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Wang Y, Heels-Ansdell D, Ge L, Parpia S, Ibrahim Q, Cook D, Deane A, Lauzier F, Hammond N, Møller MH, Krag M, Perner A, Guyatt GH. Proton pump inhibitors for gastrointestinal bleeding prophylaxis in critically ill patients: A systematic review protocol. Acta Anaesthesiol Scand 2024; 68:983-988. [PMID: 38581102 DOI: 10.1111/aas.14426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/27/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are the most commonly prescribed drugs for preventing upper gastrointestinal bleeding in critically ill patients. However, concerns have arisen about the possible harms of using PPIs, including potentially increased risk of pneumonia, Clostridioides difficile infection, and more seriously, an increased risk of death in the most severely ill patients. Triggered by the REVISE trial, which is a forthcoming large randomized trial comparing pantoprazole to placebo in invasively mechanically ventilated patients, we will conduct this systematic review to evaluate the efficacy and safety of PPIs versus no prophylaxis for critically ill patients. METHODS We will systematically search randomized trials that compared gastrointestinal bleeding prophylaxis with PPIs versus placebo or no prophylaxis in adults in the intensive care unit (ICU). Pairs of reviewers will independently screen the literature, and for those eligible trials, extract data and assess risk of bias. We will perform meta-analyses using a random-effects model, and calculate relative risks for dichotomous outcomes and mean differences for continuous outcomes, and the associated 95% confidence intervals. We will conduct subgroup analysis to explore whether the impact of PPIs on mortality differs in more and less severely ill patients. We will assess certainty of evidence using the GRADE approach. DISCUSSION This systematic review will provide the most up-to-date evidence regarding the merits and limitations of stress ulcer prophylaxis with PPIs in critically ill patients in contemporary practice.
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Affiliation(s)
- Ying Wang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Long Ge
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Sameer Parpia
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Quazi Ibrahim
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Deborah Cook
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Adam Deane
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Francois Lauzier
- Population Health and Optimal Health Practice Research Unit (Trauma-Emergency-Critical Care Medicine) CHU de Québec-Université Laval Research Centre, Québec City, Québec, Canada
- Department of Medicine, Anesthesiology and Critical Care, Université Laval, Québec, Québec, Canada
| | - Naomi Hammond
- Critical Care Program, The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Morten H Møller
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Mette Krag
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen, Denmark
| | - Anders Perner
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Halldórsdóttir AM, Hrafnkelsson B, Einarsdóttir K, Kristinsson KG. Prevalence and risk factors of extended-spectrum beta-lactamase producing E. coli causing urinary tract infections in Iceland during 2012-2021. Eur J Clin Microbiol Infect Dis 2024:10.1007/s10096-024-04882-z. [PMID: 38935227 DOI: 10.1007/s10096-024-04882-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 06/20/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE To investigate the association of potential risk factors for urinary tract infections (UTI) caused by E. coli producing ESBL vs. not producing ESBL in Iceland. METHODS Observational, case-control study including a cohort of 27,747 patients (22,800 females, 4,947 males; 1207 cases, 26,540 controls) of all ages with UTI caused by E. coli in 2012 to 2021 at the clinical microbiology laboratory covering about 2/3 of the Icelandic population. Clinical patient data was obtained from three national databases. Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) as a measure of association between ESBL and exposure variables. RESULTS The proportion of samples with ESBL-producing E. coli increased during the study period, from 2.6% in 2012 to 7.6% in 2021 (p < 0.001). ESBL-positive strains were detected in 1207 individuals (4.4%), 905 females (4.0%) and 302 males (6.1%). The following risk factors were identified: Male sex, higher age, institution type (hospital, nursing home), hospital-associated UTI, Charlson comorbidity index score ≥ 3, history of cystitis or hospitalization in the past year, and prescriptions for certain antibiotics or proton pump inhibitors (PPIs: OR 1.51) in the past half year. The antibiotic associated with the highest risk was ciprofloxacin (OR 2.45). CONCLUSION The prevalence of UTIs caused by ESBL-producing E. coli has been increasing in Iceland. The strongest risk factors for ESBL production were previous antibiotic use, especially ciprofloxacin, and previous PPI use, both considered to be overprescribed. It is important to promote the prudent use of these drugs.
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Affiliation(s)
| | - Birgir Hrafnkelsson
- Department of Mathematics, Faculty of Physical Sciences, University of Iceland, Reykjavík, Iceland
| | - Kristjana Einarsdóttir
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Karl G Kristinsson
- Department of Clinical Microbiology, Landspitali, The National University Hospital of Iceland, Reykjavík, Iceland
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland
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3
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Müskens JLJM, van Dulmen SA, Hek K, Westert GP, Kool RB. Low-value chronic prescription of acid reducing medication among Dutch general practitioners: impact of a patient education intervention. BMC PRIMARY CARE 2024; 25:106. [PMID: 38575887 PMCID: PMC10996147 DOI: 10.1186/s12875-024-02351-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 03/27/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Dyspepsia is a commonly encountered clinical condition in Dutch general practice, which is often treated through the prescription of acid-reducing medication (ARM). However, recent studies indicate that the majority of chronic ARM users lack an indication for their use and that their long-term use is associated with adverse outcomes. We developed a patient-focussed educational intervention aiming to reduce low-value (chronic) use of ARM. METHODS We conducted a randomized controlled study, and evaluated its effect on the low-value chronic prescription of ARM using data from a subset (n = 26) of practices from the Nivel Primary Care Database. The intervention involved distributing an educational waiting room posters and flyers informing both patients and general practitioners (GPs) regarding the appropriate indications for prescription of an ARM for dyspepsia, which also referred to an online decision aid. The interventions' effect was evaluated through calculation of the odds ratio of a patient receiving a low-value chronic ARM prescription over the second half of 2021 and 2022 (i.e. pre-intervention vs. post-intervention). RESULTS In both the control and intervention groups, the proportion of patients receiving chronic low-value ARM prescriptions slightly increased. In the control group, it decreased from 50.3% in 2021 to 49.7% in 2022, and in the intervention group it increased from 51.3% in 2021 to 53.1% in 2022. Subsequent statistical analysis revealed no significant difference in low-value chronic prescriptions between the control and intervention groups (Odds ratio: 1.11 [0.84-1.47], p > 0.05). CONCLUSION Our educational intervention did not result in a change in the low-value chronic prescription of ARM; approximately half of the patients of the intervention and control still received low-value chronic ARM prescriptions. The absence of effect might be explained by selection bias of participating practices, awareness on the topic of chronic AMR prescriptions and the relative low proportion of low-value chronic ARM prescribing in the intervention as well as the control group compared to an assessment conducted two years prior. TRIAL REGISTRATION 10/31/2023 NCT06108817.
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Affiliation(s)
- Joris L J M Müskens
- IQ Health Science Department, Radboud University Medical Center, Research Institute for Medical Innovation, Nijmegen, The Netherlands.
| | - Simone A van Dulmen
- IQ Health Science Department, Radboud University Medical Center, Research Institute for Medical Innovation, Nijmegen, The Netherlands
| | - Karin Hek
- Nivel, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Gert P Westert
- IQ Health Science Department, Radboud University Medical Center, Research Institute for Medical Innovation, Nijmegen, The Netherlands
| | - Rudolf B Kool
- IQ Health Science Department, Radboud University Medical Center, Research Institute for Medical Innovation, Nijmegen, The Netherlands
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4
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Piñerúa-Gonsálvez JF, Zambrano-Infantino RDC, Albornoz-Sandoval JC, Tong-Morao PW, León-Hernández MN, Matheus-Alonso BD, Suárez-López F, Flores Y, Higuera SN, Ruiz-Rebollo ML, Sulbaran M. BEHIND THE PROTON PUMP INHIBITOR PRESCRIPTION: AN INTERNATIONAL SURVEY ON PHYSICIAN PRACTICES AND KNOWLEDGE. ARQUIVOS DE GASTROENTEROLOGIA 2024; 61:e23153. [PMID: 38451672 DOI: 10.1590/s0004-2803.24612023-153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 12/15/2023] [Indexed: 03/08/2024]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are widely prescribed worldwide, often resulting in their overuse. Consequently, it is essential to identify the likely causes of this overuse to facilitate their appropriate prescription. OBJECTIVE This study aims to assess physician prescribing patterns, their knowledge of PPIs, and factors affecting their knowledge. METHODS An online survey was conducted among Latin American and Spanish physicians, collecting the following data: professional information, patterns of PPI usage, familiarity with published evidence, and the management approach in three hypothetical case-scenarios. Participant knowledge was categorized as sufficient or insufficient based on the results of the case scenarios. Subsequently, subgroup analysis was performed based on physician training level, years in practice, specialty, and time since the last PPI literature review. RESULTS A total of 371 physicians participated in the survey. Thirty-eight percent frequently prescribe PPIs, primarily for prophylactic purposes (57.9%). Eighty percent were unfamiliar with PPI deprescribing strategies, and 54.4% rarely reviewed the ongoing indication of patients taking a PPI. Sixty-four percent demonstrated sufficient knowledge in the case-scenarios. A significant association was observed between specialty type (medical vs surgical: 69.4% vs 46.8%, P<0.001), the timing of the PPI indication literature review (<5 years vs >5 years: 71.4% vs 58.7%, P=0.010), and sufficient knowledge. CONCLUSION While most participants prescribed PPIs regularly and for prophylaxis purposes, the majority were unfamiliar with deprescribing strategies and rarely reviewed ongoing indications. Sufficient knowledge is correlated with recent literature reviews and medical specialty affiliation. BACKGROUND • The study aims to evaluate physician prescribing patterns, assess their knowledge of proton pump inhibitors, and identify factors influencing their knowledge. BACKGROUND • An online survey of Latin American and Spanish physicians assessed proton pump inhibitor usage patterns and case-scenario responses, categorizing knowledge, and conducting subgroup analysis based on training, experience, specialty, and literature review timing. BACKGROUND • Thirty-eight percent of surveyed physicians commonly prescribed proton pump inhibitors, and among them, 80% were unfamiliar with deprescribing strategies, with 54.4% rarely reviewing ongoing indications. BACKGROUND • Sufficient knowledge was correlated with recent literature reviews and medical specialty affiliations.
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Affiliation(s)
| | | | | | - Pedro Waykin Tong-Morao
- "Francisco Battistini Casalta" School of Health Sciences, Universidad de Oriente, Ciudad Bolívar, Venezuela
| | | | | | - Frank Suárez-López
- Department of Internal Medicine, Hospital Clinic Universitario de Valladolid, Valladolid, Spain
| | - Yormalis Flores
- Department of Neurology, Hospital Clinic Universitario de Caracas, Caracas, Venezuela
| | | | | | - Mariseli Sulbaran
- Department of Gastroenterology, "Dr. Carlos Arvelo" Military Hospital, Caracas, Venezuela
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5
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Ishnaiwer M, Le Bastard Q, Naour M, Zeman M, Dailly E, Montassier E, Batard E, Dion M. Efficacy of an inulin-based treatment on intestinal colonization by multidrug-resistant E. coli: insight into the mechanism of action. Gut Microbes 2024; 16:2347021. [PMID: 38685762 PMCID: PMC11062366 DOI: 10.1080/19490976.2024.2347021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 04/19/2024] [Indexed: 05/02/2024] Open
Abstract
Inulin, an increasingly studied dietary fiber, alters intestinal microbiota. The aim of this study was to assess whether inulin decreases intestinal colonization by multidrug resistant E. coli and to investigate its potential mechanisms of action. Mice with amoxicillin-induced intestinal dysbiosis mice were inoculated with extended spectrum beta-lactamase producing E. coli (ESBL-E. coli). The combination of inulin and pantoprazole (IP) significantly reduced ESBL-E. coli fecal titers, whereas pantoprazole alone did not and inulin had a delayed and limited effect. Fecal microbiome was assessed using shotgun metagenomic sequencing and qPCR. The efficacy of IP was predicted by increased abundance of 74 taxa, including two species of Adlercreutzia. Preventive treatments with A. caecimuris or A. muris also reduced ESBL-E. coli fecal titers. Fecal microbiota of mice effectively treated by IP was enriched in genes involved in inulin catabolism, production of propionate and expression of beta-lactamases. They also had increased beta-lactamase activity and decreased amoxicillin concentration. These results suggest that IP act through production of propionate and degradation of amoxicillin by the microbiota. The combination of pantoprazole and inulin is a potential treatment of intestinal colonization by multidrug-resistant E. coli. The ability of prebiotics to promote propionate and/or beta-lactamase producing bacteria may be used as a screening tool to identify potential treatments of intestinal colonization by multidrug resistant Enterobacterales.
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Affiliation(s)
- Murad Ishnaiwer
- Nantes Université, CHU Nantes, Cibles et médicaments des infections et du cancer, IICiMed, Nantes, France
- College of Applied Sciences, Palestine Polytechnic University, Hebron, Palestine
| | - Quentin Le Bastard
- Nantes Université, CHU Nantes, Cibles et médicaments des infections et du cancer, IICiMed, Nantes, France
- Emergency Department, CHU Nantes, Nantes, France
| | | | - Michal Zeman
- Veterinary Research Institute, Brno, Czech Republic
| | - Eric Dailly
- Nantes Université, CHU Nantes, Cibles et médicaments des infections et du cancer, IICiMed, Nantes, France
- CHU Nantes, Clinical Pharmacology Department, Nantes, France
| | - Emmanuel Montassier
- Nantes Université, CHU Nantes, Cibles et médicaments des infections et du cancer, IICiMed, Nantes, France
- Emergency Department, CHU Nantes, Nantes, France
- Center for Research in Transplantation and Translational Immunology, Nantes Université, Inserm, CHU Nantes, Nantes, France
| | - Eric Batard
- Nantes Université, CHU Nantes, Cibles et médicaments des infections et du cancer, IICiMed, Nantes, France
- Emergency Department, CHU Nantes, Nantes, France
| | - Michel Dion
- Nantes Université, CHU Nantes, Cibles et médicaments des infections et du cancer, IICiMed, Nantes, France
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Lee I, Jo JW, Woo HJ, Suk KT, Lee SS, Kim BS. Proton pump inhibitors increase the risk of carbapenem-resistant Enterobacteriaceae colonization by facilitating the transfer of antibiotic resistance genes among bacteria in the gut microbiome. Gut Microbes 2024; 16:2341635. [PMID: 38634770 PMCID: PMC11028007 DOI: 10.1080/19490976.2024.2341635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 04/08/2024] [Indexed: 04/19/2024] Open
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE) pose a global health threat; however, there is still limited understanding of the risk factors and underlying mechanisms of CRE colonization in the gut microbiome. We conducted a matched case-control study involving 282 intensive care unit patients to analyze influencing covariates on CRE colonization. Subsequently, their effects on the gut microbiome were analyzed in a subset of 98 patients (47 CRE carriers and 51 non-CRE carriers) using whole metagenome sequences. The concomitant use of proton pump inhibitors (PPIs) and antibiotics was a significant risk factor for CRE colonization. The gut microbiome differed according to PPI administration, even within the CRE and non-CRE groups. Moreover, the transfer of mobile genetic elements (MGEs) harboring carbapenem resistance genes (CRGs) between bacteria was higher in the PPI-treated group than in the PPI-not-treated group among CRE carriers. The concomitant use of PPIs and antibiotics significantly alters the gut microbiome and increases the risk of CRE colonization by facilitating the transfer of CRGs among bacteria of the gut microbiome. Based on these findings, improved stewardship of PPIs as well as antibiotics can provide strategies to reduce the risk of CRE colonization, thereby potentially improving patient prognosis.
