Proton pump inhibitors for prophylaxis of nosocomial upper gastrointestinal tract bleeding: effect of standardized guidelines on prescribing practice

Prevalence and Risk Factors for Inappropriate Continuation of Proton Pump Inhibitors After Discharge From the Intensive Care Unit

OBJECTIVE

To determine the prevalence and risk factors for inappropriate discharge on proton pump inhibitor (PPI) therapy started in the intensive care unit (ICU) for stress ulcer prophylaxis.

PATIENTS AND METHODS

This was a retrospective cohort study of adults initiated on treatment with a PPI in any of 9 affiliated ICUs from January 1, 2014, to December 31, 2018. Patients were excluded if they had an appropriate long-term PPI indication. Logistic regression modeling was used to identify characteristics associated with discharge on treatment with an inappropriate PPI.

RESULTS

Of 24,751 patients admitted to an ICU, 4127 were initiated on treatment with a new PPI, with 2467 (60%) lacking a long-term PPI indication. Of these 2467, a total of 1122 (45%) were continued on PPI therapy after transfer to the floor and 668 (27%) were discharged on PPI therapy. On multivariable analysis, risk factors for inappropriate discharge on PPI therapy included having an upper endoscopy (adjusted odds ratio [aOR], 1.70; 95% CI, 1.08-2.66), admission to the surgical compared with medical ICU (aOR, 2.03; 95% CI, 1.32-3.10), and discharge to a nursing home or rehabilitation facility (aOR, 1.43; 95% CI, 1.04-1.96; and aOR, 2.29; 95% CI, 1.62-3.24, respectively).

CONCLUSION

Among patients started on treatment with a PPI in the ICU without an indication for outpatient PPI use, 27% (668 of 2467) were nonetheless discharged on PPI therapy. Medically complex and surgical ICU patients are at increased risk for receiving PPIs without appropriate documented indications, and careful review of medication lists at discharge should occur in these high-risk groups.

Reducing Inappropriate Proton Pump Inhibitors Use for Stress Ulcer Prophylaxis in Hospitalized Patients: Systematic Review of De-Implementation Studies

BACKGROUND

A large proportion of proton pump inhibitor (PPI) prescriptions, including those for stress ulcer prophylaxis (SUP), are inappropriate. Our study purpose was to systematically review the effectiveness of de-implementation strategies aimed at reducing inappropriate PPI use for SUP in hospitalized, non-intensive care unit (non-ICU) patients.

METHODS

We searched MEDLINE and Embase databases (from inception to January 2020). Two authors independently screened references, performed data extraction, and critical appraisal. Randomized trials and comparative observational studies were eligible for inclusion. Criteria developed by the Cochrane Effective Practice and Organisation of Care (EPOC) group were used for critical appraisal. Besides the primary outcome (inappropriate PPI prescription or use), secondary outcomes included (adverse) pharmaceutical effects and healthcare use.

RESULTS

We included ten studies in this review. Most de-implementation strategies contained an educational component (meetings and/or materials), combined with either clinical guideline implementation (n = 5), audit feedback (n = 3), organizational culture (n = 4), or reminders (n = 1). One study evaluating the de-implementation strategy effectiveness showed a significant reduction (RR 0.14; 95% CI 0.03-0.55) of new inappropriate PPI prescriptions. Out of five studies evaluating the effectiveness of de-implementing inappropriate PPI use, four found a significant reduction (RR 0.21; 95% CI 0.18-0.26 to RR 0.76; 95% CI 0.68-0.86). No significant differences in the occurrence of pharmaceutical effects (n = 1) and in length of stay (n = 3) were observed. Adverse pharmaceutical effects were reported in two studies and five studies reported on PPI or total drug costs. No pooled effect estimates were calculated because of large statistical heterogeneity between studies.

DISCUSSION

All identified studies reported mainly educational interventions in combination with one or multiple other intervention strategies and all interventions were targeted at providers. Most studies found a small to moderate reduction of (inappropriate) PPI prescriptions or use.

Estimates of all cause mortality and cause specific mortality associated with proton pump inhibitors among US veterans: cohort study

OBJECTIVE

To estimate all cause mortality and cause specific mortality among patients taking proton pump inhibitors (PPIs).

