months, n = 71) and short-term PPI groups (duration of use < 12 months, n = 763), and the control group (n = 242; P = 0.620). The effect of PPI use on change in serum magnesium concentration was affected by the use of multiple diuretics (−0.01 ± 0.25 mg/dL; P = 0.025), although a single diuretic use with PPI did not alter the change in magnesium level (0.12 ± 0.27 mg/dL). Conclusion Changes in magnesium levels might be subtle after PPI use in patients with normal baseline magnesium values.
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164
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Herzig SJ, Guess JR, Feinbloom DB, Adra M, Afonso KA, Howell MD, Marcantonio ER. Improving appropriateness of acid-suppressive medication use via computerized clinical decision support. J Hosp Med 2015; 10:41-5. [PMID: 25603790 PMCID: PMC4302762 DOI: 10.1002/jhm.2260] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 08/22/2014] [Accepted: 08/28/2014] [Indexed: 12/20/2022]
Abstract
As part of the Choosing Wisely Campaign, the Society of Hospital Medicine identified reducing inappropriate use of acid-suppressive medication for stress ulcer prophylaxis as 1 of 5 key opportunities to improve the value of care for hospitalized patients. We designed a computerized clinical decision support intervention to reduce use of acid-suppressive medication for stress ulcer prophylaxis in hospitalized patients outside of the intensive care unit at an academic medical center. Using quasiexperimental interrupted time series analysis, we found that the decision support intervention resulted in a significant reduction in use of acid-suppressive medication with stress ulcer prophylaxis selected as the only indication, a nonsignificant reduction in overall use, and no change in use on discharge. We found low rates of use of acid-suppressive medication for the purpose of stress ulcer prophylaxis even before the intervention, and continuing preadmission medication was the most commonly selected indication throughout the study. Our results suggest that attention should be focused on both the inpatient and outpatient settings when designing future initiatives to improve the appropriateness of acid-suppressive medication use.
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Affiliation(s)
- Shoshana J. Herzig
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
| | - Jamey R. Guess
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
| | - David B. Feinbloom
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
| | - May Adra
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA
| | - Kevin A. Afonso
- Department of Clinical Systems Development, Beth Israel Deaconess Medical Center, Boston, MA
| | - Michael D. Howell
- Center for Quality, and Division of Pulmonary and Critical Care, University of Chicago, Chicago, IL
| | - Edward R. Marcantonio
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA
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Acute Pneumonia. MANDELL, DOUGLAS, AND BENNETT'S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES 2015. [PMCID: PMC7151914 DOI: 10.1016/b978-1-4557-4801-3.00069-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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166
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Garcia-Martinez I, Francés R, Zapater P, Giménez P, Gómez-Hurtado I, Moratalla A, Lozano-Ruiz B, Bellot P, González-Navajas JM, Such J. Use of proton pump inhibitors decrease cellular oxidative burst in patients with decompensated cirrhosis. J Gastroenterol Hepatol 2015; 30:147-54. [PMID: 25039465 DOI: 10.1111/jgh.12667] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND AIMS Proton pump inhibitors (PPIs) are commonly used antisecretory drugs and have been linked to an increased risk of bacterial infections in cirrhosis. We investigated whether the treatment with PPIs in cirrhosis affects the oxidative burst activity of granulocytes and monocytes and its possible interference with serum norfloxacin (Nflx) levels in these patients. METHODS 70 patients with cirrhosis and ascitic fluid and 24 healthy controls were included in the study and distributed into groups according to the regular use of PPIs and/or norfloxacin. The blood granulocyte and monocyte's phagocytic activity and oxidative burst were evaluated by flow cytometry. Blood levels of norfloxacin were measured by HPLC and bacterial translocation was evaluated by detection of bacterial DNA in blood. RESULTS Use of PPIs was associated with a decreased granulocyte and monocyte oxidative burst, but not of phagocytic activity, as compared with patients not receiving PPIs. PPIs use did not affect serum norfloxacin levels in patients. A not significant trend to an increased bacterial DNA translocation was observed in patients receiving PPIs, including patients simultaneously receiving norfloxacin. CONCLUSIONS PPIs significantly decrease cellular oxidative burst in cirrhosis. This fact may provide a pathogenic explanation to the reported high rates of bacterial infections in this setting, and strongly suggests that PPIs should only be used in patients with cirrhosis when clinically indicated.
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Barletta JF, Sclar DA. Proton pump inhibitors increase the risk for hospital-acquired Clostridium difficile infection in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:714. [PMID: 25540023 PMCID: PMC4293826 DOI: 10.1186/s13054-014-0714-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 12/08/2014] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Proton pump inhibitors (PPI) have been linked to Clostridium difficile infection (CDI) but there are few data specific to ICU patients. We evaluated duration of PPI exposure as a potential risk factor for hospital-acquired CDI in the ICU. METHODS This retrospective, case-control study was conducted using the Multiparameter Intelligent Monitoring in Intensive Care II database, a large publically available database of more than 35,000 ICU patients. Adult patients with CDI were identified using the ICD-9 code for Clostridium difficile listed as a secondary diagnosis. To be included, patients had to be present in an ICU for ≥ 48 hours prior to Clostridium difficile acquisition. These patients were then matched to patients without CDI using the ICD-9 primary diagnosis, age (+/-5 years) and SOFA score (+/-1). Successfully matched patients were reviewed for PPI exposure and other potential confounding variables for CDI. PPI exposure was characterized as short (<2 days) or long (≥ 2 days). Multivariate modeling was performed to identify independent risk factors for CDI. RESULTS There were 408 patients evaluated and 81% received a PPI. The percentage of patients who had a long exposure to PPIs was 83% in the CDI group compared to 73% with controls (P = 0.012). Upon inclusion of the following variables into a multivariate analysis (long PPI exposure, histamine-2-receptor antagonist administration, antibiotic administration, immunosuppression and study duration), long PPI exposure (odds ratio (OR) (95% confidence interval (CI) = 2.03 (1.23 to 3.36), P = 0.006) and antibiotic use (OR (95% CI) = 2.52 (1.23 to 5.18), P = 0.012) were identified as independent predictors of CDI. CONCLUSIONS Proton pump inhibitors are independent risk factors for the development of CDI in ICU patients. This risk is particularly exposed after two or more days of therapy.
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Affiliation(s)
- Jeffrey F Barletta
- Department of Pharmacy Practice, College of Pharmacy-Glendale, Midwestern University, 19555 N 59th Avenue, Glendale, AZ, 85308, USA.
| | - David A Sclar
- Department of Pharmacy Practice, College of Pharmacy-Glendale, Midwestern University, 19555 N 59th Avenue, Glendale, AZ, 85308, USA.