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Affiliation(s)
- Imchang Lee
- Department of Life Science, Multidisciplinary Genome Institute, Hallym University, Chuncheon, Republic of Korea
- The Korean Institute of Nutrition, Hallym University, Chuncheon, Republic of Korea
| | - Jae-Won Jo
- Department of Life Science, Multidisciplinary Genome Institute, Hallym University, Chuncheon, Republic of Korea
- The Korean Institute of Nutrition, Hallym University, Chuncheon, Republic of Korea
| | - Heung-Jeong Woo
- Division of Infectious Diseases, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Ki Tae Suk
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, Republic of Korea
| | - Seung Soon Lee
- Division of Infectious Diseases, Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Bong-Soo Kim
- Department of Life Science, Multidisciplinary Genome Institute, Hallym University, Chuncheon, Republic of Korea
- The Korean Institute of Nutrition, Hallym University, Chuncheon, Republic of Korea
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7
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Smit CCH, Lambert M, Rogers K, Djordjevic SP, Van Oijen AM, Keighley C, Taxis K, Robertson H, Pont LG. One Health Determinants of Escherichia coli Antimicrobial Resistance in Humans in the Community: An Umbrella Review. Int J Mol Sci 2023; 24:17204. [PMID: 38139033 PMCID: PMC10743193 DOI: 10.3390/ijms242417204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 11/29/2023] [Accepted: 12/01/2023] [Indexed: 12/24/2023] Open
Abstract
To date, the scientific literature on health variables for Escherichia coli antimicrobial resistance (AMR) has been investigated throughout several systematic reviews, often with a focus on only one aspect of the One Health variables: human, animal, or environment. The aim of this umbrella review is to conduct a systematic synthesis of existing evidence on Escherichia coli AMR in humans in the community from a One Health perspective. PubMed, EMBASE, and CINAHL were searched on "antibiotic resistance" and "systematic review" from inception until 25 March 2022 (PROSPERO: CRD42022316431). The methodological quality was assessed, and the importance of identified variables was tabulated across all included reviews. Twenty-three reviews were included in this study, covering 860 primary studies. All reviews were of (critically) low quality. Most reviews focused on humans (20), 3 on animals, and 1 on both human and environmental variables. Antibiotic use, urinary tract infections, diabetes, and international travel were identified as the most important human variables. Poultry farms and swimming in freshwater were identified as potential sources for AMR transmission from the animal and environmental perspectives. This umbrella review highlights a gap in high-quality literature investigating the time between variable exposure, AMR testing, and animal and environmental AMR variables.
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Affiliation(s)
- Chloé C. H. Smit
- Graduate School of Health, University of Technology Sydney, Sydney, NSW 2008, Australia; (C.C.H.S.); (K.R.)
| | - Maarten Lambert
- Department of PharmacoTherapy, -Epidemiology and -Economics, Faculty of Science and Engineering, University of Groningen, 9713 AV Groningen, The Netherlands; (M.L.); (K.T.)
| | - Kris Rogers
- Graduate School of Health, University of Technology Sydney, Sydney, NSW 2008, Australia; (C.C.H.S.); (K.R.)
| | - Steven P. Djordjevic
- The Australian Institute for Microbiology & Infection, University of Technology Sydney, Sydney, NSW 2007, Australia;
| | - Antoine M. Van Oijen
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2050, Australia;
| | - Caitlin Keighley
- Southern.IML Pathology, Sonic Healthcare, 3 Bridge St, Wollongong, NSW 2500, Australia
- Graduate School of Medicine, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Katja Taxis
- Department of PharmacoTherapy, -Epidemiology and -Economics, Faculty of Science and Engineering, University of Groningen, 9713 AV Groningen, The Netherlands; (M.L.); (K.T.)
| | - Hamish Robertson
- School of Public Health & Social Work, Queensland University of Technology, Brisbane, QLD 4059, Australia;
| | - Lisa G. Pont
- Graduate School of Health, University of Technology Sydney, Sydney, NSW 2008, Australia; (C.C.H.S.); (K.R.)
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8
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Zhou F, Zhang GD, Tan Y, Hu SA, Tang Q, Pei G. NOD-like receptors mediate homeostatic intestinal epithelial barrier function: promising therapeutic targets for inflammatory bowel disease. Therap Adv Gastroenterol 2023; 16:17562848231176889. [PMID: 37701792 PMCID: PMC10493068 DOI: 10.1177/17562848231176889] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 05/01/2023] [Indexed: 09/14/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic gastrointestinal inflammatory disease that involves host genetics, the microbiome, and inflammatory responses. The current consensus is that the disruption of the intestinal mucosal barrier is the core pathogenesis of IBD, including intestinal microbial factors, abnormal immune responses, and impaired intestinal mucosal barrier. Cumulative data show that nucleotide-binding and oligomerization domain (NOD)-like receptors (NLRs) are dominant mediators in maintaining the homeostasis of the intestinal mucosal barrier, which play critical roles in sensing the commensal microbiota, maintaining homeostasis, and regulating intestinal inflammation. Blocking NLRs inflammasome activation by botanicals may be a promising way to prevent IBD progression. In this review, we systematically introduce the multiple roles of NLRs in regulating intestinal mucosal barrier homeostasis and focus on summarizing the activities and potential mechanisms of natural products against IBD. Aiming to propose new directions on the pathogenesis and precise treatment of IBD.
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Affiliation(s)
- Feng Zhou
- School of Pharmacy, Hunan University of Chinese Medicine, Changsha, China
- Key Laboratory of Modern Research of TCM, Education Department of Hunan Province, Changsha, China
| | | | - Yang Tan
- School of Pharmacy, Hunan University of Chinese Medicine, Changsha, China
- Science and Technology Innovation Center/State Key Laboratory Breeding Base of Chinese Medicine Powder and Innovative Medicine, Hunan University of Chinese Medicine, Changsha, China
| | - Shi An Hu
- School of Pharmacy, Hunan University of Chinese Medicine, Changsha, China
- Hunan Provincial Key Laboratory of TCM Prevention and Treatment of Depression Diseases, Changsha, China
| | - Qun Tang
- School of Pharmacy, Hunan University of Chinese Medicine, Changsha 410208, China
- Medical School, Hunan University of Chinese Medicine, Changsha, China
| | - Gang Pei
- School of Pharmacy, Hunan University of Chinese Medicine, Changsha 410208, China
- Key Laboratory of Modern Research of TCM, Education Department of Hunan Province, Changsha, China
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9
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Raffelsberger N, Buczek DJ, Svendsen K, Småbrekke L, Pöntinen AK, Löhr IH, Andreassen LLE, Simonsen GS, Sundsfjord A, Gravningen K, Samuelsen Ø. Community carriage of ESBL-producing Escherichia coli and Klebsiella pneumoniae: a cross-sectional study of risk factors and comparative genomics of carriage and clinical isolates. mSphere 2023; 8:e0002523. [PMID: 37306968 PMCID: PMC10470604 DOI: 10.1128/msphere.00025-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/05/2023] [Indexed: 06/13/2023] Open
Abstract
The global prevalence of infections caused by extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E) is increasing, and for Escherichia coli, observations indicate that this is partly driven by community-onset cases. The ESBL-E population structure in the community is scarcely described, and data on risk factors for carriage are conflicting. Here, we report the prevalence and population structure of fecal ESBL-producing E. coli and Klebsiella pneumoniae (ESBL-Ec/Kp) in a general adult population, examine risk factors, and compare carriage isolates with contemporary clinical isolates. Fecal samples obtained from 4,999 participants (54% women) ≥40 years in the seventh survey of the population-based Tromsø Study, Norway (2015, 2016), were screened for ESBL-Ec/Kp. In addition, we included 118 ESBL-Ec clinical isolates from the Norwegian surveillance program in 2014. All isolates were whole-genome sequenced. Risk factors associated with carriage were analyzed using multivariable logistic regression. ESBL-Ec gastrointestinal carriage prevalence was 3.3% [95% confidence interval (CI) 2.8%-3.9%, no sex difference] and 0.08% (0.02%-0.20%) for ESBL-Kp. For ESBL-Ec, travel to Asia was the only independent risk factor (adjusted odds ratio 3.46, 95% CI 2.18-5.49). E. coli ST131 was most prevalent in both collections. However, the ST131 proportion was significantly lower in carriage (24%) versus clinical isolates (58%, P < 0.001). Carriage isolates were genetically more diverse with a higher proportion of phylogroup A (26%) than clinical isolates (5%, P < 0.001), indicating that ESBL gene acquisition occurs in a variety of E. coli lineages colonizing the gut. STs commonly related to extraintestinal infections were more frequent in clinical isolates also carrying a higher prevalence of antimicrobial resistance, which could indicate clone-associated pathogenicity.IMPORTANCEESBL-Ec and ESBL-Kp are major pathogens in the global burden of antimicrobial resistance. However, there is a gap in knowledge concerning the bacterial population structure of human ESBL-Ec/Kp carriage isolates in the community. We have examined ESBL-Ec/Kp isolates from a population-based study and compared these to contemporary clinical isolates. The large genetic diversity of carriage isolates indicates frequent ESBL gene acquisition, while those causing invasive infections are more clone dependent and associated with a higher prevalence of antibiotic resistance. The knowledge of factors associated with ESBL carriage helps to identify patients at risk to combat the spread of resistant bacteria within the healthcare system. Particularly, previous travel to Asia stands out as a major risk factor for carriage and should be considered in selecting empirical antibiotic treatment in critically ill patients.
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Affiliation(s)
- Niclas Raffelsberger
- Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
- Department of Medical Biology, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Dorota Julia Buczek
- Department of Medical Biology, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Kristian Svendsen
- Department of Pharmacy, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Lars Småbrekke
- Department of Pharmacy, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Anna Kaarina Pöntinen
- Norwegian National Advisory Unit on Detection of Antimicrobial Resistance, Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
- Department of Biostatistics, University of Oslo, Oslo, Norway
| | - Iren H. Löhr
- Department of Medical Microbiology, Stavanger University Hospital, Stavanger, Norway
| | | | - Gunnar Skov Simonsen
- Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
- Department of Medical Biology, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Norwegian E. coli ESBL Study Group
- Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
- Department of Medical Biology, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
- Department of Pharmacy, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
- Norwegian National Advisory Unit on Detection of Antimicrobial Resistance, Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
- Department of Biostatistics, University of Oslo, Oslo, Norway
- Department of Medical Microbiology, Stavanger University Hospital, Stavanger, Norway
- Department of Microbiology and Infection Control, Akershus University Hospital, Nordbyhagen, Norway
- Division of Medicine and Laboratory Sciences, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Arnfinn Sundsfjord
- Department of Medical Biology, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
- Norwegian National Advisory Unit on Detection of Antimicrobial Resistance, Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
| | - Kirsten Gravningen
- Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
- Department of Microbiology and Infection Control, Akershus University Hospital, Nordbyhagen, Norway
- Division of Medicine and Laboratory Sciences, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ørjan Samuelsen
- Department of Pharmacy, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
- Norwegian National Advisory Unit on Detection of Antimicrobial Resistance, Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
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10
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Tian L, Huang C, Fu W, Gao L, Mi N, Bai M, Ma H, Zhang C, Lu Y, Zhao J, Zhang X, Jiang N, Lin Y, Yue P, Yuan J, Meng W. Proton pump inhibitors may enhance the risk of digestive diseases by regulating intestinal microbiota. Front Pharmacol 2023; 14:1217306. [PMID: 37529701 PMCID: PMC10387554 DOI: 10.3389/fphar.2023.1217306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/06/2023] [Indexed: 08/03/2023] Open
Abstract
Proton pump inhibitors (PPIs) are the most used acid-inhibitory drugs, with a wide range of applications in the treatment of various digestive diseases. However, recently, there has been a growing number of digestive complications linked to PPIs, and several studies have indicated that the intestinal flora play an important role in these complications. Therefore, developing a greater understanding of the role of the gut microbiota in PPI-related digestive diseases is essential. Here, we summarize the current research on the correlation between PPI-related digestive disorders and intestinal flora and establish the altered strains and possible pathogenic mechanisms of the different diseases. We aimed to provide a theoretical basis and reference for the future treatment and prevention of PPI-related digestive complications based on the regulation of the intestinal microbiota.
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Affiliation(s)
- Liang Tian
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Chongfei Huang
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Wenkang Fu
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Long Gao
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Ningning Mi
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Mingzhen Bai
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Haidong Ma
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Chao Zhang
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Yawen Lu
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Jinyu Zhao
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Xianzhuo Zhang
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Ningzu Jiang
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Yanyan Lin
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Ping Yue
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Jinqiu Yuan
- Clinical Research Center, Scientific Research Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Wenbo Meng
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
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11
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Nguyen PVQ, Boidin C, Bouin M. Effectiveness of prescribing codes in reducing inappropriate proton pump inhibitors in ambulatory care. J Am Pharm Assoc (2003) 2023; 63:1197-1202. [PMID: 37164262 DOI: 10.1016/j.japh.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 02/12/2023] [Accepted: 05/04/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Health care deciders are aware of the inappropriate use of proton pump inhibitors (PPIs). To reduce inappropriate prescriptions, the Conseil du Médicament (CdM) issued a practice guideline and the Régie de l'Assurance Maladie du Quebec (RAMQ) asked prescribers to justify its use by writing a specific indication code for their patients to obtain drug coverage. OBJECTIVES This study aimed to evaluate the effectiveness of the intervention by the RAMQ to reduce inappropriate PPI prescription. METHODS A cross-sectional quasi-experimental prospective study was performed in an emergency department. Patients aged 18 years or older were included in 2016 to 2017 and 2019 to 2021 in the pre- and postintervention group, respectively. The proportion of patients on PPI without an appropriate indication were identified from patient interviews and chart review. RESULTS A total of 871 and 1475 patients were recruited in the pre- and postintervention groups. According to the CdM guideline, the proportion of inappropriate PPI prescription was 30.7% (n = 267) in the preintervention group and 49.1% (n = 724) in the postintervention group (P < 0.001). According to the RAMQ criteria, the proportion of inappropriate PPI prescription was of 76.1% (n = 663) and 81.4% (n = 1200) in the pre- and postintervention group, respectively (P < 0.001). CONCLUSION This study highlights the ineffectiveness of the codes for PPI prescriptions in reducing inappropriate prescriptions. It seems that the obligation to write a code does not lead to a reassessment of PPI indication.