DESIGN

Longitudinal observational cohort study.

SETTING

US Department of Veterans Affairs.

PARTICIPANTS

New users of PPIs (n=157 625) or H2 blockers (n=56 842).

MAIN OUTCOME MEASURES

All cause mortality and cause specific mortality associated with taking PPIs (values reported as number of attributable deaths per 1000 patients taking PPIs).

RESULTS

There were 45.20 excess deaths (95% confidence interval 28.20 to 61.40) per 1000 patients taking PPIs. Circulatory system diseases (number of attributable deaths per 1000 patients taking PPIs 17.47, 95% confidence interval 5.47 to 28.80), neoplasms (12.94, 1.24 to 24.28), infectious and parasitic diseases (4.20, 1.57 to 7.02), and genitourinary system diseases (6.25, 3.22 to 9.24) were associated with taking PPIs. There was a graded relation between cumulative duration of PPI exposure and the risk of all cause mortality and death due to circulatory system diseases, neoplasms, and genitourinary system diseases. Analyses of subcauses of death suggested that taking PPIs was associated with an excess mortality due to cardiovascular disease (15.48, 5.02 to 25.19) and chronic kidney disease (4.19, 1.56 to 6.58). Among patients without documented indication for acid suppression drugs (n=116 377), taking PPIs was associated with an excess mortality due to cardiovascular disease (22.91, 11.89 to 33.57), chronic kidney disease (4.74, 1.53 to 8.05), and upper gastrointestinal cancer (3.12, 0.91 to 5.44). Formal interaction analyses suggested that the risk of death due to these subcauses was not modified by a history of cardiovascular disease, chronic kidney disease, or upper gastrointestinal cancer. Taking PPIs was not associated with an excess burden of transportation related mortality and death due to peptic ulcer disease (as negative outcome controls).

CONCLUSIONS

Taking PPIs is associated with a small excess of cause specific mortality including death due to cardiovascular disease, chronic kidney disease, and upper gastrointestinal cancer. The burden was also observed in patients without an indication for PPI use. Heightened vigilance in the use of PPI may be warranted.

Appropriateness of the use of proton pump inhibitors in the Emergency Department of a Spanish university hospital

BACKGROUND

the use of proton pump inhibitors (PPI) has increased substantially during the last years, possibly due to a significant proportion of prescriptions that do not follow the approved indications.

OBJECTIVE

to assess the prevalence of PPI prescription and the appropriateness of the prescription within the Emergency Department (ED) of a Spanish university hospital.

MATERIALS AND METHODS

a cross-sectional, retrospective prescription-indication drug-use study was performed, which selected 384 patients that presented to the ED over two days in January 2016.

RESULTS

of the total cohort, 23.2% were taking PPI before their hospital visit and only 20.2% had a correct indication and dosage; 2.9% of the patient cohort had an indication for PPI treatment but had not been prescribed them. A drug other than omeprazole was used in 25% of cases; 30.47% of the patients were discharged with a PPI and only 28.2% of them had the correct indication and dosage. Finally, 5.7% were not prescribed PPI even though it was warranted. PPI prescription increased with age whereas the indication for the prescription decreased. Furthermore, the use of these drugs was higher in hospitalized patients compared to discharged patients.

CONCLUSIONS

these results are in line with similar studies, which demonstrate the existence of an over-prescription of PPI. PPI prescription needs to be improved, thereby reducing drug interactions, adverse effects and unnecessary economical expenses.

Attitude and knowledge of Saudi community pharmacists towards use of proton pump inhibitors

Introduction

Proton pump inhibitors (PPIs) effectively suppress acid secretion and play an important role in peptic ulcer disease and gastroesophageal reflux disease. There is a real concern about the overutilization of PPIs, which will lead to significant high cost and undesirable outcomes. Despite that most of PPIs are classified as prescribed medications, yet most of their users take them without prescription in Saudi Arabia. Therefore, it was important to understand community pharmacists practice in dealing with PPIs and to evaluate their despising pattern of these medications.

Method

A cross-sectional survey-based study that was carried out between September and December 2017. The survey intended to evaluate the knowledge and attitude of CPs towards use of proton pump inhibitors and was built as an online survey.