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168
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MacLaren R, Kassel LE, Kiser TH, Fish DN. Proton pump inhibitors and histamine-2 receptor antagonists in the intensive care setting: focus on therapeutic and adverse events. Expert Opin Drug Saf 2014; 14:269-80. [DOI: 10.1517/14740338.2015.986456] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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169
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Park CH, Kim EH, Roh YH, Kim HY, Lee SK. The association between the use of proton pump inhibitors and the risk of hypomagnesemia: a systematic review and meta-analysis. PLoS One 2014; 9:e112558. [PMID: 25394217 PMCID: PMC4230950 DOI: 10.1371/journal.pone.0112558] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 10/08/2014] [Indexed: 01/03/2023] Open
Abstract
Background Although many case reports have described patients with proton pump inhibitor (PPI)-induced hypomagnesemia, the impact of PPI use on hypomagnesemia has not been fully clarified through comparative studies. We aimed to evaluate the association between the use of PPI and the risk of developing hypomagnesemia by conducting a systematic review with meta-analysis. Methods We conducted a systematic search of MEDLINE, EMBASE, and the Cochrane Library using the primary keywords “proton pump,” “dexlansoprazole,” “esomeprazole,” “ilaprazole,” “lansoprazole,” “omeprazole,” “pantoprazole,” “rabeprazole,” “hypomagnesemia,” “hypomagnesaemia,” and “magnesium.” Studies were included if they evaluated the association between PPI use and hypomagnesemia and reported relative risks or odds ratios or provided data for their estimation. Pooled odds ratios with 95% confidence intervals were calculated using the random effects model. Statistical heterogeneity was assessed with Cochran’s Q test and I2 statistics. Results Nine studies including 115,455 patients were analyzed. The median Newcastle-Ottawa quality score for the included studies was seven (range, 6–9). Among patients taking PPIs, the median proportion of patients with hypomagnesemia was 27.1% (range, 11.3–55.2%) across all included studies. Among patients not taking PPIs, the median proportion of patients with hypomagnesemia was 18.4% (range, 4.3–52.7%). On meta-analysis, pooled odds ratio for PPI use was found to be 1.775 (95% confidence interval 1.077–2.924). Significant heterogeneity was identified using Cochran’s Q test (df = 7, P<0.001, I2 = 98.0%). Conclusions PPI use may increase the risk of hypomagnesemia. However, significant heterogeneity among the included studies prevented us from reaching a definitive conclusion.
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Affiliation(s)
- Chan Hyuk Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Hye Kim
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Yun Ho Roh
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Yan Kim
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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170
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Cool C, Cestac P, Laborde C, Lebaudy C, Rouch L, Lepage B, Vellas B, Barreto PDS, Rolland Y, Lapeyre-Mestre M. Potentially Inappropriate Drug Prescribing and Associated Factors in Nursing Homes. J Am Med Dir Assoc 2014; 15:850.e1-9. [DOI: 10.1016/j.jamda.2014.08.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 08/05/2014] [Accepted: 08/12/2014] [Indexed: 10/24/2022]
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Albugeaey M, Alfaraj N, Garb J, Seiler A, Lagu T. Do hospitalists overuse proton pump inhibitors? Data from a contemporary cohort. J Hosp Med 2014; 9:731-3. [PMID: 25130756 PMCID: PMC4640691 DOI: 10.1002/jhm.2249] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 07/16/2014] [Accepted: 07/27/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Mohammed Albugeaey
- Division of Gastroenterology and Hepatology, Medstar Georgetown University Hospital, Washington, DC
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172
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Ingebrigtsen TS, Marott JL, Vestbo J, Nordestgaard BG, Hallas J, Lange P. Gastro-esophageal reflux disease and exacerbations in chronic obstructive pulmonary disease. Respirology 2014; 20:101-7. [PMID: 25297724 DOI: 10.1111/resp.12420] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 08/07/2014] [Accepted: 08/17/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVE We tested the hypothesis that gastro-esophageal reflux disease is a risk factor for exacerbations in individuals with chronic obstructive pulmonary disease (COPD). METHODS Among 9622 participants in the Copenhagen City Heart Study, we identified 1259 individuals with COPD and information on gastro-esophageal reflux disease and the regular use of acid inhibitory treatment. These individuals were followed for 5 years with regard to medically treated COPD exacerbations, which we defined as a short course treatment with oral corticosteroids alone or in combination with antibiotics. We applied a multivariable Cox regression analysis with adjustment for well-established risk factors associated with COPD exacerbations or gastro-esophageal reflux disease, including COPD severity, and symptoms. RESULTS Individuals with COPD and gastro-esophageal reflux disease had more chronic bronchitis (31 vs 21%, P = 0.004), more breathlessness (39 vs 22%, P < 0.001), and more of them had a history of respiratory infections (6.8 vs 1.4%, P < 0.001) than individuals with COPD but without gastro-esophageal reflux disease. Among individuals with COPD and gastro-esophageal reflux disease, those who did not use acid inhibitory treatment regularly had an increased risk of COPD exacerbations during follow-up, hazards ratio (HR): HR = 2.7 (1.3-5.4, P = 0.006). Individuals with gastro-esophageal reflux disease, using acid inhibitory treatment regularly did not have an increased risk of exacerbations, HR = 1.2 (0.6-2.7, P = 0.63). CONCLUSIONS Gastro-esophageal reflux disease was associated with an increased risk of medically treated exacerbations of COPD, but only in those individuals who did not use acid inhibitory treatment regularly.
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Affiliation(s)
- Truls S Ingebrigtsen
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark; The Copenhagen City Heart Study, Frederiksberg Hospital, Copenhagen, Denmark; The Copenhagen General Population Study, University of Copenhagen, Copenhagen, Denmark
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Moriates C, Mourad M, Novelero M, Wachter RM. Development of a hospital-based program focused on improving healthcare value. J Hosp Med 2014; 9:671-7. [PMID: 24980982 DOI: 10.1002/jhm.2235] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 06/12/2014] [Accepted: 06/12/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Frontline physicians face increasing pressure to improve the quality of care they deliver while simultaneously decreasing healthcare costs. Although hospitals and physicians are beginning to implement initiatives targeting this new goal of healthcare value, few of them have a well-developed infrastructure to support this work. METHODS In March 2012, we launched a high-value care (HVC) program within the Division of Hospital Medicine at the University of California, San Francisco. The HVC program is co-led by a physician and the division's administrator, and includes other hospitalists, resident physicians, pharmacists, and administrators. The program aims to (1) use financial and clinical data to identify areas with clear evidence of waste in the hospital, (2) promote evidence-based interventions that improve both quality of care and value, and (3) pair interventions with evidence-based cost awareness education to drive culture change. RESULTS We identified 6 ongoing projects during our first year. Preliminary data for our inaugural projects are encouraging. One initiative, which targeted decreasing nebulizer use on a high-acuity medical floor (often using metered-dose inhalers instead) led to a decrease in rates of more than 50%. CONCLUSIONS The HVC program is proving to be a successful mechanism to promote improved healthcare value and clinician engagement.