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12
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Elbaz M, Stein E, Raykhshtat E, Weiss-Meilik A, Cohen R, Ben-Ami R. Exposure to Non-Antimicrobial Drugs and Risk of Infection with Antibiotic-Resistant Enterobacteriaceae. Antibiotics (Basel) 2023; 12:antibiotics12040789. [PMID: 37107151 PMCID: PMC10135367 DOI: 10.3390/antibiotics12040789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/11/2023] [Accepted: 04/15/2023] [Indexed: 04/29/2023] Open
Abstract
Antimicrobial resistance (AMR) has consistently been linked to antibiotic use. However, the roles of commonly prescribed non-antimicrobial drugs as drivers of AMR may be under-appreciated. Here, we studied a cohort of patients with community-acquired pyelonephritis and assessed the association of exposure to non-antimicrobial drugs at the time of hospital admission with infection with drug-resistant organisms (DRO). Associations identified on bivariate analyses were tested using a treatment effects estimator that models both outcome and treatment probability. Exposure to proton-pump inhibitors, beta-blockers, and antimetabolites was significantly associated with multiple resistance phenotypes. Clopidogrel, selective serotonin reuptake inhibitors, and anti-Xa agents were associated with single-drug resistance phenotypes. Antibiotic exposure and indwelling urinary catheters were covariates associated with AMR. Exposure to non-antimicrobial drugs significantly increased the probability of AMR in patients with no other risk factors for resistance. Non-antimicrobial drugs may affect the risk of infection with DRO through multiple mechanisms. If corroborated using additional datasets, these findings offer novel directions for predicting and mitigating AMR.
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Affiliation(s)
- Meital Elbaz
- Department of Infectious Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Esther Stein
- I-Medata AI Center, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Eli Raykhshtat
- I-Medata AI Center, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Ahuva Weiss-Meilik
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- I-Medata AI Center, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Regev Cohen
- Hillel Yaffe Medical Center, Hadera 3820302, Israel
- Rappaport Faculty of Medicine, Technion, Haifa 3200003, Israel
| | - Ronen Ben-Ami
- Department of Infectious Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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13
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Piovani D, Tsantes AG, Schünemann HJ, Bonovas S. Meta-analysis: Use of proton pump inhibitors and risk of gastric cancer in patients requiring gastric acid suppression. Aliment Pharmacol Ther 2023; 57:653-665. [PMID: 36585832 DOI: 10.1111/apt.17360] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/22/2022] [Accepted: 12/06/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Proton-pump inhibitors (PPIs) are suspected to increase the risk of gastric cancer. AIM To assess the risk of gastric cancer associated with the use of PPIs. METHODS We systematically searched Medline/PubMed, Embase and Scopus databases (until June 1, 2022) for randomised and non-randomised studies (NRS) of the association between PPIs and gastric cancer having considered Histamine-2 receptor antagonists (H2RAs) users as controls. We chose this comparison to minimise confounding by indication, and focus on patients requiring gastric acid suppression. Two authors independently extracted study data and assessed each study's risk of bias. Maximally-adjusted relative risk (RR) estimates were extracted. Heterogeneity and small-study effect were examined, and summary estimates were calculated using random- and fixed-effect models. Stratified analyses and meta-regression were employed to explore heterogeneity. We used GRADE to evaluate the certainty of evidence. RESULTS Of 8375 records, 12 NRS (>6 million patients; 11,554 gastric cancers) and two randomised clinical trials (498 patients; 1 gastric cancer) fulfilled the eligibility criteria. Randomised evidence was very imprecise and provided very-low certainty evidence. Meta-analysis of six NRS providing a comprehensive adjustment for confounding (2.5 million patients; 7372 gastric cancers) did not show any association between PPIs and gastric cancer (RRrandom = 1.07, 0.97-1.19; RRfixed = 1.05, 0.98-1.12). The certainty of the evidence was low. No convincing evidence of dose-response, or increased risk with long-term use, was found. Lack of or minimal adjustment for confounding was associated with larger effect sizes. CONCLUSIONS We found no association between PPIs and gastric cancer in NRS having adequately controlled for confounding. Published studies may suffer residual confounding. SYSTEMATIC REVIEW REGISTRATION CRD42022335971.
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Affiliation(s)
- Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IRCCS Humanitas Research Hospital, Milan, Italy
| | - Andreas G Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attiko" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Microbiology Department, "Saint Savvas" Oncology Hospital, Athens, Greece
| | - Holger J Schünemann
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Michael G DeGroote Cochrane Canada and McMaster GRADE Centres, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IRCCS Humanitas Research Hospital, Milan, Italy
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14
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Li YT, Yuan WZ, Jin WL. Vagus innervation in the gastrointestinal tumor: Current understanding and challenges. Biochim Biophys Acta Rev Cancer 2023; 1878:188884. [PMID: 36990250 DOI: 10.1016/j.bbcan.2023.188884] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 02/17/2023] [Accepted: 02/28/2023] [Indexed: 03/30/2023]
Abstract
The vagus nerve (VN) is the main parasympathetic nerve of the autonomic nervous system. It is widely distributed in the gastrointestinal tract and maintains gastrointestinal homeostasis with the sympathetic nerve under physiological conditions. The VN communicates with various components of the tumor microenvironment to positively and dynamically affect the progression of gastrointestinal tumors (GITs). The intervention in vagus innervation delays GIT progression. Developments in adeno-associated virus vectors, nanotechnology, and in vivo neurobiological techniques have enabled the creation of precisely regulated "tumor neurotherapies". Furthermore, the combination of neurobiological techniques and single cell sequencing may reveal more insights into VN and GIT. The present review aimed to summarize the mechanisms of communication between the VN and the gastrointestinal TME and to explore the potential and challenges of VN-based tumor neurotherapy in GITs.
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15
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Willems RPJ, Schut MC, Kaiser AM, Groot TH, Abu-Hanna A, Twisk JWR, van Dijk K, Vandenbroucke-Grauls CMJE. Association of Proton Pump Inhibitor Use With Risk of Acquiring Drug-Resistant Enterobacterales. JAMA Netw Open 2023; 6:e230470. [PMID: 36821114 PMCID: PMC9951039 DOI: 10.1001/jamanetworkopen.2023.0470] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
IMPORTANCE Proton-pump inhibitors (PPIs) have been associated with the risk of colonization with drug-resistant bacteria; however, possible confounding by lifestyle-associated factors and disease severity casts doubt on this association, and whether the risk is dose dependent is not known. OBJECTIVES To assess the association between PPI use and the risk of acquiring drug-resistant Enterobacterales and to examine interactions with possible microbiome-altering agents. DESIGN, SETTING, AND PARTICIPANTS This nested case-control study involved 2239 hospitalized adult (aged ≥18 years) patients identified from the microbiology laboratory database of Amsterdam University Medical Centers between December 31, 2018, and January 6, 2021. Patients in the case group had newly detected extended-spectrum β-lactamase (ESBL)- or carbapenemase-producing Enterobacterales (identified by clinical specimens). Risk-set sampling was used to assign patients with negative results for ESBL- and carbapenemase-producing Enterobacterales to the control group, who were then matched on a 5:1 ratio with patients in the case group by age and culture date. A second validation case-control study included matched pairs (1:1 ratio; 94 in each group) of patients who were prospectively enrolled. EXPOSURES Proton pump inhibitor use and clinical data at 30 days (primary exposure) and 90 days (secondary exposure) before the date of culture. MAIN OUTCOMES AND MEASURES Adjusted incidence rate ratios (aIRRs) of ESBL- or carbapenemase-producing Enterobacterales acquisition by PPI dose and time risk windows (30 days for the primary outcome and 90 days for the secondary outcome) were estimated using conditional logistic regression models. RESULTS Among 2239 hospitalized patients (51.1% male; mean [SD] age, 60.9 [16.7] years), 374 were in the case group (51.6% male; mean [SD] age, 61.1 [16.5] years) and 1865 were in the matched control group (51.0% male; mean [SD] age, 60.9 [16.7] years). The aIRR for PPI use overall was 1.48 (95% CI, 1.15-1.91) at 30 days. Sensitivity analyses and the analysis of the pair-matched study with prospectively enrolled patients (aIRR, 2.96, 95% CI, 1.14-7.74) yielded similar results; findings were consistent in subgroups and corroborated by a negative-control exposure analysis. No association with microbiome-disturbing agents was found; laxatives and antibiotics were independently associated with a more than 2-fold increase in the risk of acquisition (antibiotics: aIRR, 2.78 [95% CI, 2.14-3.59]; laxatives: aIRR, 2.26 [95% CI. 1.73-2.94]). CONCLUSIONS AND RELEVANCE In this study, after careful control for confounding and sensitivity analyses, PPI use was associated with increases in the risk of acquiring ESBL- or carbapenemase-producing Enterobacterales among adult hospitalized patients. These findings emphasize the need for judicious use of PPIs.
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Affiliation(s)
- Roel P. J. Willems
- Department of Medical Microbiology and Infection Prevention, Amsterdam Infection and Immunity Institute, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Martijn C. Schut
- Department of Medical Informatics, Amsterdam Public Health, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Anna M. Kaiser
- Department of Medical Microbiology and Infection Prevention, Amsterdam University Medical Centers, Vrije University Amsterdam, Amsterdam, the Netherlands
| | - Thomas H. Groot
- Department of Medical Microbiology and Infection Prevention, Amsterdam University Medical Centers, Vrije University Amsterdam, Amsterdam, the Netherlands
| | - Ameen Abu-Hanna
- Department of Medical Informatics, Amsterdam Public Health, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Jos W. R. Twisk
- Department of Clinical Epidemiology and Data Science, Amsterdam Public Health, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Karin van Dijk
- Department of Medical Microbiology and Infection Prevention, Amsterdam Infection and Immunity Institute, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Christina M. J. E. Vandenbroucke-Grauls
- Department of Medical Microbiology and Infection Prevention, Amsterdam Infection and Immunity Institute, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
- Department of Clinical Medicine and Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
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16
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Chen X, Wen X, Jiang Z, Yan Q. Prevalence and factors associated with carbapenem-resistant Enterobacterales (CRE) infection among hematological malignancies patients with CRE intestinal colonization. Ann Clin Microbiol Antimicrob 2023; 22:3. [PMID: 36627626 PMCID: PMC9832636 DOI: 10.1186/s12941-023-00554-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/03/2023] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Knowledge about the prevalence, factors and mortality associated with subsequent carbapenem-resistant Enterobacterales (CRE) infection among hematological malignancies (HM) patients colonized with CRE is limited. METHODS HM patients were screened for rectal CRE. A retrospective case-control study of subsequent CRE infection among HM patients colonized with CRE was conducted between January 1st, 2020 and January 31st, 2022. Cases were defined as CRE colonized patients with subsequent infection and controls were those without infection. Bacterial identification was performed using MALDI Biotyper and antimicrobial susceptibility testing of strains was carried out using the VITEK 2 system or standard broth microdilution method. Logistic analysis was used for analyzing associated factors and Kaplan-Meier method was used for survival estimates. RESULTS A total of 953 HM patients were screened for rectal CRE and 98 (10.3%, 98/953) patients were colonized with CRE. Among the 98 colonized patients, 18 (18.4%, 18/98) patients developed subsequent infection. Most of the colonizing CRE isolates were Klebsiella pneumoniae (50.0%, 27/54), followed by Escherichia coli (27.8%, 15/54) and Enterobacter cloacae (9.3%, 5/54). As for the subsequent infecting CRE isolates, the dominated species was K. pneumoniae (55.6%, 10/18), followed by E. coli (33.3%, 6/18) and others (11.2%, 2/18). Receiving proton pump inhibitors and admission to ICU (P < 0.05) were the associated factors. Patients with subsequent CRE infection had significant higher mortality (33.3% vs 2.8%, P = 0.001) and shock was an associated factor (P = 0.008). CONCLUSIONS Klebsiella pneumoniae was the dominate colonizing species and subsequent infecting species among HM patients with CRE colonization. Receiving proton pump inhibitors and admission to ICU increased the risk of subsequent CRE infection among CRE colonized HM patients. Implementing strict infection control measures targeting those high- risk patients may prevent subsequent CRE infection.
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Affiliation(s)
- Xia Chen
- grid.452223.00000 0004 1757 7615Department of Clinical Laboratory, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008 Hunan China
| | - Ximao Wen
- grid.452223.00000 0004 1757 7615Infection Control Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008 Hunan China
| | - Zhiping Jiang
- grid.452223.00000 0004 1757 7615Department of Hematolology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008 Hunan China
| | - Qun Yan
- grid.452223.00000 0004 1757 7615Department of Clinical Laboratory, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008 Hunan China ,grid.452223.00000 0004 1757 7615National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008 Hunan China
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17
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Jafri F, Taylor ZL, Gonzalez D, Shakhnovich V. Effects of obesity on the pharmacology of proton pump inhibitors: current understanding and future implications for patient care and research. Expert Opin Drug Metab Toxicol 2023; 19:1-11. [PMID: 36800927 PMCID: PMC10065909 DOI: 10.1080/17425255.2023.2178897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/07/2023] [Indexed: 02/20/2023]
Abstract
INTRODUCTION In the United States, obesity affects approximately ⅖ adults and ⅕ children, leading to increased risk for comorbidities, like gastroesophageal reflux disease (GERD), treated increasingly with proton pump inhibitors (PPIs). Currently, there are no clinical guidelines to inform PPI dose selection for obesity, with sparse data regarding whether dose augmentation is necessary. AREAS COVERED We provide a review of available literature regarding the pharmacokinetics (PK), pharmacodynamics (PD), and/or metabolism of PPIs in children and adults with obesity, as a step toward informing PPI dose selection. EXPERT OPINION Published PK data in adults and children are limited to first-generation PPIs and point toward reduced apparent oral drug clearance in obesity, with equipoise regarding obesity impact on drug absorption. Available PD data are sparse, conflicting, and limited to adults. No studies are available to inform the PPI PK→PD relationship in obesity and if/how it differs compared to individuals without obesity. In the absence of data, best practice may be to dose PPIs based on CYP2C19 genotype and lean body weight, so as to avoid systemic overexposure and potential toxicities, while monitoring closely for efficacy.