Results

The results of this study showed that almost all CPs prescribe anti-ulcer drugs for their patients. Most of the participants (68.4%) have prescribed PPI for acute gastritis (68.4%), prophylaxis for stress ulcers (17.7%) and stress ulcer (11.1%). 54.9 percent of the participants recommend using acid suppression drugs for 1 to 2 weeks when they prescribe them to their patients. Thirty-two percent of the respondents had reported adverse events with PPIs. The study showed a significant association between length of work experience in community pharmacy and reporting adverse events.

Conclusion

Community pharmacists in Saudi Arabia usually recommend and prescribe PPIs to their patients. Most of them have some knowledge on PPIs indications and side effects. Managing OTC PPI use in the community pharmacy setting is necessary to promote both patient and medication safety.

Magnitude and direction of the association between Clostridium difficile infection and proton pump inhibitors in adults and pediatric patients: a systematic review and meta-analysis

BACKGROUND

Clostridium difficile infection (CDI) is a cause of increased morbidity and health care costs among hospitalized patients. Proton pump inhibitors (PPIs) are mainly used for the treatment of acid-related upper gastrointestinal diseases. The aim of the study was to assess the risks associated with initial and recurrent CDI in adult and pediatric patients treated with PPIs.

METHODS

A systematic search was performed using PubMed (Medline), Embase, and Web of Science with the following search terms: ("proton pump inhibitor," "PPI," or "acid suppression") AND ("infection," "diarrhea," "diarrhoea," "colitis," or "disease") AND ("Clostridium difficile"). Meta-analysis was performed using Revman5.3 software. Pooled odds ratios (ORs) presented as standard plots with 95% confidence intervals (CIs) were determined.

RESULTS

Sixty-seven eligible studies were selected. PPI use was significantly associated with risk of CDI (OR 2.34, 95% CI 1.94-2.82; P < 0.00001). Pooled data from twelve studies demonstrated a significant association between PPI use and recurrent CDI (OR 1.73, 95% CI 1.39-2.15; P = 0.02). Subgroup analysis revealed significant associations between PPI use and an increased incidence of CDI among adult (OR 2.30, 95% CI 1.89-2.80; P < 0.00001) and pediatric (OR 3.00, 95% CI 1.44-6.23; P < 0.00001) patients.

CONCLUSIONS

PPI use was associated with CDI in adult and pediatric patients, and with recurrent CDI. Although many risk factors are associated with the occurrence and recurrence of CDI, consideration should be given to not administering PPIs at any age if they are unnecessary.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Risk of death among users of Proton Pump Inhibitors: a longitudinal observational cohort study of United States veterans

OBJECTIVE

Proton pump inhibitors (PPIs) are widely used, and their use is associated with increased risk of adverse events. However, whether PPI use is associated with excess risk of death is unknown. We aimed to examine the association between PPI use and risk of all-cause mortality.

DESIGN

Longitudinal observational cohort study.

SETTING

US Department of Veterans Affairs.

PARTICIPANTS

Primary cohort of new users of PPI or histamine H2 receptor antagonists (H2 blockers) (n=349 312); additional cohorts included PPI versus no PPI (n=3 288 092) and PPI versus no PPI and no H2 blockers (n=2 887 030).

MAIN OUTCOME MEASURES

Risk of death.

RESULTS

Over a median follow-up of 5.71 years (IQR 5.11-6.37), PPI use was associated with increased risk of death compared with H2 blockers use (HR 1.25, CI 1.23 to 1.28). Risk of death associated with PPI use was higher in analyses adjusted for high-dimensional propensity score (HR 1.16, CI 1.13 to 1.18), in two-stage residual inclusion estimation (HR 1.21, CI 1.16 to 1.26) and in 1:1 time-dependent propensity score-matched cohort (HR 1.34, CI 1.29 to 1.39). The risk of death was increased when considering PPI use versus no PPI (HR 1.15, CI 1.14 to 1.15), and PPI use versus no PPI and no H2 blockers (HR 1.23, CI 1.22 to 1.24). Risk of death associated with PPI use was increased among participants without gastrointestinal conditions: PPI versus H2 blockers (HR 1.24, CI 1.21 to 1.27), PPI use versus no PPI (HR 1.19, CI 1.18 to 1.20) and PPI use versus no PPI and no H2 blockers (HR 1.22, CI 1.21 to 1.23). Among new PPI users, there was a graded association between the duration of exposure and the risk of death.