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Affiliation(s)
- Christopher Moriates
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California
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174
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Klompas M. Editorial commentary: Evidence vs instinct for pneumonia prevention in hospitalized patients. Clin Infect Dis 2014; 60:76-8. [PMID: 25252683 PMCID: PMC4264582 DOI: 10.1093/cid/ciu744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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175
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Preslaski CR, Mueller S, Kiser TH, Fish DN, MacLaren R. A survey of prescriber perceptions about the prevention of stress-related mucosal bleeding in the intensive care unit. J Clin Pharm Ther 2014; 39:658-62. [DOI: 10.1111/jcpt.12208] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 08/25/2014] [Indexed: 12/29/2022]
Affiliation(s)
- C. R. Preslaski
- Department of Pharmacy; Denver Health Medical Center; Denver CO USA
| | - S.W. Mueller
- Department of Clinical Pharmacy; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences; Aurora CO USA
| | - T. H. Kiser
- Department of Clinical Pharmacy; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences; Aurora CO USA
| | - D. N. Fish
- Department of Clinical Pharmacy; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences; Aurora CO USA
| | - R. MacLaren
- Department of Clinical Pharmacy; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences; Aurora CO USA
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Herzig SJ, Doughty C, Lahoti S, Marchina S, Sanan N, Feng W, Kumar S. Acid-suppressive medication use in acute stroke and hospital-acquired pneumonia. Ann Neurol 2014; 76:712-8. [PMID: 25164323 DOI: 10.1002/ana.24262] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 07/24/2014] [Accepted: 08/22/2014] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Pneumonia is a morbid complication of stroke, but evidence-based strategies for its prevention are lacking. Acid-suppressive medications have been associated with increased risk for nosocomial pneumonia in hospitalized patients. It is unclear whether these results can be extrapolated to stroke patients, where other factors strongly modulate pneumonia risk. We investigated the association between acid-suppressive medication and hospital-acquired pneumonia in patients with acute stroke. METHODS All patients hospitalized with acute ischemic stroke or intracerebral hemorrhage in a large, urban academic medical center in Boston, Massachusetts from June 2000 to June 2010 who were ≥18 years of age and hospitalized for ≥2 days were eligible for inclusion. Acid-suppressive medication use was defined as any pharmacy charge for a proton-pump inhibitor or histamine-2 receptor antagonist. Multivariate logistic regression was used to control for confounders. The main outcome measure was hospital-acquired pneumonia, defined via International Classification of Diseases, Ninth Revision, Clinical Modification codes. RESULTS The cohort comprised 1,676 admissions. Acid-suppressive medication was ordered in 1,340 (80%) and hospital-acquired pneumonia occurred in 289 (17.2%). The unadjusted incidence of hospital-acquired pneumonia was higher in the group exposed to acid-suppressive medication compared to those unexposed (20.7% vs 3.6%, odds ratio [OR] = 7.0, 95% confidence interval [CI] = 3.9-12.7). After adjustment, the OR of hospital-acquired pneumonia in the exposed group was 2.3 (95% CI = 1.2-4.6). The association was significant for proton-pump inhibitors (OR = 2.7, 95% CI = 1.4-5.4), but not for histamine-2 receptor antagonists (OR = 1.6, 95% CI = 0.8-3.4). INTERPRETATION In this large hospital-based cohort of patients presenting with acute stroke, acid-suppressive medication use was associated with increased odds of hospital-acquired pneumonia.
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Affiliation(s)
- Shoshana J Herzig
- Department of Medicine, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
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177
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Ballantine DL, Fisquet SJ, Winearls JR, Fraser JF. Use of acid suppression medications in postoperative cardiac surgical intensive care unit patients. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2014. [DOI: 10.1002/jppr.1010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Daniel L. Ballantine
- Medical Student, Department of Medicine; University of Queensland; Herston Australia
| | - Stephanie J. Fisquet
- Critical Care Research Group, Adult Intensive Care Services; The Prince Charles Hospital and University of Queensland; Chermside Australia
| | - James R. Winearls
- Intensive Care Services; Gold Coast University Hospital; Southport Australia
| | - John F. Fraser
- Critical Care Research Group; Professor Intensive Care, Adult Intensive Care Services, The Prince Charles Hospital; Chermside Australia
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178
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Lee EA, Gibbs NE, Fahey L, Whiffen TL. Making hospitals safer for older adults: updating quality metrics by understanding hospital-acquired delirium and its link to falls. Perm J 2014; 17:32-6. [PMID: 24361018 DOI: 10.7812/tpp/13-065] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The medical care of hospitalized geriatric patients must differ from the care of younger adults. Because of reduced "reserve capacity," hospitalized older adults are at high risk of development of geriatric syndromes such as delirium and falls. Geriatric syndromes often lead to functional decline and dependence. Patients who experience geriatric syndromes in the hospital are more likely to have a longer length of stay, higher risk of readmissions, and worse medical outcomes. Incident delirium in hospitalized geriatric patients has been shown to be preventable by intervening in established risk factors. Prevention of hospital-related falls has not been consistently demonstrated. Analysis from Kaiser Permanente data demonstrated a correlation with delirium and hospital-related falls. We propose that age-specific quality metrics should be made to reduce the risk of the development of geriatric syndromes in hospitalized older adults. By preventing delirium, we believe that health care practitioners can reduce hospital-related falls in geriatric patients and improve the quality of care delivered to hospitalized older adults. An illustrative fictional case study is presented.
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Affiliation(s)
- Eric A Lee
- Assistant Chief of Internal Medicine at the West Los Angeles Medical Center and former Chair of the Southern California Permanente Medical Group Geriatric Hospital Safety Committee in Los Angeles.
| | - Nancy E Gibbs
- Regional Coordinating Chair for Geriatrics and Continuing Care for Kaiser Permanente Southern California in Pasadena.
| | - Linda Fahey
- Regional Director of Quality and Patient Safety for Patient Care Services for Kaiser Permanente Southern California in Pasadena.
| | - Teri L Whiffen
- Quality and Patient Safety Consultant for Patient Care Services for Kaiser Permanente Southern California in Pasadena.
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Morice AH, Millqvist E, Belvisi MG, Bieksiene K, Birring SS, Chung KF, Dal Negro RW, Dicpinigaitis P, Kantar A, McGarvey LP, Pacheco A, Sakalauskas R, Smith JA. Expert opinion on the cough hypersensitivity syndrome in respiratory medicine. Eur Respir J 2014; 44:1132-48. [PMID: 25142479 DOI: 10.1183/09031936.00218613] [Citation(s) in RCA: 228] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In 2011, a European Respiratory Society Task Force embarked on a process to determine the position and clinical relevance of the cough hypersensitivity syndrome, a disorder characterised by troublesome coughing often triggered by low levels of thermal, mechanical or chemical exposure, in the management of patients with chronic cough. A 21-component questionnaire was developed by an iterative process supported by a literature review. 44 key opinion leaders in respiratory medicine were selected and interviewed as to their opinions. There was a high degree of unanimity in the responses obtained, with all opinion leaders supporting the concept of cough hypersensitivity as a clinically useful paradigm. The classic stratification of cough into asthmatic, rhinitic and reflux-related phenotypes was supported. Significant disparity of opinion was seen in the response to two questions concerning the therapy of chronic cough. First, the role of acid suppression in reflux cough was questioned. Secondly, the opinion leaders were split as to whether a trial of oral steroids was indicated to establish a diagnosis of eosinophilic cough. The cough hypersensitivity syndrome was clearly endorsed by the opinion leaders as a valid and useful concept. They considered that support of patients with chronic cough was inadequate and the Task Force recommends that further work is urgently required in this neglected area.