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Affiliation(s)
- Farwa Jafri
- College of Osteopathic Medicine, Kansas City University, Kansas City, MO
| | - Zachary L. Taylor
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Valentina Shakhnovich
- University of Missouri-Kansas City School of Medicine, Kansas City, MO
- Children’s Mercy Kansas City, Kansas City, MO
- Center for Children’s Healthy Lifestyles and Nutrition, Kansas City, MO
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18
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Buti S, Tommasi C, Scartabellati G, De Giorgi U, Brighi N, Rebuzzi SE, Puglisi S, Caffo O, Kinspergher S, Mennitto A, Cattrini C, Santoni M, Verzoni E, Rametta A, Stellato M, Malgeri A, Roviello G, de Filippo M, Cortellini A, Bersanelli M. The impact of proton-pump inhibitors administered with tyrosine kinase inhibitors in patients with metastatic renal cell carcinoma. Anticancer Drugs 2023; 34:178-186. [PMID: 36539370 PMCID: PMC9760470 DOI: 10.1097/cad.0000000000001356] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 12/24/2022]
Abstract
Tyrosine kinase inhibitors (TKIs) are the backbone of the systemic treatment for patients with metastatic renal cell carcinoma (mRCC). TKIs such as pazopanib and cabozantinib can interact with other drugs concomitantly administered, particularly with proton-pump inhibitors (PPIs), possibly impacting the effectiveness of the anticancer treatment and patients outcome. Few data are available about this interaction. We conducted a multicenter retrospective observational data collection of patients with mRCC treated with pazopanib or cabozantinib between January 2012 and December 2020 in nine Italian centers. Univariate and multivariate analyses were performed. The aim was to describe the impact of baseline concomitant PPIs on the outcome of patients to pazopanib and cabozantinib in terms of response, progression-free survival (PFS) and overall survival (OS), toxicity, and treatment compliance. The use of PPI in our study population (301 patients) significantly influenced the effectiveness of TKIs with worse PFS (16.3 vs. 9.9 months; P < 0.001) and OS (30.6 vs. 18.4 months; P = 0.013) in patients taking PPI at TKI initiation. This detrimental effect was maintained both in the pazopanib and cabozantinib groups. The use of PPI influenced the toxicity and TKI treatment compliance with a reduction of dose or schedule modifications, and treatment interruptions in the population taking PPIs. Our study demonstrates that the use of PPIs can significantly influence the outcome and compliance of patients with mRCC to TKI treatment, suggesting the importance of a more careful selection of patients who need a gastroprotective therapy, avoiding indiscriminate use of PPIs.
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Affiliation(s)
- Sebastiano Buti
- Medical Oncology Unit, University Hospital of Parma
- Department of Medicine and Surgery, University of Parma
- Gruppo Oncologico Italiano di Ricerca Clinica (GOIRC), Parma
| | - Chiara Tommasi
- Medical Oncology Unit, University Hospital of Parma
- Department of Medicine and Surgery, University of Parma
- Gruppo Oncologico Italiano di Ricerca Clinica (GOIRC), Parma
| | | | - Ugo De Giorgi
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola
| | - Nicole Brighi
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola
| | - Sara Elena Rebuzzi
- Medical Oncology Unit, Ospedale San Paolo, Savona
- Department of Internal Medicine and Medical Specialties (Di.M.I.), University of Genova
| | - Silvia Puglisi
- Medical Oncology Unit 1, IRCCS Ospedale Policlinico San Martino, Genova
| | - Orazio Caffo
- Department of Medical Oncology, Santa Chiara Hospital, Trento
| | | | - Alessia Mennitto
- Division of Oncology, University Hospital ‘Maggiore della Carità’, Novara
| | - Carlo Cattrini
- Division of Oncology, University Hospital ‘Maggiore della Carità’, Novara
| | - Matteo Santoni
- Department of Medical Oncology, University of Marche, University Hospital Ospedali Riuniti, Ancona
| | - Elena Verzoni
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan
| | - Alessandro Rametta
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan
| | - Marco Stellato
- Department of Medical Oncology, Università Campus Bio-Medico di Roma, Rome
| | - Andrea Malgeri
- Department of Medical Oncology, Università Campus Bio-Medico di Roma, Rome
| | | | - Massimo de Filippo
- Department of Medicine and Surgery, University of Parma
- Radiology Unit, University Hospital of Parma, Parma, Italy
| | | | - Melissa Bersanelli
- Medical Oncology Unit, University Hospital of Parma
- Department of Medicine and Surgery, University of Parma
- Gruppo Oncologico Italiano di Ricerca Clinica (GOIRC), Parma
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Lata T, Trautman J, Townend P, Wilson RB. Current management of gastro-oesophageal reflux disease-treatment costs, safety profile, and effectiveness: a narrative review. Gastroenterol Rep (Oxf) 2023; 11:goad008. [PMID: 37082451 PMCID: PMC10112961 DOI: 10.1093/gastro/goad008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 12/09/2022] [Accepted: 02/01/2023] [Indexed: 04/22/2023] Open
Abstract
Background The purpose of this study was to review the current management of gastro-oesophageal reflux disease (GORD), including treatment costs, safety profile and effectiveness. Methods A literature review was performed of randomized-controlled trials, systematic reviews, Cochrane reports and National/Societal guidelines of the medical, endoscopic and surgical management of GORD. Proton pump inhibitor (PPI) prescribing patterns and expenditure were reviewed in different countries, including Australia, Canada, New Zealand, UK and USA. Results Proton pump inhibitors (PPIs) are primarily indicated for control of GORD, Helicobacter pylori eradication (combined with antibiotics), preventing NSAID-induced gastrointestinal bleeding and treating peptic ulcer disease. There is widespread overprescribing of PPIs in Western and Eastern nations in terms of indication and duration, with substantial expense for national health providers. Despite a favourable short-term safety profile, there are observational associations of adverse effects with long-term PPIs. These include nutrient malabsorption, enteric infections and cardiovascular events. The prevalence of PPI use makes their long-term safety profile clinically relevant. Cost-benefit, symptom control and quality-of-life outcomes favour laparoscopic fundoplication rather than chronic PPI treatment. Laparoscopic fundoplication in long-term management of PPI-responsive GORD is supported by SAGES, NICE and ACG, and PPI-refractory GORD by AGA and SAGES guidelines. The importance of establishing a definitive diagnosis prior to invasive management is emphasized, especially in PPI-refractory heartburn. Conclusions We examined evidence-based guidelines for PPI prescribing and deprescribing in primary care and hospital settings and the need for PPI stewardship and education of health professionals. This narrative review presents the advantages and disadvantages of surgical, endoscopic and medical management of GORD, which may assist in shared decision making and treatment choice in individual patients.This paper was presented (GS020) at the 88th RACS Annual Scientific Conference, 6-10 May, 2019.
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Affiliation(s)
- Tahmina Lata
- Corresponding author. Faculty of Medicine and Health, University of Sydney, City Road, Camperdown, NSW 2006, Australia. Tel: +0061-2-93512222.
| | - Jodie Trautman
- General Surgery Department, Wollongong Hospital, Wollongong, NSW, Australia
| | - Philip Townend
- General Surgery Department, Gold Coast University Hospital, Southport, QLD, Australia
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20
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Bosserman RE, Kwon JH. Know your Microbe Foes: The Role of Surveillance in Combatting Antimicrobial Resistance. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2022; 95:517-523. [PMID: 36568832 PMCID: PMC9765335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Antibiotic-resistant organisms (AROs) are difficult and costly to treat, associated with high mortality rates, and are on the rise. In the United States, there is limited tracking of AROs, which can contribute to transmission and inhibit infection prevention interventions. Surveillance is limited by a lack of standardized methods for colonization screening and limited communication regarding patient ARO-status between healthcare settings. Some regional surveillance and reporting efforts are in place for extensively-resistant AROs such as carbapenem-resistant Enterobacterales (CRE), but need to be further expanded nationwide and to include other AROs such as extended-spectrum β-lactamase (ESBL) producing organisms. Increased surveillance of ARO infections and colonization will inform future targeted intervention and infection prevention strategies.
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Affiliation(s)
| | - Jennie H. Kwon
- To whom all correspondence should be addressed:
Jennie H. Kwon, DO, MSCI, Washington University School of Medicine, Division of
Infectious Diseases, St. Louis, MO 63110;
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21
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Gastrointestinal Colonization of Carbapenem-Resistant Acinetobacter baumannii: What Is the Implication for Infection Control? Antibiotics (Basel) 2022; 11:antibiotics11101297. [PMID: 36289955 PMCID: PMC9598245 DOI: 10.3390/antibiotics11101297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 12/02/2022] Open
Abstract
The epidemiology of patients with gastrointestinal colonization of carbapenem-resistant Acinetobacter baumannii (CRAB) has not been systematically analyzed. We aimed to analyze the incidence, risk factors, and clinical outcomes of patients with newly identified gastrointestinal colonization of CRAB in a healthcare region in Hong Kong, where a multi-pronged screening strategy for gastrointestinal colonization of CRAB, together with other multidrug-resistant organisms (MDROs), was conducted by collecting fecal specimens (rectal swab or stool) upon admission and during hospitalization. From 1 October 2015 to 31 December 2019, a total of 161,339 fecal specimens from 63,588 patients, 61,856 (97.3%) of whom were hospitalized patients, and 54,525 (88.1%) were screened upon admission, with 1309 positive for CRAB (2.4% prevalence). Among patients positive for CRAB in fecal specimens, 698 (53.3%) had newly detected gastrointestinal colonization of CRAB, giving an incidence of 10.03 per 10,000 patient admissions and constituting 2646 CRAB colonization days in the general wards. Excluding the 164 patients with co-colonization of other MDROs, 534 patients had gastrointestinal colonization with only CRAB, and 12.5% (67/534) developed symptomatic CRAB infections at a median of 61 days (range: 2 to 671 days), during prospective follow-up for 2 years. Compared with age- and sex-matched controls, patients being referred from residential care homes for the elderly, the presence of indwelling devices, use of beta-lactam/beta-lactamase inhibitors, carbapenems, and proton pump inhibitors in the preceding 6 months, and history of hospitalization in the past 6 months were significantly associated with gastrointestinal colonization with CRAB, as shown by multivariable analysis. Log-rank test showed that cases had significantly shorter survival duration than controls (p < 0.001). The adjusted hazard ratio of gastrointestinal colonization of CRAB was 1.8 (95% CI: 1.5−2.2; p < 0.001), as shown by Cox regression analysis. Whole-genome sequencing of eight patients with CRAB isolates in their blood cultures and rectal swabs during the same episode of hospitalization revealed ST-195 as the predominant type, as shown by multilocus sequencing type. Gastrointestinal colonization of CRAB poses a considerable challenge for infection prevention and control.
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22
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Jones CA, Betthauser KD, Lizza BD, Juang PA, Micek ST, Kollef MH. Impact of Stress Ulcer Prophylaxis Discontinuation Guidance in Mechanically Ventilated, Critically Ill Patients: A Pre-Post Cohort Study. Hosp Pharm 2022; 57:510-517. [PMID: 35898251 PMCID: PMC9310319 DOI: 10.1177/00185787211061371] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
Purpose Recent data highlight unclear efficacy and potential negative sequelae of stress ulcer prophylaxis (SUP) in the intensive care unit (ICU). Minimizing SUP exposure has pertinent clinical and other implications. This study assessed medication use and clinical outcomes before and after implementation of a practice guideline promoting early discontinuation of SUP in mechanically ventilated ICU patients. Methods Retrospective, single-center, pre-post cohort study within a medical ICU at a large, academic medical center. Adult patients requiring mechanical ventilation and receiving SUP via a histamine-2 receptor antagonist (H2RA) or proton pump inhibitor (PPI) were eligible for inclusion. The clinical practice guideline was implemented on January 1, 2020. The impact of implementation was assessed via percent of patient-days with inappropriate SUP. Incidence of clinically important GI bleed was the primary safety outcome. Results A total of 137 pre-guideline and 112 post-guideline patients were included. Comorbidity burden was similar between groups. A higher prevalence of baseline vasopressor receipt (39% vs 67%, P < .01) and acute kidney injury (56% vs 69%, P = .04) was observed in post-guideline patients. Post-guideline patients experienced a significantly lower percentage of patient-days of inappropriate SUP (25% vs 50%, P < .01) as well as higher rates of SUP discontinuation before extubation (71% vs 12%, P < .01) and during ICU stay (93% vs 50%, P < .01). Post-guideline patients observed a significantly lower incidence of SUP at hospital discharge (4% vs 35%, P < .01). No differences in bleeding outcomes were observed, though post-guideline patients experienced longer durations of mechanical ventilation, ICU stay, and hospital stay. Conclusions Implementation of an early SUP discontinuation guideline was associated with significant improvements in SUP prescribing practices. Baseline differences between groups likely explain observed differences in clinical outcomes.
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Affiliation(s)
| | | | | | - Paul A. Juang
- Barnes-Jewish Hospital, Saint Louis, MO, USA
- University of Health Sciences and Pharmacy, St. Louis- College of Pharmacy, Saint Louis, MO, USA
| | - Scott T. Micek
- Barnes-Jewish Hospital, Saint Louis, MO, USA
- University of Health Sciences and Pharmacy, St. Louis- College of Pharmacy, Saint Louis, MO, USA
| | - Marin H. Kollef
- Washington University School of Medicine, Saint Louis, MO, USA
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23
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Xie J, Chen Q, He D. Pre-existing Proton Pump Inhibitor Treatment and Short-Term Prognosis of Acute Myocardial Infarction Patients. Front Cardiovasc Med 2022; 9:919716. [PMID: 35859584 PMCID: PMC9289161 DOI: 10.3389/fcvm.2022.919716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionEvidence suspects proton pump inhibitor (PPI) use is a risk factor of poor prognosis of acute myocardial infarction (AMI). We aimed to investigate the association between pre-existing PPI use before emergency department (ED) visit and short-term prognosis of AMI patients.Materials and MethodsAMI patients admitted to ED were included and categorized as cohorts with or without pre-existing PPI use. Hospital mortality, length of hospital stay, being admitted to intensive care unit (ICU), and length of (total) ICU stay were studied as prognostic outcomes. Multivariable logistic regression or linear regression were used to estimate the associations between pre-existing PPI use and the outcomes after adjusting for potential confounders.ResultsA total of 2001 AMI patients were included. No significant difference was found in hospital mortality and length of ICU stay between cohorts; patients with pre-existing PPI use showed a significantly longer length of hospital stay (median 3.81 vs. 3.20 days, P = 0.002) but lower proportion of being admitted to ICU (25.59% vs. 40.83%, P < 0.001) compared to those without pre-existing PPI use. Pre-existing PPI use was not associated with hospital mortality [odds ratio (OR) 1.08, 95% confidence interval (CI) 0.58–1.99], length of hospital stay (β = 0.23, 95% CI −0.35 to 0.82), and length of ICU stay (β = −0.18, 95% CI −1.06 to 0.69), but was statistically significantly associated with lower risk of being admitted to ICU (OR 0.69, 95% CI 0.52–0.92).ConclusionThe current study does not support newly diagnosed AMI patients with pre-existing PPI use before ED visit would experience worse short-term prognosis than those without.