CONCLUSIONS

The results suggest excess risk of death among PPI users; risk is also increased among those without gastrointestinal conditions and with prolonged duration of use. Limiting PPI use and duration to instances where it is medically indicated may be warranted.

Proton pump inhibitors alter the composition of the gut microbiota

OBJECTIVE

Proton pump inhibitors (PPIs) are drugs used to suppress gastric acid production and treat GI disorders such as peptic ulcers and gastro-oesophageal reflux. They have been considered low risk, have been widely adopted, and are often over-prescribed. Recent studies have identified an increased risk of enteric and other infections with their use. Small studies have identified possible associations between PPI use and GI microbiota, but this has yet to be carried out on a large population-based cohort.

DESIGN

We investigated the association between PPI usage and the gut microbiome using 16S ribosomal RNA amplification from faecal samples of 1827 healthy twins, replicating results within unpublished data from an interventional study.

RESULTS

We identified a significantly lower abundance in gut commensals and lower microbial diversity in PPI users, with an associated significant increase in the abundance of oral and upper GI tract commensals. In particular, significant increases were observed in Streptococcaceae. These associations were replicated in an independent interventional study and in a paired analysis between 70 monozygotic twin pairs who were discordant for PPI use. We propose that the observed changes result from the removal of the low pH barrier between upper GI tract bacteria and the lower gut.

CONCLUSIONS

Our findings describe a significant impact of PPIs on the gut microbiome and should caution over-use of PPIs, and warrant further investigation into the mechanisms and their clinical consequences.

Defining Appropriate Use of Proton-Pump Inhibitors Among Medical Inpatients

BACKGROUND

Proton-pump inhibitors (PPIs) are commonly used among medical inpatients, both for prophylaxis against upper gastrointestinal bleeding (UGIB) and continuation of outpatient use. While PPIs reduce the risk of UGIB, they also appear to increase the risk of hospital-acquired pneumonia (HAP) and Clostridium difficile infection (CDI). Depending upon the underlying risks of these conditions and the changes in those risks with PPIs, use of proton-pump inhibitors may lead to a net benefit or net harm among medical inpatients.

OBJECTIVE

We aimed to determine the net impact of PPIs on hospital mortality among medical inpatients.

DESIGN

A microsimulation model, using literature-derived estimates of the risks of UGIB, HAP, and CDI among medical inpatients, along with the changes in risk associated with PPI use for each of these outcomes. The primary outcome was change in inpatient mortality.

PARTICIPANTS

Simulated general medical inpatients outside the intensive care unit (ICU).

MAIN MEASURE

Change in overall mortality during hospitalization.

KEY RESULTS

New initiation of PPI therapy led to an increase in hospital mortality in about 90% of simulated patients. Continuation of outpatient PPI therapy on admission led to net increase in hospital mortality in 79% of simulated patients. Results were robust to both one-way and multivariate sensitivity analyses, with net harm occurring in at least two-thirds of patients in all scenarios.

CONCLUSIONS

For the majority of medical inpatients outside the ICU, use of PPIs likely leads to a net increase in hospital mortality. Even in patients at particularly high risk of UGIB, only those at the very lowest risk of HCAP and CDI should be considered for prophylactic PPI use. Continuation of outpatient PPIs may also increase expected hospital mortality. Apart from patients with active UGIB, use of PPIs in hospitalized patients should be discouraged.

Systematic review and meta-analysis of the possible association between pharmacological gastric acid suppression and spontaneous bacterial peritonitis

BACKGROUND

Observational studies have presented conflicting results with regard to an association between gastric acid suppression and spontaneous bacterial peritonitis (SBP). Our aim was to carry out a meta-analysis investigating the possible association between the use of proton pump inhibitors or H2-receptor antagonists and SBP.

METHODS

We searched several databases from inception through 15 December 2014 to identify observational studies that provided data on the association of gastric acid suppression with SBP as their primary outcome, and carried out random effects meta-analyses.