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Affiliation(s)
- Alyn H Morice
- Centre for Cardiovascular and Metabolic Research, Respiratory Medicine, Hull York Medical School, University of Hull, Cottingham, UK
| | - Eva Millqvist
- Dept of Internal Medicine/Respiratory Medicine and Allergology, University of Gothenburg, Gothenburg, Sweden
| | - Maria G Belvisi
- Respiratory Pharmacology Group, Pharmacology and Toxicology Section, National Heart and Lung Institute, Imperial College London, London, UK
| | - Kristina Bieksiene
- Dept of Pulmonology and Immunology, Lithuanian University of Health Science, Kaunas, Lithuania
| | - Surinder S Birring
- Division of Asthma, Allergy and Lung Biology, King's College London, London, UK
| | - Kian Fan Chung
- National Heart and Lung Institute, Imperial College London and Biomedical Research Unit, Royal Brompton and Harefield NHS Trust, London, UK
| | - Roberto W Dal Negro
- Centro Nazionale Studi di Farmacoeconomia e Farmacoepidemiologua Respiratoria CESFAR, Verona, Italy
| | - Peter Dicpinigaitis
- Einstein Division/Montefiore Medical Center, Albert Einstein College of Medicine, New York, , NY, USA
| | - Ahmad Kantar
- Paediatric Cough and Asthma Centre, Istituti Ospedalieri Bergamaschi, Bergamo, Italy
| | - Lorcan P McGarvey
- Centre for Infection and Immunity, Queen's University Belfast, Belfast, UK
| | - Adalberto Pacheco
- Chronic Cough Unit, Pneumology Service, Hospital Ramón y Cajal, Madrid, Spain
| | - Raimundas Sakalauskas
- Dept of Pulmonology and Immunology, Lithuanian University of Health Science, Kaunas, Lithuania
| | - Jaclyn A Smith
- Centre for Respiratory and Allergy, University of Manchester, University Hospital of South Manchester, Manchester, UK
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Abstract
OBJECTIVES To provide an overview of the benefits of clinical data collected as a by-product of the care process, the potential problems with large aggregations of these data, the policy frameworks that have been formulated, and the major challenges in the coming years. METHODS This report summarizes some of the major observations from AMIA and IMIA conferences held on this admittedly broad topic from 2006 through 2013. This report also includes many unsupported opinions of the author. RESULTS The benefits of aggregating larger and larger sets of routinely collected clinical data are well documented and of great societal benefit. These large data sets will probably never answer all possible clinical questions for methodological reasons. Non-traditional sources of health data that are patient-sources will pose new data science challenges. CONCLUSIONS If we ever hope to have tools that can rapidly provide evidence for daily practice of medicine we need a science of health data perhaps modeled after the science of astronomy.
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Affiliation(s)
- C Safran
- Charles Safran, MD, Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA, E-mail:
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181
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Buendgens L, Bruensing J, Matthes M, Dückers H, Luedde T, Trautwein C, Tacke F, Koch A. Administration of proton pump inhibitors in critically ill medical patients is associated with increased risk of developing Clostridium difficile–associated diarrhea. J Crit Care 2014; 29:696.e11-5. [DOI: 10.1016/j.jcrc.2014.03.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 01/30/2014] [Accepted: 03/02/2014] [Indexed: 12/12/2022]
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182
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DiBardino DM, Wunderink RG. Aspiration pneumonia: a review of modern trends. J Crit Care 2014; 30:40-8. [PMID: 25129577 DOI: 10.1016/j.jcrc.2014.07.011] [Citation(s) in RCA: 155] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 07/14/2014] [Accepted: 07/15/2014] [Indexed: 01/18/2023]
Abstract
PURPOSE The purpose was to describe aspiration pneumonia in the context of other lung infections and aspiration syndromes and to distinguish between the main scenarios commonly implied when the terms aspiration or aspiration pneumonia are used. Finally, we aim to summarize current evidence surrounding the diagnosis, microbiology, treatment, risks, and prevention of aspiration pneumonia. MATERIALS AND METHODS Medline was searched from inception to November 2013. All descriptive or experimental studies that added to the understanding of aspiration pneumonia were reviewed. All studies that provided insight into the clinical aspiration syndromes, historical context, diagnosis, microbiology, risk factors, prevention, and treatment were summarized within the text. RESULTS Despite the original teaching, aspiration pneumonia is difficult to distinguish from other pneumonia syndromes. The microbiology of pneumonia after a macroaspiration has changed over the last 60 years from an anaerobic infection to one of aerobic and nosocomial bacteria. Successful antibiotic therapy has been achieved with several antibiotics. Various risks for aspiration have been described leading to several proposed preventative measures. CONCLUSIONS Aspiration pneumonia is a disease with a distinct pathophysiology. In the modern era, aspiration pneumonia is rarely solely an anaerobic infection. Antibiotic treatment is largely dependent on the clinical scenario. Several measures may help prevent aspiration pneumonia.
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Affiliation(s)
- David M DiBardino
- Department of Pulmonary, Allergy, and Critical Care Medicine, Columbia University, New York, NY.
| | - Richard G Wunderink
- Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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Ji R, Shen H, Pan Y, Du W, Wang P, Liu G, Wang Y, Li H, Zhao X, Wang Y. Risk score to predict hospital-acquired pneumonia after spontaneous intracerebral hemorrhage. Stroke 2014; 45:2620-8. [PMID: 25028448 DOI: 10.1161/strokeaha.114.005023] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We aimed to develop a risk score (intracerebral hemorrhage-associated pneumonia score, ICH-APS) for predicting hospital-acquired stroke-associated pneumonia (SAP) after ICH. METHODS The ICH-APS was developed based on the China National Stroke Registry (CNSR), in which eligible patients were randomly divided into derivation (60%) and validation (40%) cohorts. Variables routinely collected at presentation were used for predicting SAP after ICH. For testing the added value of hematoma volume measure, we separately developed 2 models with (ICH-APS-B) and without (ICH-APS-A) hematoma volume included. Multivariable logistic regression was performed to identify independent predictors. The area under the receiver operating characteristic curve (AUROC), Hosmer-Lemeshow goodness-of-fit test, and integrated discrimination index were used to assess model discrimination, calibration, and reclassification, respectively. RESULTS The SAP was 16.4% and 17.7% in the overall derivation (n=2998) and validation (n=2000) cohorts, respectively. A 23-point ICH-APS-A was developed based on a set of predictors and showed good discrimination in the overall derivation (AUROC, 0.75; 95% confidence interval, 0.72-0.77) and validation (AUROC, 0.76; 95% confidence interval, 0.71-0.79) cohorts. The ICH-APS-A was more sensitive for patients with length of stay >48 hours (AUROC, 0.78; 95% confidence interval, 0.75-0.81) than those with length of stay <48 hours (AUROC, 0.64; 95% confidence interval, 0.55-0.73). The ICH-APS-A was well calibrated (Hosmer-Lemeshow test) in the derivation (P=0.20) and validation (P=0.66) cohorts. Similarly, a 26-point ICH-APS-B was established. The ICH-APS-A and ICH-APS-B were not significantly different in discrimination and reclassification for SAP after ICH. CONCLUSION The ICH-APSs are valid risk scores for predicting SAP after ICH, especially for patients with length of stay >48 hours.