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Affiliation(s)
- Juntao Xie
- Intensive Care Unit, The First People’s Hospital of Chenzhou, Chenzhou, China
- Intensive Care Unit, The Chenzhou Affiliated Hospital, Hengyang Medical School, University of South China, Chenzhou, China
| | - Qingui Chen
- Department of Medical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dejian He
- Department of Emergency, The First People’s Hospital of Chenzhou, Chenzhou, China
- Department of Emergency, The Chenzhou Affiliated Hospital, Hengyang Medical School, University of South China, Chenzhou, China
- *Correspondence: Dejian He,
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24
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Liu YB, Chen MK. The impact of proton pump inhibitors in liver diseases and the effects on the liver. J Dig Dis 2022; 23:196-208. [PMID: 35357775 DOI: 10.1111/1751-2980.13093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/09/2022] [Accepted: 03/29/2022] [Indexed: 12/11/2022]
Abstract
In this systematic and comprehensive overview, we aimed to evaluate the impact of proton pump inhibitors (PPIs) on chronic liver diseases, especially on cirrhosis. A manual and comprehensive search of the PubMed database was conducted to obtain relevant literatures. PPIs altered the composition and function of the intestinal microflora and might lead to small intestinal bacterial overgrowth and bacterial translocation, which were associated with adverse effects in liver diseases. They might increase the risk of hepatic encephalopathy, spontaneous bacterial peritonitis, infections, and are related to an increased mortality in cirrhosis. PPIs might lead to an increased risk of hepatocellular carcinoma, although the mechanism is unknown, and the results are controversial. PPIs also had an impact on the direct-acting antiviral regimen in patients with chronic hepatitis C. They were associated with an increased risk of liver abscess and increased mortality. Additionally, PPIs might lead to metabolic risk events, such as liver steatosis and weight gain. PPIs are associated with several adverse outcomes in liver diseases. Cautious use of PPIs is recommended and clinicians should be aware of the indications for their use in patients with liver diseases.
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Affiliation(s)
- Yuan Bin Liu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Ming Kai Chen
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
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25
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Inappropriateness of Proton Pump Inhibitors After Hospital Discharge Is Associated with Thirty-Day Hospital Readmission. Dig Dis Sci 2022; 67:817-825. [PMID: 33723702 DOI: 10.1007/s10620-021-06909-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 02/19/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Concerns have been raised about the adverse effects of proton pump inhibitors (PPIs). Rather than PPIs themselves causing harm, we hypothesized that PPIs prescribed without appropriate indications would be associated with adverse outcomes compared to appropriately indicated PPIs. METHODS Adult patients initiated on a new PPI during a hospitalization at our institution from 2014 to 2018 were analyzed. The primary outcome was all-cause 30-day readmission rate. The primary exposure was long-term appropriateness of PPI determined by the presence of prespecified diagnostic codes and discharge medications. Logistic regression modeling was used to estimate the odds of 30-day readmission in patients discharged on inappropriate compared to appropriate new PPIs. RESULTS Of 84,236 patients admitted to our institution, 7745 (9.2%) were discharged on a new PPI, of which 5136 (66.3%) lacked an appropriately documented indication. Inappropriate PPIs were associated with 30-day hospital readmission after adjusting for other factors (adjusted odds ratio 1.30, 95% confidence interval 1.10-1.53). The excess risk associated with lack of appropriate documentation for PPIs in these patients was 44 readmissions per 1000 hospitalizations (95% confidence interval 21-67). CONCLUSIONS Discharge on inappropriate PPIs was associated with 30-day hospital readmission compared to appropriate PPIs. The harm associated with inappropriate PPIs is not likely due to direct effects of PPIs because all patients in the study received PPIs. Rather, patients who receive inappropriate PPIs may have additional patient-specific factors that place them at increased risk for hospital readmission.
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26
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Veettil SK, Sadoyu S, Bald EM, Chandran VP, Khuu SAT, Pitak P, Lee YY, Nair AB, Antony PT, Ford AC, Chaiyakunapruk N. Association of proton-pump inhibitor use with adverse health outcomes: A systematic umbrella review of meta-analyses of cohort studies and randomised controlled trials. Br J Clin Pharmacol 2022; 88:1551-1566. [PMID: 34622475 DOI: 10.1111/bcp.15103] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 12/13/2022] Open
Abstract
AIMS The aim was to perform an umbrella review to summarise the existing evidence on proton-pump inhibitor (PPI) use and adverse outcomes and to grade the certainty of evidence. METHODS Electronic databases were searched up to July 2021 for meta-analyses of cohort studies and/or randomised controlled trials (RCTs). Summary effect sizes from a random-effects model, between-study heterogeneity, 95% prediction interval, small-study effect, excess significance and credibility ceilings were devised to classify the credibility of evidence from meta-analyses of cohort studies, whereas the GRADE approach was used for meta-analyses of RCTs. RESULTS In meta-analyses of cohort studies, 52 of the 91 examined associations were statistically significant (P ≤ .05). Convincing evidence emerged from main analysis for the association between PPI use and risk of all-site fracture and chronic kidney disease in the elderly population. However, none of these associations remained supported by convincing evidence after sensitivity analyses. The use of PPI is also associated with an increased risk of mortality due to COVID-19 infection and other related adverse outcomes, but the quality of evidence was weak. In meta-analyses of RCTs, 38 of the 63 examined associations were statistically significant. However, no associations were supported by high or moderate-quality evidence. CONCLUSION This study's findings imply that most putative adverse outcomes associated with PPI use may not be supported by high-quality evidence and are likely to have been affected by underlying confounding factors. Future research is needed to confirm the causal association between PPI use and risk of fracture and chronic kidney disease.
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Affiliation(s)
- Sajesh K Veettil
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Saranrat Sadoyu
- Department of Pharmacy, Pakchongnana Hospital, Pakchong, Thailand
| | - Elizabeth M Bald
- College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Viji P Chandran
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | | | | | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
- GI Function and Motility Unit, Hospital USM, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Athira Balakrishnan Nair
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Paul T Antony
- Department of Rheumatology, Amala Institute of Medical Sciences, Kerala, India
| | - Alexander C Ford
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
- School of Pharmacy, University of Wisconsin, Madison, WI, USA
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27
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Raffelsberger N, Hetland MAK, Svendsen K, Småbrekke L, Löhr IH, Andreassen LLE, Brisse S, Holt KE, Sundsfjord A, Samuelsen Ø, Gravningen K. Gastrointestinal carriage of Klebsiella pneumoniae in a general adult population: a cross-sectional study of risk factors and bacterial genomic diversity. Gut Microbes 2022; 13:1939599. [PMID: 34182896 PMCID: PMC8244762 DOI: 10.1080/19490976.2021.1939599] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Antibiotic resistant Klebsiella pneumoniae is a leading public health threat and gastrointestinal carriage is an established risk factor for subsequent infections during hospitalization. Our study contributes new knowledge of risk factors for gastrointestinal carriage and the genomic population structure of K. pneumoniae colonizing humans in a representative sample of a general population in a community setting. Altogether, 2,975 participants (54% women) >40 y in the population-based Tromsø Study: Tromsø7, Norway (2015-2016) were included. Fecal samples were screened for K. pneumoniae, which were characterized using whole-genome sequencing. Risk factors for carriage were analyzed using multivariable logistic regression on data from questionnaires and the Norwegian Prescription Database. Prevalence of K. pneumoniae gastrointestinal carriage was 16.3% (95% CI 15.0-17.7, no gender difference). Risk factors associated with carriage included age ≥60 y, travel to Greece or Asia past 12 months (adjusted odds ratio 1.49, 95% CI 1.11-2.00), Crohn's disease/ulcerative colitis (2.26, 1.20-4.27), use of proton pump inhibitors (1.62, 1.18-2.22) and non-steroidal anti-inflammatory drugs past 6 months (1.38, 1.04-1.84), and antibiotic use the last month (1.73, 1.05-2.86). Prevalence was higher among those having used combinations of drug classes and decreased over time with respect to preceding antibiotic use. The K. pneumoniae population was diverse with 300 sequence types among 484 isolates distributed across four phylogroups. Only 5.2% of isolates harbored acquired resistance and 11.6% had virulence factors. Identification of risk factors for gastrointestinal carriage allows for identification of individuals that may have higher risk of extraintestinal infection during hospitalization. The findings that specific diseases and drugs used were associated with carriage show an impact of these possibly through modulating the human gut microbiota promoting colonization. The diverse population structure of carriage isolates reflects the ecologically adaptive capacity of the bacterium and challenges for vaccine prospects and the identification of reservoirs as a potential source for human colonization.
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Affiliation(s)
- Niclas Raffelsberger
- Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway,Department of Medical Biology, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway,CONTACT Niclas Raffelsberger Department of Microbiology and Infection Control, University Hospital of North Norway, TromsøN-9038, Norway
| | - Marit Andrea Klokkhammer Hetland
- Department of Medical Microbiology, Stavanger University Hospital, Stavanger, Norway,Department of Biological Sciences, Faculty of Mathematics and Natural Sciences, University of Bergen, Bergen, Norway
| | - Kristian Svendsen
- Department of Pharmacy, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
| | - Lars Småbrekke
- Department of Pharmacy, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
| | - Iren Høyland Löhr
- Department of Medical Microbiology, Stavanger University Hospital, Stavanger, Norway
| | | | - Sylvain Brisse
- Institut Pasteur, Biodiversity and Epidemiology of Bacterial Pathogens, Paris, France
| | - Kathryn E. Holt
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Australia,Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Arnfinn Sundsfjord
- Department of Medical Biology, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway,Norwegian National Advisory Unit on Detection of Antimicrobial Resistance, Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
| | - Ørjan Samuelsen
- Department of Pharmacy, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway,Norwegian National Advisory Unit on Detection of Antimicrobial Resistance, Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
| | - Kirsten Gravningen
- Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway,Department of Infection Control and Preparedness, Norwegian Institute of Public Health, Oslo, Norway
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28
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Abrahami D, McDonald EG, Schnitzer ME, Barkun AN, Suissa S, Azoulay L. Proton pump inhibitors and risk of gastric cancer: population-based cohort study. Gut 2022; 71:16-24. [PMID: 34226290 DOI: 10.1136/gutjnl-2021-325097] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/18/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine whether new users of proton pump inhibitors (PPIs) are at an increased risk of gastric cancer compared with new users of histamine-2 receptor antagonists (H2RAs). DESIGN Using the UK Clinical Practice Research Datalink, we conducted a population-based cohort study using a new-user active comparator design. From 1 January 1990 to 30 April 2018, we identified 973 281 new users of PPIs and 193 306 new users of H2RAs. Cox proportional hazards models were fit to estimate HRs and 95% CIs of gastric cancer, and the number needed to harm was estimated using the Kaplan-Meier method. The models were weighted using standardised mortality ratio weights using calendar time-specific propensity scores. Secondary analyses assessed duration and dose-response associations. RESULTS After a median follow-up of 5.0 years, the use of PPIs was associated with a 45% increased risk of gastric cancer compared with the use of H2RAs (HR 1.45, 95% CI 1.06 to 1.98). The number needed to harm was 2121 and 1191 for five and 10 years after treatment initiation, respectively. The HRs increased with cumulative duration, cumulative omeprazole equivalents and time since treatment initiation. The results were consistent across several sensitivity analyses. CONCLUSION The findings of this large population-based cohort study indicate that the use of PPIs is associated with an increased risk of gastric cancer compared with the use of H2RAs, although the absolute risk remains low.
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Affiliation(s)
- Devin Abrahami
- Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada.,Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - Emily Gibson McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada.,Division of Experimental Medicine, McGill University, Montreal, Quebec, Canada
| | - Mireille E Schnitzer
- Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada.,Faculty of Pharmacy and the Department of Social and Preventive Medicine, Universite de Montreal, Montreal, Quebec, Canada
| | - Alan N Barkun
- Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada.,Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Samy Suissa
- Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada.,Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Quebec, Canada.,Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Laurent Azoulay
- Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada .,Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Quebec, Canada.,Gerald Bronfman Department of Oncology, McGill University, Montreal, Quebec, Canada
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29
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Wong SC, Chen JHK, So SYC, Ho PL, Yuen KY, Cheng VCC. Gastrointestinal colonization of methicillin-resistant Staphylococcus aureus: an unrecognized burden in the hospital infection control. J Hosp Infect 2021; 121:65-74. [PMID: 34953945 DOI: 10.1016/j.jhin.2021.12.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/15/2021] [Accepted: 12/15/2021] [Indexed: 12/22/2022]
Abstract
The incidence, risk factors, outcomes, and genomic relatedness of patients with newly diagnosed gastrointestinal colonization of meticillin-resistant Staphylococcus aureus (MRSA) were analyzed epidemiologically and genetically by whole genome sequencing (WGS) in a hospital network in Hong Kong. Between 1 October 2015 and 31 December 2018, 919 (2.7%) of 34,667 patients had newly diagnosed gastrointestinal MRSA colonization by admission screening. The incidence was 0.67±0.32 per 1,000-patient-days-per-quarter. Including patients with gastrointestinal MRSA colonization, the overall burden of MRSA increased by 59.2% (from 1.13±0.13 to 1.80±0.36 case per 1,000-patient-days-per-quarter), with an addition of MRSA 4,727 patient-days during the study period. Patients referred from residential care home for the elderly [odds ratio (95% confidential interval): 4.18 (3.50-4.99), p<0.001], with history of hospitalization in the past 6 months [1.90 (1.56-2.30), p<0.001], and consumption of fluoroquinolones [1.76 (1.34-2.30), p<0.001], cephalosporins [1.61 (1.11-2.31), p=0.011], and proton pump inhibitors [1.31 (1.10-1.56), p=0.002] in the preceding 6 months were found to be independent risk factors by multivariable analysis in the case-control analysis. The median survival of case was significantly shorter than control (860 vs 1507 days, p<0.001). 127 (13.8%) of 919 patients developed symptomatic MRSA infection in 112 days (median, range: 2-712 days). Of 19 patients with paired MRSA faecal and blood culture isolates subjected to WGS, clonality was found in 16 (84.2%) pairs of MRSA isolates. MRSA ST45 constituted 44.7% (17/38) of MRSA isolates. Gastrointestinal MRSA colonization may contribute to adverse clinical outcomes and pose an unrecognized burden to the hospital infection control.
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Affiliation(s)
- Shuk-Ching Wong
- Infection Control Team, Queen Mary Hospital, Hong Kong West Cluster, Hong Kong Special Administrative Region, China
| | - Jonathan Hon-Kwan Chen
- Department of Microbiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Simon Yung-Chun So
- Department of Microbiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Pak-Leung Ho
- Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Kwok-Yung Yuen
- Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Vincent Chi-Chung Cheng
- Infection Control Team, Queen Mary Hospital, Hong Kong West Cluster, Hong Kong Special Administrative Region, China; Department of Microbiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China.