RESULTS

Fourteen observational studies (six case-control and eight cohort) evaluating the association between proton pump inhibitors and SBP revealed a pooled odds ratio (OR) of 2.32 [95% confidence interval (CI) 1.57-3.42, I(2)=82%]. The subgroup analysis based on study design revealed a pooled OR of 2.52 (95% CI 1.71-3.71, I(2)=16%) for case-control studies, and a pooled OR of 2.18 (95% CI 1.24-3.82, I(2)=89%) for cohort studies. Sensitivity analysis including only the peer-reviewed publications in the cohort subgroup revealed a pooled OR of 1.49 (95% CI 1.15-1.95, I(2)=27%). The subgroup analysis for high-quality studies revealed a pooled OR of 1.49 (95% CI 1.19-1.88, I(2)=21%). The pooled OR for H2-receptor antagonists and SBP was 1.93 (95% CI 1.15-3.24, I(2)=0%).

CONCLUSIONS

There appear to be statistically significant, but quantitatively small, associations between gastric acid suppression and SBP. However, the magnitude of the possible association diminished when analysis focused on higher quality data that were more robust. Furthermore, the quality evidence in support of the association, as per the GRADE framework, was very low.

Review of Proton Pump Inhibitor Overuse in the US Veteran Population

Objective: A growing body of evidence provides proof that proton pump inhibitors (PPIs) are overused in the general population and that such use is associated with adverse risks and unnecessary costs. Our objective was to systematically evaluate PPI overuse in the veteran population. Data Sources: A literature search using MEDLINE and CINHAL databases (1946-December 2014) was performed using the search term proton pump inhibitors coupled with each of the following key words: inappropriate use, misuse, and overuse. Searches were limited to studies and reviews in English language and human subjects. Additional references were identified from a review of literature citations. Study Selection and Data Extraction: All articles that centrally addressed the issue of PPI overuse were evaluated, following the PRISMA guidelines for systematic reviews. Data were extracted into Microsoft Excel 2013. Articles that focused on the pediatric or non-US veteran populations were excluded. Data Synthesis: Among 30 articles included, 5 evaluated PPI overuse in veterans. The reported prevalence rate of PPI overuse in veterans ranged from 33% to 67%. Several cases reported PPI-associated Clostridium difficile-associated diarrhea and pneumonia. One Veterans Affairs center reported the total cost of PPI overuse to be more than $200 000 based on over-the-counter costs and more than $1.5 million based on average wholesale price cost. Conclusions: PPI overuse is common among veterans and exposes them to adverse risks and costs the system enormous dollars. Based on the findings of this review, we provide recommendations to curb PPI overuse among veterans and in the Veterans Affairs system.

Risk factors for gastrointestinal dysfunction in patients with depression

AIM: To investigate the risk factors for gastrointestinal dysfunction in patients with depression.

METHODS: One hundred and eight patients with depression treated from June 2012 to June 2014 at the First Affiliated Hospital of Zhengzhou University were studied. The incidence of depression in patients with gastrointestinal dysfunction was observed. The patients' basic information, Self-rating Anxiety Scale (SAS) score, Self-rating Depression Scale (SDS) score, Hamilton Depression Scale (HAMD) score, serum ghrelin and interleukin-6 (IL-6) levels were analyzed by univariate and multivariate Logistic regression analyses.

RESULTS: Forty-seven (43.52%) of the 108 depression patients had gastrointestinal dysfunction. Univariate analysis showed that patient age, sex, SAS score, SDS score, HAMD score, serum ghrelin and IL-6 levels were risk factors for gastrointestinal dysfunction in patients with depression (P < 0.05). Multivariate Logistic regression analysis showed that age, HAMD score, serum ghrelin and IL-6 levels were independent risk factors for gastrointestinal dysfunction in patients with depression (P < 0.05). Serum ghrelin levels were negatively correlated with HAMD score (r = -0.72, P < 0.05), and were positively correlated with IL-6 levels (r = 0.65, P < 0.05).

CONCLUSION: The incidence of gastrointestinal dysfunction is high in depression patients. Patient age, HAMD score, serum ghrelin and IL-6 levels are independent risk factors for gastrointestinal dysfunction in depression patients.

Making hospitals safer for older adults: updating quality metrics by understanding hospital-acquired delirium and its link to falls

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.