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Affiliation(s)
- Ruijun Ji
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.)
| | - Haipeng Shen
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.)
| | - Yuesong Pan
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.)
| | - Wanliang Du
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.)
| | - Penglian Wang
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.)
| | - Gaifen Liu
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.)
| | - Yilong Wang
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.)
| | - Hao Li
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.)
| | - Xingquan Zhao
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.)
| | - Yongjun Wang
- From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang, H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.).
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Abstract
BACKGROUND Proton pump inhibitors (PPIs) are commonly overused in hospitalized patients. The objectives of this study were to determine the extent of their inappropriate initiation in patients with low risk for gastrointestinal hemorrhage, factors associated with their continuation on discharge and potential cost of this trend. METHODS Retrospective examination of patients with low risk for gastrointestinal hemorrhage admitted to a tertiary-care teaching hospital over a 3-month period who received esomeprazole. The following information was collected: age, gender, PPI status (de novo or continued) and admitting diagnoses. Additional information collected from the de novo subgroup included indication for PPI, number of days on PPI and continuation of the drug on discharge. The cost of the medication was obtained from pharmacy records. RESULTS Four hundred nine patients were admitted during the study period and 204 (49.9%) received PPI de novo. Among these, 155 patients (76%) had an inappropriate indication for PPI. Of these, 62 (40%) patients were continued on PPI on discharge. Older age was a significant predictor of continuation of PPI at discharge. The estimated cost of the inpatient and outpatient inappropriate use of PPI was $12,272 and $59,272, respectively. CONCLUSIONS PPIs are overused in the majority of hospitalized patients with low risk for gastrointestinal bleeding and this practice gets perpetuated at discharge, especially in older patients. The cost of this phenomenon is alarming.
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Pharmacoepidemiology of stress ulcer prophylaxis in the United States and Canada. J Crit Care 2014; 29:955-60. [PMID: 25081626 DOI: 10.1016/j.jcrc.2014.06.025] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 06/19/2014] [Accepted: 06/21/2014] [Indexed: 01/18/2023]
Abstract
PURPOSE This study sought to identify the medication class most commonly prescribed for stress ulcer prophylaxis (SUP), assess trends in SUP utilization, and report the use of acid suppressive therapy stratified by bleeding risk. MATERIALS AND METHODS This multicenter, prospective, point prevalence study reviewed adult patients over a 24-hour period for demographics, medications used for SUP, and risk factors for clinically important bleeding. Stress ulcer prophylaxis was deemed appropriate if acid suppressive therapy was administered to patients at high risk for bleeding or no therapy in patients considered at low bleeding risk. High risk was defined as the presence of mechanical ventilation, coagulopathy, or shock. For patients receiving acid suppression before hospital admission, SUP was considered appropriate if the same drug class was continued regardless of risk factors. A planned subgroup analysis was conducted whereby patients on acid suppressive medications before admission were excluded. RESULTS There were 584 patients from 58 intensive care units in 27 hospitals. The most common drug class was proton pump inhibitors (70%). Despite receiving other enteral/oral medications, 36% received intravenous acid suppressive therapy. Overall, SUP was considered appropriate in 78% of patients and 68% when patients on acid suppression before admission were excluded. When stratified by risk, acid suppressive medications were used in 92% of high-risk patients and 71% of low-risk patients. CONCLUSION Stress ulcer prophylaxis is frequently administered to patients who are not at high risk for clinically important bleeding. Proton pump inhibitors are the overwhelming first choice among practitioners. Several opportunities exist for improvement regarding the provision of SUP.
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186
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Barletta JF. Histamine-2-Receptor Antagonist Administration and Gastrointestinal Bleeding When Used for Stress Ulcer Prophylaxis in Patients With Severe Sepsis or Septic Shock. Ann Pharmacother 2014; 48:1276-81. [DOI: 10.1177/1060028014540513] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Background: The Surviving Sepsis Campaign suggests that proton pump inhibitors (PPIs) be considered over histamine-2-receptor antagonists (H2RA) for stress ulcer prophylaxis (SUP), but there are no studies demonstrating superiority with PPIs in this population. Objective: To determine if H2RAs are associated with an increased risk for gastrointestinal (GI) bleeding in patients with severe sepsis or septic shock. Methods: This study queried the Multiparameter Intelligent Monitoring in Intensive Care II database to identify adult patients with severe sepsis or septic shock requiring mechanical ventilation for at least 48 hours. Patients were excluded if they had GI bleeding as a primary diagnosis, variceal bleeding, received both PPIs and H2RAs or no acid suppression. Demographic characteristics, medication use and potential confounders for GI bleeding were recorded. ICD-9 coding was used to identify GI bleeding listed as a secondary diagnosis. Multivariate analysis was performed to assess the role of H2RAs as an independent risk factor for GI bleeding. Results: There were 686 patients evaluated. The incidence of GI bleeding was 9.5%. Patients who received H2RAs had a bleeding incidence of 2.3% versus 10% with PPIs ( P = 0.111). On controlling for confounding variables, drug selection (H2RA or PPI) was not associated with an increased risk for bleeding. Acute or chronic liver disease was the only independent risk factor identified: odds ratio [OR] (95% CI) = 3.75 (2.19-6.44); P < 0.001. Conclusion: H2RAs are not associated with an increased risk for GI bleeding in patients with severe sepsis or septic shock who require mechanical ventilation. These data do not support the Surviving Sepsis Campaign recommendation of PPIs as the preferred agent in this population.
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Hsu WH, Kuo CH, Wang SSW, Lu CY, Liu CJ, Chuah SK, Kuo FC, Chen YH, Huang YB, Hou MF, Wu DC, Hu HM. Acid suppressive agents and risk of Mycobacterium tuberculosis: case-control study. BMC Gastroenterol 2014; 14:91. [PMID: 24884853 PMCID: PMC4030068 DOI: 10.1186/1471-230x-14-91] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 05/02/2014] [Indexed: 12/19/2022] Open
Abstract
Background The acid-suppressive agents have been linked with an increased risk of infectious disease. The relationship between these drugs and Mycobacterium Tuberculosis (TB) was not been reported. Methods We conducted a case–control study using data from National Health Insurance research database of Taiwan. From 1996 till 2008, and 6541 cases were defined as TB infection/activation (ICD-9 coding plus prescription two of four first-line anti-TB regimen for at least one month). Control subjects who were matched to the TB cases by age and sex were selected with 10:1 ratio. Medical records including acid-suppressive agent prescription and comorbidity, and socioeconomic status were analyzed. Results TB infection/activation was more frequent to comorbidity with chronic diseases, alcohol abuse, malignancy, immune deficient/suppression status and acid-related disease (peptic ulcer, reflux esophagitis). Among the TB cases, there was higher exposure record to acid-suppressive agents within 3 months before TB index date (OR 2.43(2.06-2.88) and 1.90 (1.68-2.14) for proton pump inhibitor (PPI) and histamine 2 receptor antagonist (H2RA) respectively). After adjusting confounding factors, PPIs prescription 3 months before TB index date had an association of TB infection/activation (adjusted OR 1.63(1.61-1.63)). Similar result was found in H2RA user (adjusted OR 1.51(1.50-1.52)). The association of acid-suppressive agents in TB infection/activation was fade gradually when the drug prescription period extended. Conclusions Recent prescription of acid-suppressive agent seems to associate the TB infection/activation. In the society where TB was prevalent, evaluation of pulmonary TB before prescription of PPI or H2RA is warranted.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Huang-Ming Hu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung City 807, Taiwan.