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Javaudin F, Bémer P, Batard E, Montassier E. Impact of Phage Therapy on Multidrug-Resistant Escherichia coli Intestinal Carriage in a Murine Model. Microorganisms 2021; 9:microorganisms9122580. [PMID: 34946183 PMCID: PMC8708983 DOI: 10.3390/microorganisms9122580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/02/2021] [Accepted: 12/10/2021] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION The growing resistance of bacteria to antibiotics is a major global public health concern. An important reservoir of this resistance is the gut microbiota. However, limited data are available on the ability of phage therapy to reduce the digestive carriage of multidrug-resistant bacteria. MATERIALS AND METHODS Four novel lytic phages were isolated in vitro for efficacy against an extended-spectrum beta-lactamase-producing (ESBL) Escherichia coli strain also resistant to carbapenems through a carbapenemase OXA-48. The first step was to develop models of ESBL E. coli digestive carriage in mice. The second step was to test the efficacy of an oral and rectal phage therapy (a cocktail of four phages or microencapsulated phage) to reduce this carriage. RESULTS The two most intense models of digestive carriage were obtained by administering amoxicillin (0.5 g·L-1) continuously in the drinking water (Model 1) or pantoprazole (0.1 g·L-1) continuously in the drinking water, combined with amoxicillin (0.5 g·L-1), for the first 8 days (Model 2). Oral administration of the phage cocktail to Model 1 resulted in a transient reduction in the concentration of ESBL E. coli in the faeces 9 days after the bacterial challenge (median = 5.33 × 108 versus 2.76 × 109 CFU·g-1, p = 0.02). In contrast, in Model 2, oral or oral + rectal administration of this cocktail did not alter the bacterial titre compared to the control (area under the curve, AUC, 3.49 × 109; 3.41 × 109 and 3.82 × 109 for the control, oral and oral + rectal groups, respectively; p-value > 0.8 for each two-by-two group comparison), as well as the administration of an oral microencapsulated phage in Model 1 (AUC = 8.93 × 109 versus 9.04 × 109, p = 0.81). CONCLUSIONS Oral treatment with amoxicillin promoted digestive carriage in mice, which was also the case for the addition of pantoprazole. However, our study confirms the difficulty of achieving efficacy with phage therapy to reduce multidrug-resistant bacterial digestive carriage in vivo.
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Affiliation(s)
- François Javaudin
- MiHAR Laboratary, EE1701, University of Nantes, 44200 Nantes, France; (P.B.); (E.B.); (E.M.)
- Emergency Department, Nantes University Hospital, 44000 Nantes, France
- Correspondence:
| | - Pascale Bémer
- MiHAR Laboratary, EE1701, University of Nantes, 44200 Nantes, France; (P.B.); (E.B.); (E.M.)
- Department of Bacteriology, Nantes University Hospital, 44000 Nantes, France
| | - Eric Batard
- MiHAR Laboratary, EE1701, University of Nantes, 44200 Nantes, France; (P.B.); (E.B.); (E.M.)
- Emergency Department, Nantes University Hospital, 44000 Nantes, France
| | - Emmanuel Montassier
- MiHAR Laboratary, EE1701, University of Nantes, 44200 Nantes, France; (P.B.); (E.B.); (E.M.)
- Emergency Department, Nantes University Hospital, 44000 Nantes, France
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Marinescu AR, Lăzureanu V, Laza R, Musta V, Nicolescu N, Cuț TG, Dehelean C, Oancea C, Licker M. Association between ribotype and clinical form of enterocolitis with C. difficile in Western Romania: A 2-year study. Exp Ther Med 2021; 23:22. [PMID: 34815774 PMCID: PMC8593920 DOI: 10.3892/etm.2021.10944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 08/24/2021] [Indexed: 11/06/2022] Open
Abstract
During the last decade, several changes in the epidemiology, clinical symptoms, and evolution of Clostridium difficile infection (CDI) have been reported. The number of diagnosed cases has increased, especially in individuals over 60 years of age. There has also been an increase in the share of severe forms of the disease, the number of patients with recurrent infections and the lethality caused by this condition. The aim of the present study was to determine the incidence of CDI over the past few years; to monitor the bacterial toxin by ribotyping; to observe the migration of circulating toxins; to correlate the ribotyping with the clinical form of the disease; and to correlate the treatment with the ribotyping and the clinical form. Therefore, we performed an observational retrospective study regarding the incidence of CDI at ‘Victor Babeș’ Hospital of Infectious Diseases and Pneumophtisiology of Timișoara, between January 2016 and December 2017. The results revealed that 210 patients were hospitalized with a diagnosis of acute enterocolitis with C. difficile. All patients tested showed C. difficile toxin A/B positivity. In 28 cases, the ribotyping was positive with binary toxin and hypervirulent strain 027. The tested patients were discharged or transferred from various medical/surgical clinics. In the study, we also ascertained the correlation between the clinical form of the disease and comorbidities and pre-hospital treatments as risk factors in the occurrence of the infection. In accordance with the rise of CDI during the last decade, it was possible to observe the increase in the number of infectious recurrences. From this point of view, highlighting of the ribotype in this pathology becomes a primary aspect both by increasing the success rate in curing the disease (with a reduction in the risk of recurrence) and by targeted and non-empirical administration of the antibiotic.
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Affiliation(s)
- Adelina-Raluca Marinescu
- Department XIII, 'Victor Babeș' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Voichița Lăzureanu
- Department XIII, 'Victor Babeș' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Ruxandra Laza
- Department XIII, 'Victor Babeș' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Virgil Musta
- Department XIII, 'Victor Babeș' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Narcisa Nicolescu
- Department XIII, 'Victor Babeș' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Talida Georgiana Cuț
- Department XIII, 'Victor Babeș' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Cristina Dehelean
- Department II, 'Victor Babeș' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Cristian Oancea
- Department XIII, 'Victor Babeș' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Monica Licker
- Department XIV, 'Victor Babeș' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
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Klauke P, Schwab F, Gastmeier P, Maechler F. The impact of non-antimicrobial drug agents on the acquisition of ESBL-producing Enterobacterales in non-critical care wards in a German university hospital: an exploratory, matched case-control study. J Antimicrob Chemother 2021; 77:229-236. [PMID: 34791310 DOI: 10.1093/jac/dkab373] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/03/2021] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES To investigate therapeutical drugs other than antimicrobials as risk factors for the acquisition of ESBL-producing Enterobacterales (ESBL-E). METHODS This matched case-control study is based on rectal surveillance screening data obtained during a larger trial between 2014 and 2016 upon patients' admission and at least once before discharge in eight non-ICU wards. Patients with ward-acquired ESBL-E (cases) were matched 1:1 to non-ESBL-E carriers (controls) based on ward, number of screening samples, days at risk and Charlson comorbidity index (CCI). Daily medication data were documented according to the Anatomical Therapeutic Chemical classification system. Multivariable conditional logistic regression models were used to calculate risk factors for ESBL-E acquisition. RESULTS Of the 232 cases and 232 controls analysed, baseline characteristics such as gender (male 56.9%), median age (65 years old, IQR 52-74), number of screening samples (N = 3, IQR 2-4), days to first sample (2, IQR 1-2), days at risk (8, IQR 6-11) and CCI (4, IQR 2-6) were similar. Multivariable analysis showed that glucocorticoids, opium alkaloids and selective β-2-adrenoreceptor agonists increased the chance to detect ESBL-E (OR 1.07, 95% CI 1.001-1.13, P = 0.047; OR 1.06, 95% CI 1.007-1.12, P = 0.027; and OR 1.31, 95% CI 1.105-1.55, P = 0.001, respectively), while antihistamines decreased it (OR 0.61, 95% CI 0.39-0.97, P = 0.034). In a sensitivity analysis, including drugs prescribed to at least 50 patients, proton pump inhibitors remained as risk factors (OR 1.049, 95% CI 1.001-1.100, P = 0.047). CONCLUSIONS In a non-ICU setting, drugs other than antimicrobials were determined as potential independent risk factors for ESBL-E acquisition.
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Affiliation(s)
- Paula Klauke
- Institute of Hygiene and Environmental Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Frank Schwab
- Institute of Hygiene and Environmental Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Petra Gastmeier
- Institute of Hygiene and Environmental Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Friederike Maechler
- Institute of Hygiene and Environmental Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Abdel Moneim M, Abdelaziz DH, Ibrahim Nagy Y, Abdel Baki A, Attia AS, Sabry N. Rifaximin microbial resistance and its efficacy and safety as a secondary prophylaxis of hepatic encephalopathy in patients with hepatitis C virus-related cirrhosis. Int J Clin Pract 2021; 75:e14807. [PMID: 34487412 DOI: 10.1111/ijcp.14807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/14/2021] [Accepted: 09/03/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIM Rifaximin is an oral antibiotic with promising efficacy in the reduction of hepatic encephalopathy (HE) recurrence. Development of microbial resistance to rifaximin is not studied yet in HE. The study aim was to assess the microbial resistance, safety and efficacy of rifaximin as secondary prophylaxis of HE. METHOD In this open-label parallel, prospective interventional study, 100 patients were randomly allocated either to receive 400 mg rifaximin 3 times/d plus 30-45 mL lactulose 3 times/d (intervention group) or to receive the standard of care only which is lactulose alone (control group) for 6 months. The primary outcome of the study was the difference between minimum inhibitory concentration (MIC) of rifaximin among the two studied groups at the end of treatment. The secondary outcomes included the time to first episode of HE, time to first hospitalisation, and patient's survival. RESULTS The MIC did not differ significantly after treatment exposure compared with baseline either between groups or within the same group. The time to new episode of HE was 18.84 ± 6.49 weeks (mean ± SD) in the intervention group and was significantly longer (P = .002) than that in the control group 14 ± 7.52 weeks. Moreover, only 23 (46%) patients developed overt HE in the intervention group compared with 35 patients (70%) in the control group (P = .005). Also, there was an observed 32% reduction in the risk of hospitalisation in intervention group compared with control group. CONCLUSION Rifaximin succeeded to maintain remission from new episodes of HE in hepatitis C virus cirrhotic patients with limited potential for development of microbial resistance over the study period. ClinicalTrials.gov Identifier: NCT04736836.
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Affiliation(s)
- Mai Abdel Moneim
- Clinical Pharmacy Department, The National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - Doaa H Abdelaziz
- Clinical Pharmacy Department, The National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Future University in Egypt, Cairo, Egypt
| | - Yosra Ibrahim Nagy
- Department of Microbiology and Immunology, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Amin Abdel Baki
- Hepatology, Gastroenterology and Infectious Diseases Department, The National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - Ahmed S Attia
- Department of Microbiology and Immunology, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Nirmeen Sabry
- Clinical Pharmacy Department, Faculty of Pharmacy, Cairo University, Cairo, Egypt
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Carriage of Multidrug-Resistant Bacteria in Healthy People: Recognition of Several Risk Groups. Antibiotics (Basel) 2021; 10:antibiotics10101163. [PMID: 34680744 PMCID: PMC8533013 DOI: 10.3390/antibiotics10101163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/08/2021] [Accepted: 09/21/2021] [Indexed: 12/16/2022] Open
Abstract
The increase in multidrug-resistant (MDR) bacteria in hospitalized people and the hospital environment has been thoroughly documented. In contrast, little is known about their presence in the community. However, increasing evidence is showing a high level of carriage in people without infectious signs. Colonized people can later develop infections due to MDR bacteria and may be able to transmit them to susceptible people (the number of which is increasing worldwide), for example, people with comorbidities such as diabetes, cancer, or inflammatory diseases and those in extreme age groups. Risk factors for the acquisition of MDR bacteria are as follows: (1) residence or travel in countries with high levels of MDR bacteria; (2) occupational risks such as health workers or people with close contact with animals (farmers, veterinarians) who frequently use antibiotics; and (3) comorbidities. Eradication is rather difficult and, thus far, has not shown clear-cut results. Preventive measures will be important in the future with a reinforcement of hygienic measures not only in the hospital, but also in the community.
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35
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Willems RPJ, van Dijk K, Dierikx CM, Twisk JWR, van der Klis FRM, de Greeff SC, Vandenbroucke-Grauls CMJE. Gastric acid suppression, lifestyle factors and intestinal carriage of ESBL and carbapenemase-producing Enterobacterales: a nationwide population-based study. J Antimicrob Chemother 2021; 77:237-245. [PMID: 34550358 PMCID: PMC8730682 DOI: 10.1093/jac/dkab345] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 08/15/2021] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Gastric acid-suppressive therapy has been suggested to increase the risk for intestinal carriage of MDR Enterobacterales, but there is scarce community-based evidence substantiating this risk. OBJECTIVES To investigate if acid-suppressant use is associated with a risk of intestinal carriage of ESBL and carbapenemase-producing Enterobacterales (ESBL-E) in the open population, and to assess possible modifying factors. METHODS Within the framework of a nationwide seroprevalence study, we identified a population-based cross-sectional cohort comprising 2746 adults (≥18 years), who provided stool specimens between February 2016 and June 2017. Specimens were tested by phenotypic assays and confirmatory genotype analysis to detect carriage of ESBL-E. Covariate data were extracted from self-administered questionnaires. ORs and 95% CIs were estimated using multivariable multilevel logistic regression, controlling for confounders informed by directed acyclic graphs. RESULTS Among 2746 participants, 316 (11.5%) used acid suppressants; the prevalence of ESBL-E carriage was 7.4% (95% CI, 6.1%-8.6%). Current use of acid suppressants was not associated with ESBL-E carriage (adjusted OR [aOR], 1.05; 95% CI, 0.64-1.74); lifestyle and comorbidity did not modify this association. A higher BMI (≥25 kg/m2) (aOR, 1.42 [95% CI, 1.02-1.98]), non-Western ethnic origin (aOR, 1.96 [95% CI, 1.34-2.87]), travel to Eastern-Mediterranean, Western-Pacific or South-East Asia regions (aOR, 3.16 [95% CI, 1.71-5.83]) were associated with ESBL-E carriage. Sensitivity analyses confirmed these results; spline analysis supported a BMI-associated risk. CONCLUSIONS In this open population study, current use of acid suppressants was not associated with ESBL-E carriage. Travel to high-endemic regions and non-Western ethnicity were confirmed as risk factors, while a higher BMI emerged as a potential new risk for ESBL-E carriage.