Why do GPs continue inappropriate hospital prescriptions of proton pump inhibitors? A qualitative study

BACKGROUND

Inappropriate prescriptions of Proton pump inhibitors (PPIs) initiated in hospitals are frequently continued in primary care. No research has explored why general practitioners (GPs) continue or discontinue inappropriate drug therapy.

OBJECTIVES

This study aims to describe factors and motives associated with the continuation of inappropriate prescriptions of PPIs in primary care.

METHODS

Semi-structured qualitative interviews on basis of a purposive sampling of five GPs who often continued inappropriate prescriptions and five GPs who frequently discontinued inappropriate drug therapy with PPIs (10 GPs total, of which four were female and six male).

RESULTS

Although all GPs enrolled in the study were enthusiastic about the effectiveness of PPIs, differences between the continuing and discontinuing GPs exists in three areas: The two groups varied ( 1 ) in awareness of indications and general attitudes towards prescribing ( 2 ) in perception of the hospital physicians' competence in prescribing and ( 3 ) appreciation of general prescribing conditions in hospitals.

CONCLUSION

Differences between the continuing and discontinuing GPs were found in their level of knowledge and their perceptions of the hospital physicians' competence and the threshold to prescribing in hospitals. Financial pressure and possible adverse effects demand a more balanced and evidence-based prescribing of PPIs. Attempts to change behaviour should focus on the GPs' awareness of indications for PPIs, NSAID risks, and prescribing approaches in hospitals. Default prescribing in hospital demands critical examination.

Proton Pump Inhibitors and the Risk for Hospital-Acquired Clostridium difficile Infection

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.

Proton pump inhibitor use and the risk of small intestinal bacterial overgrowth: a meta-analysis

BACKGROUND & AIMS

Use of proton pump inhibitors (PPIs) could predispose individuals to small intestinal bacterial overgrowth (SIBO) by altering the intraluminal environment and bacterial flora. There is controversy regarding the risk of SIBO among PPI users because of conflicting results from prior studies. A systematic review and meta-analysis were performed to evaluate the association between PPI use and SIBO, using objective clinical outcome measures.

METHODS

Clinical studies comparing SIBO risk among adult users of PPIs vs nonusers were identified in MEDLINE/PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, and the National Institutes of Health Clinical Trials databases through July 2012. Two reviewers independently extracted data on study characteristics and outcomes. The primary metameter was the odds ratio (OR) of SIBO among PPI users vs nonusers. Subgroup analyses were performed to examine the influence of study characteristics, such as SIBO diagnostic modality, on study outcome.

RESULTS

Eleven studies (n = 3134) met inclusion criteria. The pooled OR of SIBO in PPI users vs nonusers was 2.282 (95% confidence interval [CI], 1.238-4.205). No significant single large study or temporal effect was seen. Subgroup analysis revealed an association between SIBO and PPI use in studies that used duodenal or jejunal aspirate cultures to diagnose SIBO (OR, 7.587; 95% CI, 1.805-31.894), but no relationship was found between SIBO and PPI use in studies that used the glucose hydrogen breath test (OR, 1.93; 95% CI, 0.69-5.42). Funnel plot analysis identified 4 outlying studies, indicating the possible presence of publication bias.

CONCLUSIONS

PPI use statistically was associated with SIBO risk, but only when the diagnosis was made by a highly accurate test (duodenal or jejunal aspirate culture). Differences in study results could arise from the use of different tests to diagnose SIBO.

Use of proton pump inhibitors with lack of diagnostic indications in 22 Midwestern US skilled nursing facilities

OBJECTIVES

The primary objective of this study was to identify proton pump inhibitor (PPI) prescribing patterns in a population of older adults admitted to 22 Midwestern skilled long term care facilities (LTCF) with medical coverage provided by the US Medicare Part A program. The relationship between PPI prescribing patterns and specific ICD-9 diagnostic codes and symptoms management was examined. The long-term objective is appropriate PPI prescription guidance through the development of evidence- and regulation-based pharmacy formulary and policy practices, as well as practical prescribing guidance for practitioners who are supported by this pharmacy.

DESIGN

An observational cohort study was conducted, using prospectively collected and de-identified prescribing and diagnostic data from a convenience sample of all Medicare A skilled nursing patients admitted between January 1, 2010, and May 31, 2011, to 22 urban, suburban, and rural Midwestern US LTCFs.