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188
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Cost-effectiveness of histamine receptor-2 antagonist versus proton pump inhibitor for stress ulcer prophylaxis in critically ill patients*. Crit Care Med 2014; 42:809-15. [PMID: 24365863 DOI: 10.1097/ccm.0000000000000032] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To examine the cost-effectiveness of using histamine receptor-2 antagonist or proton pump inhibitor for stress ulcer prophylaxis. DESIGN Decision analysis model examining costs and effectiveness of using histamine receptor-2 antagonist or proton pump inhibitor for stress ulcer prophylaxis. Costs were expressed in 2012 U.S. dollars from the perspective of the institution and included drug regimens and the following outcomes: clinically significant stress-related mucosal bleed, ventilator-associated pneumonia, and Clostridium difficile infection. Effectiveness was the mortality risk associated with these outcomes and represented by survival. Costs, occurrence rates, and mortality probabilities were extracted from published data. SETTING A simulation model. PATIENTS A mixed adult ICU population. INTERVENTIONS Histamine receptor-2 antagonist or proton pump inhibitor for 9 days of stress ulcer prophylaxis therapy. MAIN MEASUREMENTS AND RESULTS Output variables were expected costs, expected survival rates, incremental cost, and incremental survival rate. Univariate sensitivity analyses were conducted to determine the drivers of incremental cost and incremental survival. Probabilistic sensitivity analysis was conducted using second-order Monte Carlo simulation. For the base case analysis, the expected cost of providing stress ulcer prophylaxis was $6,707 with histamine receptor-2 antagonist and $7,802 with proton pump inhibitor, resulting in a cost saving of $1,095 with histamine receptor-2 antagonist. The associated mortality probabilities were 3.819% and 3.825%, respectively, resulting in an absolute survival benefit of 0.006% with histamine receptor-2 antagonist. The primary drivers of incremental cost and survival were the assumptions surrounding ventilator-associated pneumonia and bleed. The probabilities that histamine receptor-2 antagonist was less costly and provided favorable survival were 89.4% and 55.7%, respectively. A secondary analysis assuming equal rates of C. difficile infection showed a cost saving of $908 with histamine receptor-2 antagonists, but the survival benefit of 0.0167% favored proton pump inhibitors. CONCLUSIONS Histamine receptor-2 antagonist therapy appears to reduce costs with survival benefit comparable to proton pump inhibitor therapy for stress ulcer prophylaxis. Ventilator-associated pneumonia and bleed are the variables most affecting these outcomes. The uncertainty in the findings justifies a prospective trial.
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189
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Lin ZN, Zuo YQ, Hu P. Association of Proton Pump Inhibitor Therapy with Hepatic Encephalopathy in Hepatitis B Virus-related Acute-on-Chronic Liver Failure. HEPATITIS MONTHLY 2014; 14:e16258. [PMID: 24748895 PMCID: PMC3989600 DOI: 10.5812/hepatmon.16258] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 01/20/2014] [Accepted: 02/14/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hepatic encephalopathy (HE) is an important neuropsychiatry complication of acute-on-chronic liver failure (ACLF). PPI therapy may increase the intestinal bacterial overgrowth and infections. OBJECTIVES The aim of this study was to assess whether PPI use in ACLF is associated with HE. PATIENTS AND METHODS A retrospective case-control study was performed. Fifty five admitted patients with hepatitis B virus (HBV)-related ACLF complicated by Stage II-IV HE developed after admission between January 2008 and December 2012 were matched (by sex, age, and MELD score) with comparable HBV-related ACLF patients (n = 110) who did not develop this complication during hospitalization. We excluded combined HE upon admission and other neurological disorders in patients with ACLF. Univariate and multivariate analyses of 30 variables (laboratory examination, predisposition, treatment, etc.) before the occurrence of HE were carried out to identify the factors predictive of HE. RESULTS In univariate analysis, patients with HE in ACLF had a significantly higher rate of PPI use (89.1%) compared with non-HE (63.6%, P = 0.001). In addition, clinical and standard laboratory variables were significantly different between the two groups regarding the infection rate, hyponatremia, alpha-fetoprotein (AFP), Arginine Hydrochloride use and Lactulose use. Logistic regression analysis was used to examine the combined effects of the variables with HE as the outcome. HE in ACLF was associated with hyponatremia (odds ratio (OR) = 6. 318, 95% confidence interval (CI) = 2. 803-14.241; P = 0. 000), PPI use was independently associated with HE (OR = 4. 392, CI = 1. 604-12.031; P = 0. 004), and lactulose use was protective (OR = 0. 294, CI = 0. 136-0.675; P = 0. 003). CONCLUSIONS The occurrence of HE is associated with hyponatremia and PPI use in patients with ACLF.
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Affiliation(s)
- Zhao-Ni Lin
- Department of Infectious Diseases, Institute for Viral Hepatitis, Key Laboratory of Molecular Biology for Infectious Diseases, Ministry of Education, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yong-Qing Zuo
- Department of Infectious Diseases, Institute for Viral Hepatitis, Key Laboratory of Molecular Biology for Infectious Diseases, Ministry of Education, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Peng Hu
- Department of Infectious Diseases, Institute for Viral Hepatitis, Key Laboratory of Molecular Biology for Infectious Diseases, Ministry of Education, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Corresponding Author: Peng Hu, Department of Infectious Diseases, Institute for Viral Hepatitis, Key Laboratory of Molecular Biology for Infectious Diseases, Ministry of Education, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China. Tel: +86-2363693289, Fax: +86-2363703790, E-mail:
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190
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Avendaño-Reyes JM, Jaramillo-Ramírez H. [Prophylaxis for stress ulcer bleeding in the intensive care unit]. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2014; 79:50-5. [PMID: 24629722 DOI: 10.1016/j.rgmx.2013.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 05/17/2013] [Accepted: 05/30/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND The critically ill patient can develop gastric erosions and, on occasion, stress ulcers with severe gastrointestinal bleeding that can be fatal. AIMS The purpose of this review was to provide current information on the pathophysiology, risk factors, and prophylaxis of digestive tract bleeding from stress ulcers in the intensive care unit. METHODS We identified articles through a PubMed search, covering the years 1970 to 2013. The most relevant articles were selected using the search phrases "stress ulcer", "stress ulcer bleeding prophylaxis", and "stress-related mucosal bleeding" in combination with "intensive care unit". RESULTS The incidence of clinically significant bleeding has decreased dramatically since 1980. The most important risk factors are respiratory failure and coagulopathy. Proton pump inhibitors (PPIs) or H2 receptor antagonists (H2RAs) are used in stress ulcer bleeding prophylaxis. Both drugs have been shown to be superior to placebo in reducing the risk for gastrointestinal bleeding and PPIs are at least as effective as H2RAs. Early enteral feeding has been shown to reduce the risk for stress ulcer bleeding, albeit in retrospective studies. CONCLUSIONS Admittance to the intensive care unit in itself does not justify prophylaxis. PPIs are at least as effective as H2RAs. We should individualize the treatment of each patient in the intensive care unit, determining risk and evaluating the need to begin prophylaxis.