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Affiliation(s)
- Roel P J Willems
- Department of Medical Microbiology and Infection Prevention, Amsterdam Infection and Immunity Institute, Amsterdam UMC, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - Karin van Dijk
- Department of Medical Microbiology and Infection Prevention, Amsterdam Infection and Immunity Institute, Amsterdam UMC, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - Cindy M Dierikx
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Jos W R Twisk
- Department of Clinical Epidemiology and Biostatistics, Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Fiona R M van der Klis
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands.,Centre for Immunology of Infectious Diseases and Vaccines-Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Sabine C de Greeff
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands.,Centre for Epidemiology and Surveillance of Infectious Diseases-Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Christina M J E Vandenbroucke-Grauls
- Department of Medical Microbiology and Infection Prevention, Amsterdam Infection and Immunity Institute, Amsterdam UMC, Amsterdam Medical Center, Amsterdam, The Netherlands
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Kohler P, Seiffert SN, Kessler S, Rettenmund G, Lemmenmeier E, Qalla Widmer L, Nolte O, Seth-Smith HMB, Albrich WC, Babouee Flury B, Gardiol C, Harbarth S, Münzer T, Schlegel M, Petignat C, Egli A, Héquet D. Molecular Epidemiology and Risk Factors for Extended-Spectrum β-Lactamase-Producing Enterobacterales in Long-Term Care Residents. J Am Med Dir Assoc 2021; 23:475-481.e5. [PMID: 34297981 DOI: 10.1016/j.jamda.2021.06.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/21/2021] [Accepted: 06/24/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVES We aimed to assess the burden of extended-spectrum β-lactamase (ESBL)-producing Enterobacterales in Swiss long-term care facilities (LTCFs) to describe the molecular epidemiology, describe the intrainstitutional and regional clusters of resistant pathogens, and identify independent institution- and resident-level factors associated with colonization. DESIGN Cross-sectional study. SETTING AND PARTICIPANTS From August to October 2019, we performed a point prevalence study among residents from 16 LTCFs in Western and Eastern Switzerland (8 per region). METHODS Residents underwent screening for ESBL-producing Enterobacterales (ESBL-E); whole-genome sequencing (WGS) was performed. We gathered institution-level (eg, number of beds, staff-resident ratio, alcoholic hand rub consumption) and resident-level [eg, anthropometric data, time in facility, dependency, health care exposure, antibiotic treatment, proton-pump inhibitor (PPI) use] characteristics. Factors associated with colonization were identified using a generalized linear model. RESULTS Among 1185 eligible residents, 606 (51%) consented to the study. ESBL-E prevalence was 11.6% (70/606), ranging from 1.9% to 33.3% between institutions, with a median of 12.5% in the West and 6.9% in the East (P = .03). Among 59 Escherichia coli (from 58 residents), multilocus sequence type (ST) 131 was most common (n = 43/59, 73%), predominantly its subclone H30R1 (n = 37/43, 86%). WGS data identified multiple intrainstitutional and regional clusters. Independent risk factors for ESBL carriage were previous ESBL colonization [adjusted odds ratio (aOR) 23.5, 95% confidence interval (CI) 6.6-83.8, P < .001), male gender (aOR 2.6, 95% CI 1.5-4.6, P = .002), and use of PPIs (aOR 2.2, 95% CI 1.2-3.8, P = .01). CONCLUSIONS AND IMPLICATIONS Overall ESBL-E prevalence in Swiss LTCF residents is low. Yet, we identified several clusters of residents with identical pathogens within the same institution. This implies that particularly affected institutions might benefit from targeted infection control interventions. PPI use was the only modifiable factor associated with carriage of ESBL producers. This study adds to the growing list of adverse outcomes associated with PPIs, calling for action to restrict their use in the long-term care setting.
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Affiliation(s)
- Philipp Kohler
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland.
| | - Salome N Seiffert
- Division of Human Microbiology, Centre for Laboratory Medicine, St Gallen, Switzerland
| | - Simone Kessler
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Gabriela Rettenmund
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Eva Lemmenmeier
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Laetitia Qalla Widmer
- Unité cantonale hygiène, prévention et contrôle de l'infection, Canton of Vaud, Switzerland
| | - Oliver Nolte
- Division of Human Microbiology, Centre for Laboratory Medicine, St Gallen, Switzerland
| | - Helena M B Seth-Smith
- Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland; Applied Microbiology Research, University of Basel, Basel, Switzerland
| | - Werner C Albrich
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Baharak Babouee Flury
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | | | - Stephan Harbarth
- Division of Infectious Diseases and Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | | | - Matthias Schlegel
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Christiane Petignat
- Unité cantonale hygiène, prévention et contrôle de l'infection, Canton of Vaud, Switzerland
| | - Adrian Egli
- Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland; Applied Microbiology Research, University of Basel, Basel, Switzerland
| | - Delphine Héquet
- Unité cantonale hygiène, prévention et contrôle de l'infection, Canton of Vaud, Switzerland
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Abstract
OBJECTIVE The first 70 years of critical care can be considered a period of "industrial revolution-like" advancement in terms of progressing the understanding and care of critical illness. Unfortunately, like the industrial revolution's impact on the environment, advancing ICU care of increasingly elderly, immunosuppressed, and debilitated individuals has resulted in a greater overall burden and complexity of nosocomial infections within modern ICUs. Given the rapid evolution of nosocomial infections, the authors provide an updated review. DATA SOURCES AND STUDY SELECTION We searched PubMed and OVID for peer-reviewed literature dealing with nosocomial infections in the critically ill, as well as the websites of government agencies involved with the reporting and prevention of nosocomial infections. Search terms included nosocomial infection, antibiotic resistance, microbiome, antibiotics, and intensive care. DATA EXTRACTION AND DATA SYNTHESIS Nosocomial infections in the ICU setting are evolving in multiple domains including etiologic pathogens plus novel or emerging pathogens, prevalence, host risk factors, antimicrobial resistance, interactions of the host microbiome with nosocomial infection occurrence, and understanding of pathogenesis and prevention strategies. Increasing virulence and antimicrobial resistance of nosocomial infections mandate increasing efforts toward their prevention. CONCLUSIONS Nosocomial infections are an important determinant of outcome for patients in the ICU setting. Systematic research aimed at improving the prevention and treatment of nosocomial infections is still needed.
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Le Bastard Q, Berthelot L, Soulillou JP, Montassier E. Impact of non-antibiotic drugs on the human intestinal microbiome. Expert Rev Mol Diagn 2021; 21:911-924. [PMID: 34225544 DOI: 10.1080/14737159.2021.1952075] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The gut microbiota is composed of trillions of microbial cells and viruses that interact with hosts. The composition of the gut microbiota is influenced by several factors including age, diet, diseases, or medications. The impact of drugs on the microbiota is not limited to antibiotics and many non-antibiotic molecules significantly alter the composition of the intestinal microbiota. AREAS COVERED This review focuses on the impact of four of the most widely prescribed non-antibiotic drugs in the world: Proton-pump inhibitors, metformin, statins, and non-steroidal anti-inflammatory. We conducted a systematic review by searching online databases including Medline, Web of science, and Scopus for indexed articles published in English until February 2021. We included studies assessing the intestinal microbiome alterations associated with proton pump inhibitors (PPIs), metformin, statins, and nonsteroidal anti-inflammatory drugs (NSAIDs). Only studies using culture-independent molecular techniques were included. EXPERT OPINION The taxonomical signature associated with non-antibiotic drugs are not yet fully described, especially in the field of metabolomic. The identification of taxonomic profiles associated a specific molecule provides information on its mechanism of action through interaction with the intestinal microbiota. Many side effects could be related to the dysbiosis induced by these molecules.
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Affiliation(s)
- Quentin Le Bastard
- Microbiota Hosts Antibiotics and Bacterial Resistances (Mihar), Université De Nantes, Nantes, France.,Service Des Urgences, CHU De Nantes, Nantes, France
| | - Laureline Berthelot
- Centre De Recherche En Transplantation Et Immunologie UMR 1064, INSERM, Université De Nantes, Nantes, France.,Institut De Transplantation Urologie Néphrologie (ITUN), CHU De Nantes, Nantes, France
| | - Jean-Paul Soulillou
- Centre De Recherche En Transplantation Et Immunologie UMR 1064, INSERM, Université De Nantes, Nantes, France.,Institut De Transplantation Urologie Néphrologie (ITUN), CHU De Nantes, Nantes, France
| | - Emmanuel Montassier
- Microbiota Hosts Antibiotics and Bacterial Resistances (Mihar), Université De Nantes, Nantes, France.,Service Des Urgences, CHU De Nantes, Nantes, France
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Orelio CC, Heus P, Kroese-van Dieren JJ, Spijker R, van Munster BC, Hooft L. Reducing Inappropriate Proton Pump Inhibitors Use for Stress Ulcer Prophylaxis in Hospitalized Patients: Systematic Review of De-Implementation Studies. J Gen Intern Med 2021; 36:2065-2073. [PMID: 33532958 PMCID: PMC8298652 DOI: 10.1007/s11606-020-06425-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 12/08/2020] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Claudia C Orelio
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands. .,Research Support, Diakonessenhuis Utrecht, Utrecht, The Netherlands.
| | - Pauline Heus
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Judith J Kroese-van Dieren
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - René Spijker
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Barbara C van Munster
- University Medical Center Groningen, University Center for Geriatric Medicine, University of Groningen, Groningen, The Netherlands
| | - Lotty Hooft
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Meriggi F. Controversial link between proton pump inhibitors and anticancer agents: review of the literature. TUMORI JOURNAL 2021; 108:204-212. [PMID: 34159850 DOI: 10.1177/03008916211025091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Drug-drug interactions represent a topic of great interest, not only due to the risk of unexpected adverse events but also due to the possibility of altering the effectiveness of a specific treatment. Inappropriate or concomitant use of drugs can often lead to changes in the bioavailability of various compounds, resulting in pharmacokinetic alterations. A recent example is the concomitant administration of proton pump inhibitors (PPIs) and anticancer agents. PPIs are overused beyond their classic indications, resulting in a high risk of interactions with other drugs, such as anticancer agents, both PO and intravenous. However, the real clinical impact of concomitant acid suppression therapy and anticancer therapies remains controversial and is not yet fully understood. Certainly, the gut microbiota plays a key role in regulating the response of the immune system, and PPIs can significantly alter the gut microbiome, resulting in gut dysbiosis. Indeed, while the link sometimes appears to lead to negative outcomes, as in the case of immunotherapy, oral capecitabine, or tyrosine kinase inhibitors, in other cases, it seems to enhance the effectiveness of intravenous chemotherapy. In this review, I analyse the possible drug interactions between PPIs and the main classes of anticancer drugs.
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Affiliation(s)
- Fausto Meriggi
- Oncology Department, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
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Wilson GM, Suda KJ, Fitzpatrick MA, Bartle B, Pfeiffer CD, Jones M, Rubin MA, Perencevich E, Evans M, Evans CT. Risk Factors Associated with Carbapenemase Producing Carbapenem-Resistant Enterobacteriaceae (CP-CRE) Positive Cultures in a Cohort of U.S. Veterans. Clin Infect Dis 2021; 73:1370-1378. [PMID: 33973631 DOI: 10.1093/cid/ciab415] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Carbapenem-resistant Enterobacterales (CRE) cause approximately 13,100 infections with 8% mortality in the United States annually. The subset of carbapenemase-producing CRE (CP-CRE) infections have much higher mortality rates (40% -50%). There has been little research on characteristics unique to CP-CRE. The goal of this study was to assess differences between those with nonCP-CRE and CP-CRE cultures in U.S. Veterans. METHODS A retrospective cohort of Veterans with CRE cultures from 2013-2018 and their demographic, medical, and facility level covariates were collected. Clustered multiple logistic regression models were used to assess independent factors associated with CP-CRE. RESULTS 3,096 unique patients with cultures positive for either nonCP-CRE or CP-CRE were included. Being African American (Odds Ratio (OR)=1.44 (95% Confidence Interval (CI) 1.15,1.80), diagnosis in 2017 (OR=3.11 (95% CI 2.13,4.54)) or 2018 (OR=3.93 (95%CI 2.64,5.84)), congestive heart failure (OR=1.35 (95%CI 1.11,1.64)), and gastroesophageal reflux disease (OR=1.39 (95%CI 1.03,1.87)) were associated with CP-CRE cultures. 752 (24.3%) patients had no known antibiotic exposure in the year before culture; these individuals had a comparatively increased frequency of prolonged PPI use (17.3% vs 5.6%). DISCUSSION Among a cohort of patients with CRE, African Americans, individuals with congestive heart failure, and patients with gastroesophageal reflux disease had greater odds of having a CP-CRE culture. Roughly one in four patients with CP-CRE had no known antibiotic exposure in the year before their positive culture.
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Affiliation(s)
- Geneva M Wilson
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines Jr. Veterans Affairs Hospital, Hines, IL,USA
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Heath Care System, Pittsburgh, PA, USA.,University of Pittsburgh School of Medicine, Department of Medicine, Pittsburgh, PA, USA
| | - Margaret A Fitzpatrick
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines Jr. Veterans Affairs Hospital, Hines, IL,USA.,Department of Medicine, Division of Infectious Diseases, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Brian Bartle
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines Jr. Veterans Affairs Hospital, Hines, IL,USA
| | - Christopher D Pfeiffer
- Department of Veterans Affairs, Portland VA Healthcare System, Portland, OR, USA.,Department of Medicine, Division of Infectious Diseases, Oregon Health Science University, Portland, OR, USA
| | - Makoto Jones
- Department of Veterans Affairs, VA Salt Lake City Healthcare System, Salt Lake City, UT, USA.,Department of Medicine, Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Michael A Rubin
- Department of Veterans Affairs, Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Eli Perencevich
- Department of Veterans Affairs, Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Martin Evans
- Department of Veterans Affairs, Lexington VA Medical Center, Lexington, KY, USA
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines Jr. Veterans Affairs Hospital, Hines, IL,USA.,Department of Preventive Medicine, Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Rogers J, Eastland T. Understanding the most commonly billed diagnoses in primary care: Gastroesophageal reflux disease. Nurse Pract 2021; 46:50-55. [PMID: 33739328 DOI: 10.1097/01.npr.0000737196.69218.b6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Gastroesophageal reflux disease (GERD) is a chronic, relapsing condition encountered commonly in primary care with an estimated worldwide prevalence of up to 33%. GERD affects all age groups, races, and genders with 25% of the population in the Western world experiencing heartburn at least once a month.