SETTING AND PARTICIPANTS

A common pharmacy service de-identified and aggregated PPI prescribing data and patient diagnostic information. These secondary data were analyzed for trends and patterns related to PPI use for all Medicare A patients admitted to these 22 facilities during a 17-month period in 2010 and 2011.

MEASUREMENT AND RESULTS

Rates of PPI use were determined and were compared with diagnostic codes. Of 1381 total admissions, 1100 patients (79.7%) were prescribed PPI. There was no appropriate diagnosis for PPI use in 718 patients (65.3%). Gastroesophageal reflux disease (GERD) tended to be the blanket diagnosis that was used most frequently for PPIs, but there was usually no follow-up or symptomatic evidence documented of active GERD. When long-term (current) use of nonsteroidal anti-inflammatory drugs (NSAIDs) (including aspirin) and/or anticoagulant therapy (warfarin) was considered as appropriate indications for 382 patients, 336 (24%) of all Medicare patients were still receiving PPIs with no relevant gastrointestinal ICD-9 diagnostic code. Total cost of PPIs prescribed from January 2010 to June 2011 was $348,414.

CONCLUSIONS

The examined PPI prescribing patterns show discordance between ICD-9 diagnostic code and prescribed use of PPIs in the study population. More than half (52%) of the total number of Medicare A patients were taking the medication without an indicated diagnosis. Even when NSAIDs and anticoagulant therapy were taken into consideration as valid reasons for PPI use, 24% of all patients admitted were still prescribed PPIs without a diagnosis that indicated the need for a PPI. Considering the economic cost, potential side effects, and CMS F329 regulations, which require that an LTCF resident's drug regimen be free from unnecessary medication, it is important that prescribers in LTCFs carefully consider use of PPIs in older adults in LTCFs and monitor the continued use of PPIs to prevent both the personal cost of physical side effects and drug-drug interactions, as well as the economic cost of unnecessary medication use.

Relationship between serum gastrin levels and severe gastrointestinal dysfunction in emergency intensive care unit patients

AIM: To detect serum gastrin (GAS) levels and calculate APACHE Ⅱ score in emergency intensive care unit (EICU) patients with gastrointestinal dysfunction and to analyze the clinical significance of GAS levels in the occurrence of early gastrointestinal dysfunction.

METHODS: Eighty-four patients were divided into three groups: gastrointestinal function impairment group (n = 23), early gastrointestinal failure group (n = 22), and gastrointestinal failure group (n = 39). Twenty healthy persons were used as normal controls. Serum GAS levels were detected and APACHE Ⅱ scores were calculated on the 1st, 3rd, and 5th day after admission, and patients were divided into three groups based on APACHE Ⅱ score: < 15, 15-25, and > 25.

RESULTS: Except that there was no significant difference in serum GAS levels between the gastrointestinal failure group and early gastrointestinal failure group on day 5 (q = 2.456, P = 0.086), significant differences were noted at all time points in pairwise comparisons between various groups (all P < 0.05). There was a significant correlation between GAS levels and severity of gastrointestinal functional disorders at various time points (r = 0.855, 0.895, 0.682, all P = 0.000). There was a significant difference in GAS levels among groups with different APACHE Ⅱ scores (P < 0.05), and pairwise comparisons of these groups also showed significant differences (all P < 0.05). GAS levels were significantly correlated with APACHE Ⅱ score (r = 0.805, P = 0.000).

CONCLUSION: Elevated GAS levels in early stage could help judge the presence and severity of early gastrointestinal dysfunction in EICU patients.

Association between proton pump inhibitor therapy and clostridium difficile infection: a contemporary systematic review and meta-analysis

Introduction

Emerging epidemiological evidence suggests that proton pump inhibitor (PPI) acid-suppression therapy is associated with an increased risk of Clostridium difficile infection (CDI).

Methods

Ovid MEDLINE, EMBASE, ISI Web of Science, and Scopus were searched from 1990 to January 2012 for analytical studies that reported an adjusted effect estimate of the association between PPI use and CDI. We performed random-effect meta-analyses. We used the GRADE framework to interpret the findings.