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Affiliation(s)
- J M Avendaño-Reyes
- Servicio de Endoscopia Digestiva, Hospital General de Mexicali ISESALUD, Mexicali B.C., México.
| | - H Jaramillo-Ramírez
- Servicio de Medicina Interna, Hospital General de Mexicali ISESALUD, Mexicali B. C., México
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191
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Tasaka CL, Burg C, VanOsdol SJ, Bekeart L, Anglemyer A, Tsourounis C, Rennke S. An interprofessional approach to reducing the overutilization of stress ulcer prophylaxis in adult medical and surgical intensive care units. Ann Pharmacother 2014; 48:462-9. [PMID: 24473490 DOI: 10.1177/1060028013517088] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Overutilization of stress ulcer prophylaxis (SUP) in the intensive care unit (ICU) is common. Acid-suppressive therapies routinely used for SUP are best reserved for patients with greatest risk of clinically important bleeding as they have been associated with nosocomial pneumonia, Clostridium difficile infection and increased hospital cost. OBJECTIVE The primary objective was to reduce inappropriate utilization of SUP in 2 adult medical and surgical ICU settings at the University of California, San Francisco Medical Center. Secondary objectives included reduction of inappropriate continuation of SUP at ICU and hospital discharge. METHODS To attain the study objective, an interprofessional team developed a bundled quality improvement initiative, including an institution SUP guideline, pharmacist-led intervention, and an education and awareness campaign. To assess the impact of these interventions, we conducted a retrospective cohort study comparing data on prescribing practices at baseline before and after the intervention. Since computerized prescriber order entry (CPOE) was implemented during this time frame, preintervention data collection consisted of 2 periods, one before and one after CPOE implementation. RESULTS The incidence of the inappropriate use of SUP was not significantly different between the pre-CPOE and post-CPOE groups (20 and 19 per 100 patient-days, respectively; P = .88), but the incidence of inappropriate use of SUP was significantly lower in the postintervention group versus the post-CPOE group (9 and 19 per 100 patient-days, respectively; P = .03). At ICU discharge, 4% of patients in the post-intervention group were discharged inappropriately on SUP compared with 8% in the post-CPOE group (P = .54). At hospital discharge, none of the patients in the postintervention group were discharged inappropriately on SUP compared with 7% in the post-CPOE group (P = .22). CONCLUSIONS Implementation of an interprofessional bundled quality improvement initiative is effective in decreasing inappropriate use of SUP in adult medical and surgical ICUs at a university-affiliated, tertiary care academic medical center.
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193
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Barletta JF, Sclar DA. Use of proton pump inhibitors for the provision of stress ulcer prophylaxis: clinical and economic consequences. PHARMACOECONOMICS 2014; 32:5-13. [PMID: 24271943 DOI: 10.1007/s40273-013-0119-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The provision of stress ulcer prophylaxis (SUP) for the prevention of clinically significant bleeding is widely recognized as a crucial component of care in critically ill patients. Nevertheless, SUP is often provided to non-critically ill patients despite a risk for clinically significant bleeding of roughly 0.1 %. The overuse of SUP therefore introduces added risks for adverse drug events and cost, with minimal expected benefit in clinical outcome. Historically, histamine-2-receptor antagonists (H2RAs) have been the preferred agent for SUP; however, recent data have revealed proton pump inhibitors (PPIs) as the most common modality (76 %). There are no high quality randomized controlled trials demonstrating superiority with PPIs compared with H2RAs for the prevention of clinically significant bleeding associated with stress ulcers. In contrast, PPIs have recently been linked to several adverse effects including Clostridium difficile diarrhea and pneumonia. These complications have substantial economic consequences and have a marked impact on the overall cost effectiveness of PPI therapy. Nevertheless, PPI use remains widespread in patients who are at both high and low risk for clinically significant bleeding. This article will describe the utilization of PPIs for SUP and present the clinical and economic consequences linked to their use/overuse.
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Affiliation(s)
- Jeffrey F Barletta
- Department of Pharmacy Practice, College of Pharmacy-Glendale, Midwestern University, 19555 N 59th Avenue, Glendale, AZ, 85308, USA,
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194
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Sopena N, Heras E, Casas I, Bechini J, Guasch I, Pedro-Botet ML, Roure S, Sabrià M. Risk factors for hospital-acquired pneumonia outside the intensive care unit: a case-control study. Am J Infect Control 2014; 42:38-42. [PMID: 24199911 DOI: 10.1016/j.ajic.2013.06.021] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 06/24/2013] [Accepted: 06/24/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hospital-acquired pneumonia (HAP) is one of the leading nosocomial infections and is associated with high morbidity and mortality. Numerous studies on HAP have been performed in intensive care units (ICUs), whereas very few have focused on patients in general wards. This study examined the incidence of, risk factors for, and outcomes of HAP outside the ICU. METHODS An incident case-control study was conducted in a 600-bed hospital between January 2006 and April 2008. Each case of HAP was randomly matched with 2 paired controls. Data on risk factors, patient characteristics, and outcomes were collected. RESULTS The study group comprised 119 patients with HAP and 238 controls. The incidence of HAP outside the ICU was 2.45 cases per 1,000 discharges. Multivariate analysis identified malnutrition, chronic renal failure, anemia, depression of consciousness, Charlson comorbidity index ≥3, previous hospitalization, and thoracic surgery as significant risk factors for HAP. Complications occurred in 57.1% patients. The mortality attributed to HAP was 27.7%. CONCLUSIONS HAP outside the ICU prevailed in patients with malnutrition, chronic renal failure, anemia, depression of consciousness, comorbidity, recent hospitalization, and thoracic surgery. HAP in general wards carries an elevated morbidity and mortality and is associated with increased length of hospital stay and increased rate of discharge to a skilled nursing facility.