Results

We identified 47 eligible citations (37 case-control and 14 cohort studies) with corresponding 51 effect estimates. The pooled OR was 1.65, 95% CI (1.47, 1.85), I² = 89.9%, with evidence of publication bias suggested by a contour funnel plot. A novel regression based method was used to adjust for publication bias and resulted in an adjusted pooled OR of 1.51 (95% CI, 1.26–1.83). In a speculative analysis that assumes that this association is based on causality, and based on published baseline CDI incidence, the risk of CDI would be very low in the general population taking PPIs with an estimated NNH of 3925 at 1 year.

Conclusions

In this rigorously conducted systemic review and meta-analysis, we found very low quality evidence (GRADE class) for an association between PPI use and CDI that does not support a cause-effect relationship.

Proton Pump Inhibitor use in Hospitalized Patients: Is Overutilization Becoming a Problem?

Proton pump inhibitors (PPIs) are among the most common classes of medications prescribed. Though they were previously thought of as safe, recent literature has shown risks associated with their use including increased risk for Clostridium difficile infection, pneumonia, and fractures. Due to these risks, it is important to determine if PPIs are being used appropriately. This review evaluates seven studies in hospitalized patients. Additionally, this review evaluates literature pertaining to recently discovered adverse reactions; all studies found PPIs are being overutilized. Findings highlight the importance of evaluating appropriate therapy with these agents and recommending discontinuation if a proper indication does not exist.

Inappropriate prescribing of proton pump inhibitors in hospitalized patients

BACKGROUND

Proton pump inhibitors have numerous important side effects, yet they are prescribed for outpatients who do not have recognized indications. Less is known with respect to prescribing for inpatients.

OBJECTIVE

To determine the rate of inappropriate prescribing of protein pump inhibitors and to assess reasons why they are prescribed.

DESIGN AND PARTICIPANTS

The study was a retrospective review of administrative data for adult hospital patients discharged from the Medicine service of Denver Health (DH) and from the University HealthSystem Consortium (UHC) between January 1, 2008 and December 31, 2009.

MEASUREMENTS

Valid indications for proton pump inhibitors were sought from discharge diagnoses, prescription records, and, in a randomly selected group of patients from DH, from direct review of records.

RESULTS

Inclusion criteria were met by 9875 DH patients and 6,592,100 UHC patients; of patients receiving a proton pump inhibitor, 61% and 73%, respectively, did not have a valid indication. Increased rates of Clostridium difficile infection were found in both groups of patients receiving proton pump inhibitors. Chart reviews found valid indications for proton pump inhibitors in 19% of patients who did not have a valid indication on the basis of the administrative data, and "prophylaxis" was the justification for inappropriate prescribing in 56%.

CONCLUSION

Proton pump inhibitors are frequently inappropriately prescribed to Medicine inpatients who do not have a valid indication and this practice is associated with an increase in C. difficile infection. Interventions are needed to curtail this inappropriate prescribing practice.

[Proton pump inhibitors: impact of professional practice evaluation on prescriptions pertinence]

OBJECTIVE

To improve the quality of proton pump inhibitors (PPI) prescription in an orthopaedic department.

STUDY DESIGN

Prospective professional practice evaluation study.

PATIENTS AND METHODS

A specific protocol concerning the best practice for using PPI in the perioperative period was established by anaesthesiologists and validated by all prescribers, according to recent recommendations published by French Afssaps. PPI prescription pertinence, mainly using the oral route, was based upon the presence of clearly identified risk factors. PPI mensual consumption and severe gastric complications were analyzed and compared with those obtained from the previous year. Ten months after the beginning of the protocol, the pertinence of PPI prescription was analyzed in 20 randomly selected medical records. Data are expressed in defined daily dose (DDD).

RESULTS

After one year, a 35.5% decrease in oral PPI consumption was noted (901 ± 211 before vs 581 ± 235 DDD, after, P<0.05). A similar trend to a decrease in intravenous PPI consumption was observed (40 ± 23 vs 22 ± 26, P=0.06). During the same period, the overall incidence of severe gastric complication remained stable. The PPI prescription was pertinent in 85% of selected medical records.

CONCLUSION

This study confirmed the interest of professional practice evaluation protocols to improve PPI prescription. A strong implication of all medical staff members is mandatory to maintain such benefits over time.