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Affiliation(s)
- Nieves Sopena
- Infectious Diseases Unit, Internal Medicine Department, Germans Trias i Pujol University Hospital, Autonomous University of Barcelona, Badalona, Spain.
| | - Eva Heras
- Infectious Diseases Unit, Internal Medicine Department, Germans Trias i Pujol University Hospital, Autonomous University of Barcelona, Badalona, Spain
| | - Irma Casas
- Preventive Medicine Department, Germans Trias i Pujol University Hospital, Autonomous University of Barcelona, Badalona, Spain
| | - Jordi Bechini
- Radiology Department, Germans Trias i Pujol University Hospital, Autonomous University of Barcelona, Badalona, Spain
| | - Ignasi Guasch
- Radiology Department, Germans Trias i Pujol University Hospital, Autonomous University of Barcelona, Badalona, Spain
| | - Maria Luisa Pedro-Botet
- Infectious Diseases Unit, Internal Medicine Department, Germans Trias i Pujol University Hospital, Autonomous University of Barcelona, Badalona, Spain
| | - Silvia Roure
- Infectious Diseases Unit, Internal Medicine Department, Germans Trias i Pujol University Hospital, Autonomous University of Barcelona, Badalona, Spain
| | - Miquel Sabrià
- Infectious Diseases Unit, Internal Medicine Department, Germans Trias i Pujol University Hospital, Autonomous University of Barcelona, Badalona, Spain
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Pneumonia. PRINCIPLES OF PULMONARY MEDICINE 2014. [PMCID: PMC7170200 DOI: 10.1016/b978-1-4557-2532-8.00023-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Ströker E, Leone L, Vandeput Y, Borbath I, Lefebvre C. Severe symptomatic hypomagnesaemia induced by the chronic use of proton pump inhibitors: a case report of a patient with Zollinger-Ellison syndrome. Acta Clin Belg 2014; 69:62-5. [PMID: 24635401 DOI: 10.1179/0001551213z.0000000008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The association between proton pump inhibitor (PPI) therapy and hypomagnesaemia has been recognized since 2006. We report the case of a 51-year-old woman who developed severe symptomatic hypomagnesaemia after a long-term PPI therapy given for recurrent peptic ulcer disease. Hypomagnesaemia could only partially be resolved during substitution therapy, but was corrected after withdrawal of the PPI. Recurrence of hypomagnesaemia occurred after retreatment with PPIs, supporting the causal relationship. An underlying gastric acid hypersecretion (Zollinger-Ellison syndrome) was highly suspected and eventually controlled by a combination of a histamine 2-receptor antagonist and octreotide, without the need for further PPI therapy after 2 years of follow-up.
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197
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Avendaño-Reyes J, Jaramillo-Ramírez H. Prophylaxis for stress ulcer bleeding in the intensive care unit. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2014. [DOI: 10.1016/j.rgmxen.2013.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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198
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Shindo Y, Ito R, Kobayashi D, Ando M, Ichikawa M, Shiraki A, Goto Y, Fukui Y, Iwaki M, Okumura J, Yamaguchi I, Yagi T, Tanikawa Y, Sugino Y, Shindoh J, Ogasawara T, Nomura F, Saka H, Yamamoto M, Taniguchi H, Suzuki R, Saito H, Kawamura T, Hasegawa Y. Risk factors for drug-resistant pathogens in community-acquired and healthcare-associated pneumonia. Am J Respir Crit Care Med 2013; 188:985-95. [PMID: 23855620 DOI: 10.1164/rccm.201301-0079oc] [Citation(s) in RCA: 203] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Identification of patients with drug-resistant pathogens at initial diagnosis is essential for treatment of pneumonia. OBJECTIVES To elucidate clinical features of community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP), and to clarify risk factors for drug-resistant pathogens in patients with CAP and HCAP. METHODS A prospective observational study was conducted in hospitalized patients with pneumonia at 10 institutions in Japan. Pathogens identified as not susceptible to ceftriaxone, ampicillin-sulbactam, macrolides, and respiratory fluoroquinolones were defined as CAP drug-resistant pathogens (CAP-DRPs). MEASUREMENTS AND MAIN RESULTS In total, 1,413 patients (887 CAP and 526 HCAP) were analyzed. CAP-DRPs were more frequently found in patients with HCAP (26.6%) than in patients with CAP (8.6%). Independent risk factors for CAP-DRPs were almost identical in patients with CAP and HCAP. These included prior hospitalization (adjusted odds ratio [AOR], 2.06; 95% confidence interval [CI], 1.23-3.43), immunosuppression (AOR, 2.31; 95% CI, 1.05-5.11), previous antibiotic use (AOR, 2.45; 95% CI, 1.51-3.98), use of gastric acid-suppressive agents (AOR, 2.22; 95% CI, 1.39-3.57), tube feeding (AOR, 2.43; 95% CI, 1.18-5.00), and nonambulatory status (AOR, 2.45; 95% CI, 1.40-4.30) in the combined patients with CAP and HCAP. The area under the receiver operating characteristic curve for counting the number of risk factors was 0.79 (95% CI, 0.74-0.84). CONCLUSIONS The clinical profile of HCAP was different from that of CAP. However, physicians can predict drug resistance in patients with either CAP or HCAP by taking account of the cumulative number of the risk factors. Clinical trial registered with https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&type=summary&recptno=R000004001&language=E ; number UMIN000003306.
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Affiliation(s)
- Yuichiro Shindo
- 1 Institute for Advanced Research, Nagoya University, Nagoya, Japan
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Atkins R, Smith L. Impact of Pharmacy Intervention on the Use of Proton-Pump Inhibitors in the Hospital Setting. ACTA ACUST UNITED AC 2013; 28:786-92. [DOI: 10.4140/tcp.n.2013.786] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Barletta JF, El-Ibiary SY, Davis LE, Nguyen B, Raney CR. Proton Pump Inhibitors and the Risk for Hospital-Acquired Clostridium difficile Infection. Mayo Clin Proc 2013; 88:1085-90. [PMID: 24012413 DOI: 10.1016/j.mayocp.2013.07.004] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 06/25/2013] [Accepted: 07/01/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To examine the relationship between proton pump inhibitor (PPI) usage and nosocomial Clostridium difficile infection (CDI) and determine the duration of therapy at which CDI risk increases. PATIENTS AND METHODS This retrospective case-control study included consecutive adult patients in whom nosocomial CDI developed after hospitalization for 3 or more days at one of 2 affiliated hospitals between June 1, 2010, and October 31, 2011. These patients were matched to patients hospitalized within 6 months who did not have CDI development in a 1:2 ratio using age, sex, and antibiotic usage. Potential risk factors for CDI, including PPI use and duration, were evaluated. Multivariate analysis was performed to control for confounding variables and identify risk factors. RESULTS A total of 201 patients were evaluated, 67 with CDI and 134 matched controls. Patients in whom CDI developed were more likely to have received a PPI (76% vs 39%; P<.001) and had a longer duration of PPI therapy (median [range], 5 [0-20] days vs 0 [0-11] days; P<.001) than those who did not have CDI development. After controlling for prior hospital admission, intensive care unit admission, admission from a skilled nursing facility, immunosuppression, number of antibiotics received, PPI duration, and time to event via multivariate analysis, PPI duration was found to be a risk factor for CDI (odds ratio, 1.14; 95% CI, 1.02-1.27; P=.018). The probability for CDI was higher when PPI use exceeded 2 days in patients without a prior hospital admission and 1 day in patients with a prior admission. CONCLUSION The duration of PPI therapy is significantly associated with CDI. Clinicians should strongly consider restricting PPI use given the short exposure time associated with this increased risk.
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Affiliation(s)
- Jeffrey F Barletta
- Department of Pharmacy Practice, Midwestern University College of Pharmacy-Glendale, Glendale, AZ.
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