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Colonization Dynamics of Multidrug-Resistant Klebsiella pneumoniae Are Dictated by Microbiota-Cluster Group Behavior over Individual Antibiotic Susceptibility: A Metataxonomic Analysis. Antibiotics (Basel) 2021; 10:antibiotics10030268. [PMID: 33800048 PMCID: PMC8001907 DOI: 10.3390/antibiotics10030268] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/25/2021] [Accepted: 03/04/2021] [Indexed: 12/17/2022] Open
Abstract
Gastrointestinal carriage of multidrug-resistant (MDR) bacteria is one of the main risk factors for developing serious, difficult-to-treat infections. Given that there is currently no all-round solution to eliminate colonization with MDR bacteria, it is particularly important to understand the dynamic process of colonization to aid the development of novel decolonization strategies. The aim of our present study was to perform metataxonomic analyses of gut microbiota dynamics during colonization with an extended-spectrum β-lactamase (ESBL)- and carbapenemase-producing Klebsiella pneumoniae (ECKP) strain in mice; additionally, to ascertain the effects of antibiotic administration (ampicillin, ceftazidime, and ciprofloxacin) on the establishment and elimination of ECKP intestinal colonization. We have found that the phyla Bacteroidetes and Firmicutes were most dominant in all of the treatment groups; however, Bacteroidetes was more common in the groups treated with antibiotics compared to the control group. Significant differences were observed among the different antibiotic-treated groups in beta but not alpha diversity, implying that the difference is the relative abundance of some bacterial community members. Bacteria from the Lachnospiraceae family (including Agathobacter, Anaerostipes, Lachnoclostridium 11308, Lachnospiraceae UCG-004, Lachnospiraceae NK3A20 group 11318, Lachnospiraceae NK4A136 group 11319, Roseburia, and Tyzzerella) showed an inverse relationship with the carriage rate of the ECKP strain, whereas members of Enterobacteriaceae and the ECKP strain have shown a correlational relationship. Our results suggest that the composition of the microbial community plays a primary role in the MDR-colonization rate, whereas the antibiotic susceptibility of individual MDR strains affects this process to a lesser extent. Distinct bacterial families have associated into microbial clusters, collecting taxonomically close species to produce survival benefits in the gut. These associations do not develop at random, as they may be attributed to the presence of specific metabolomic networks. A new concept should be introduced in designing future endeavors for MDR decolonization, supplemented by knowledge of the composition of the host bacterial community and the identification of bacterial clusters capable of suppressing or enhancing the invader species.
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Lee TC, Goodwin Wilson M, Lawandi A, McDonald EG. Proton Pump Inhibitors Versus Histamine-2 Receptor Antagonists Likely Increase Mortality in Critical Care: An Updated Meta-Analysis. Am J Med 2021; 134:e184-e188. [PMID: 32931766 DOI: 10.1016/j.amjmed.2020.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Upper gastrointestinal bleeding is common among the critically ill. Recently, the Proton Pump Inhibitors (PPIs) vs. Histamine-2 Receptor Blockers for Ulcer Prophylaxis Therapy in the Intensive Care Unit (PEPTIC) trial suggested PPIs might increase mortality. We performed an updated meta-analysis to further inform discussion. METHODS We leveraged 2 recent systematic reviews to identify randomized controlled trials directly comparing PPIs and H-2 Receptor Antagonists (H2RAs) for stress ulcer prophylaxis in critically ill patients and reporting mortality. We extracted mortality data from each study and meta-analyzed them with the PEPTIC trial using a random effects model. RESULTS Of 28,559 total patients, 14,436 (50.5%) were allocated to PPI and 14,123 to H2RAs (49.5%). Compared to H2RAs, the pooled relative risk for mortality was 1.05 (95% confidence interval 1.00-1.10) with an estimated risk difference for mortality of 9 additional deaths per 1000 patients exposed to PPI (95% confidence interval 0-18); heterogeneity was low (I2 = 0%; P = 0.826). CONCLUSIONS Stress ulcer prophylaxis with PPIs likely increases mortality compared to H2RAs. Whether stress ulcer prophylaxis is beneficial in critical care remains open to further study.
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Affiliation(s)
- Todd C Lee
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montréal, Québec, Canada; Centre for Outcomes Research and Evaluation (CORE), Department of Medicine, Research Institute, McGill University Health Centre, Montréal, Québec, Canada.
| | - Marnie Goodwin Wilson
- Division of General Internal Medicine, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Alexander Lawandi
- Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Md
| | - Emily G McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montréal, Québec, Canada; Centre for Outcomes Research and Evaluation (CORE), Department of Medicine, Research Institute, McGill University Health Centre, Montréal, Québec, Canada
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Wilson GM, Fitzpatrick M, Walding K, Gonzalez B, Schweizer ML, Suda KJ, Evans CT. Meta-analysis of Clinical Outcomes Using Ceftazidime/Avibactam, Ceftolozane/Tazobactam, and Meropenem/Vaborbactam for the Treatment of Multidrug-Resistant Gram-Negative Infections. Open Forum Infect Dis 2021; 8:ofaa651. [PMID: 33598503 PMCID: PMC7875326 DOI: 10.1093/ofid/ofaa651] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/04/2021] [Indexed: 02/07/2023] Open
Abstract
Ceftolozane-tazobactam (C/T), ceftazidime-avibactam (C/A), and meropenem/vaborbactam (M/V) are new beta-lactam/beta-lactamase combination antibiotics commonly used to treat multidrug-resistant Pseudomonas aeruginosa (MDRPA) and carbapenem-resistant Enterobacteriaceae (CRE) infections. This review reports the clinical success rates for C/T, C/A, and M/V. PubMed and EMBASE were searched from January 1, 2012, through September 2, 2020, for publications detailing the use of C/T, C/A, and M/V. A meta-analysis determined the pooled effectiveness of C/T, C/A, and M/V. The literature search returned 1950 publications; 29 publications representing 1620 patients were retained. Pneumonia was the predominant infection type (49.8%). MDRPA was the major pathogen treated (65.3%). The pooled clinical success rate was 73.3% (95% CI, 68.9%-77.5%). C/T, C/A, or M/V resistance was reported in 8.9% of the population. These antibiotics had a high clinical success rate in patients with complicated infections and limited treatment options. Larger studies comparing C/T, C/A, and M/V against other antibiotic regimens are needed.
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Affiliation(s)
- Geneva M Wilson
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. Veterans Affairs Hospital, Hines, Illinois, USA
| | - Margaret Fitzpatrick
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. Veterans Affairs Hospital, Hines, Illinois, USA
- Loyola Medical Center, Maywood, Illinois, USA
| | | | - Beverly Gonzalez
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. Veterans Affairs Hospital, Hines, Illinois, USA
| | - Marin L Schweizer
- College of Public Health, University of Iowa, Iowa City, Iowa, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Heath Care System, Pittsburgh, Pennsylvania, USA
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. Veterans Affairs Hospital, Hines, Illinois, USA
- Department of Preventive Medicine, Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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D'Silva KM, Mehta R, Mitchell M, Lee TC, Singhal V, Wilson MG, McDonald EG. Proton pump inhibitor use and risk for recurrent Clostridioides difficile infection: a systematic review and meta-analysis. Clin Microbiol Infect 2021; 27:S1198-743X(21)00035-5. [PMID: 33465501 DOI: 10.1016/j.cmi.2021.01.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/04/2021] [Accepted: 01/09/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Proton pump inhibitor (PPI) therapy is a potentially modifiable risk factor for recurrent Clostridioides difficile infection (CDI). Citing an absence of clinical trials, many guidelines do not provide recommendations for addressing PPI management. Our aim was to perform an updated systematic review and meta-analysis evaluating the association between PPI use and recurrent CDI addressing prior methodological limitations. METHODS Data sources were MEDLINE and EMBASE. Eligible studies were cohort and case-control studies; there were no restrictions on study setting or duration of follow-up. Participants were adults with prior CDI who did or did not receive PPI therapy and were assessed for recurrent CDI. Summary (unadjusted) odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random effects model. Prespecified subgroup analyses were performed to explore heterogeneity including study design, study quality, duration of follow-up, adjustment for confounders, and outcome definition. RESULTS Sixteen studies were included in the meta-analysis, comprising 57 477 patients with CDI, of whom 6870 (12%) received PPIs. The rate of recurrent CDI was 24% in patients treated with PPIs versus 18% in those who were not. A meta-analysis that pooled unadjusted odds ratios demonstrated higher odds of recurrent CDI in patients who received PPIs (OR 1.69, 95%CI 1.46-1.96) versus those who did not. There was moderate heterogeneity between studies (I2 56%); however, a sensitivity analysis restricted to studies with 56 days of follow-up substantially reduced the heterogeneity (OR 1.59, 95%CI 1.36-1.85; I2 12%). An analysis restricted to multivariate studies that combined adjusted ORs also demonstrated higher odds of recurrent CDI in patients who received PPIs (OR 1.49, 95%CI 1.12-2.00). No publication bias was identified. CONCLUSIONS We found significantly higher odds of recurrent CDI among users of PPIs that persisted across multiple sensitivity analyses. These results support stronger recommendations for PPI stewardship at CDI diagnosis.
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Affiliation(s)
- Kristin M D'Silva
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
| | - Raaj Mehta
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
| | - Michael Mitchell
- Division of Respirology, Department of Medicine, Western University, London, Ontario, Canada
| | - Todd C Lee
- Clinical Practice Assessment Unit, McGill University Health Centre, Montreal, Canada; Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Vibha Singhal
- Division of Pediatric Endocrinology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Emily G McDonald
- Clinical Practice Assessment Unit, McGill University Health Centre, Montreal, Canada; Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada.
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Abrahami D, McDonald EG, Schnitzer M, Azoulay L. Trends in acid suppressant drug prescriptions in primary care in the UK: a population-based cross-sectional study. BMJ Open 2020; 10:e041529. [PMID: 33293322 PMCID: PMC7722810 DOI: 10.1136/bmjopen-2020-041529] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To examine proton pump inhibitor (PPI) and histamine-2 receptor antagonist (H2RA) prescribing patterns over a 29-year period by quantifying annual prevalence and prescribing intensity over time. DESIGN Population-based cross-sectional study. SETTING More than 700 general practices contributing data to the UK Clinical Practice Research Datalink (CPRD). PARTICIPANTS Within a cohort of 14 242 329 patients registered in the CPRD, 3 027 383 patients were prescribed at least one PPI or H2RA from 1 January 1990 to 31 December 2018. PRIMARY AND SECONDARY OUTCOME MEASURES Annual prescription rates were estimated by dividing the number of patients prescribed a PPI or H2RA by the total CPRD population. Change in prescribing intensity (number of prescriptions per year divided by person-years of follow-up) was calculated using negative binomial regression. RESULTS From 1990 to 2018, 21.3% of the CPRD population was exposed to at least one acid suppressant drug. During that period, PPI prevalence increased from 0.2% to 14.2%, while H2RA prevalence remained low (range: 1.2%-3.4%). Yearly prescribing intensity to PPIs increased during the first 15 years of the study period but remained relatively constant for the remainder of the study period. In contrast, yearly prescribing intensity of H2RAs decreased from 1990 to 2009 but has begun to slightly increase over the past 5 years. CONCLUSIONS While PPI prevalence has been increasing over time, its prescribing intensity has recently plateaued. Notwithstanding their efficacy, PPIs are associated with a number of adverse effects not attributed to H2RAs, whose prescribing intensity has begun to increase. Thus, H2RAs remain a valuable treatment option for individuals with gastric conditions.
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Affiliation(s)
- Devin Abrahami
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Québec, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Québec, Canada
| | - Emily Gibson McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Québec, Canada
- Division of Experimental Medicine, McGill University, Montreal, Québec, Canada
| | | | - Laurent Azoulay
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Québec, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Québec, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montreal, Québec, Canada
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Abstract
The Centers for Disease Control and Prevention estimates that VRE causes an estimated 54,000 infections and 539 million dollars in attributable health care costs annually. Despite improvements in hand washing, environmental cleaning, and antibiotic use, VRE is still prevalent in many hospitals. There is a pressing need to better understand the processes by which patients acquire VRE. Multiple lines of evidence suggest that intestinal microbiota may help some patients resist VRE acquisition. In this large case-control study, we compared the 16S profile of intestinal microbiota on admission in patients that did and did not subsequently acquire VRE. The 16S profile did not predict subsequent VRE acquisition, in part due to rapid and dramatic change in the gut microbiome following hospitalization. However, Blautia spp. present on admission predicted decreased Enterococcus abundance after VRE acquisition, and Lactobacillus spp. present on admission predicted Enterococcus dominance after VRE acquisition. Thus, VRE acquisition and domination may be distinct processes. Vancomycin-resistant Enterococcus (VRE) is a leading cause of hospital-acquired infections and continues to spread despite widespread implementation of pathogen-targeted control guidelines. Commensal gut microbiota provide colonization resistance to VRE, but the role of gut microbiota in VRE acquisition in at-risk patients is unknown. To address this gap in our understanding, we performed a case-control study of gut microbiota in hospitalized patients who did (cases) and did not (controls) acquire VRE. We matched case subjects to control subjects by known risk factors and “time at risk,” defined as the time elapsed between admission until positive VRE screen. We characterized gut bacterial communities using 16S rRNA gene amplicon sequencing of rectal swab specimens. We analyzed 236 samples from 59 matched case-control pairs. At baseline, case and control subjects did not differ in gut microbiota when measured by community diversity (P = 0.33) or composition (P = 0.30). After hospitalization, gut communities of cases and controls differed only in the abundance of the Enterococcus-containing operational taxonomic unit (OTU), with the gut microbiota of case subjects having more of this OTU than time-matched control subjects (P = 0.01). Otherwise, case and control communities after the time at risk did not differ in diversity (P = 0.33) or community structure (P = 0.12). Among patients who became VRE colonized, those having the Blautia-containing OTU on admission had lower Enterococcus relative abundance once colonized (P = 0.004). Our results demonstrate that the 16S profile of the gut microbiome does not predict VRE acquisition in hospitalized patients, likely due to rapid and profound microbiota change. The gut microbiome does not predict VRE acquisition, but it may be associated with Enterococcus expansion, suggesting that these should be considered two distinct processes. IMPORTANCE The Centers for Disease Control and Prevention estimates that VRE causes an estimated 54,000 infections and 539 million dollars in attributable health care costs annually. Despite improvements in hand washing, environmental cleaning, and antibiotic use, VRE is still prevalent in many hospitals. There is a pressing need to better understand the processes by which patients acquire VRE. Multiple lines of evidence suggest that intestinal microbiota may help some patients resist VRE acquisition. In this large case-control study, we compared the 16S profile of intestinal microbiota on admission in patients that did and did not subsequently acquire VRE. The 16S profile did not predict subsequent VRE acquisition, in part due to rapid and dramatic change in the gut microbiome following hospitalization. However, Blautia spp. present on admission predicted decreased Enterococcus abundance after VRE acquisition, and Lactobacillus spp. present on admission predicted Enterococcus dominance after VRE acquisition. Thus, VRE acquisition and domination may be distinct processes.
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Abstract
PURPOSE OF REVIEW The current review summarizes and attempts to place in proper perspective the past year's literature regarding purported adverse effects of proton pump inhibitors (PPIs). RECENT FINDINGS Although generally considered safe, physicians are inundated with retrospective database-driven epidemiologic studies, and meta-analyses on the same studies, claiming a panoply of serious adverse effects associated with long-term use of PPIs. The quality of the evidence underlying most of these associations is very low and cannot ascribe cause and effect. Nonetheless, these reports have stoked fears, in both prescribers and patients. As a result, patients are being harmed. Physicians are not prescribing PPIs when medically indicated and patients are stopping PPIs without consulting their caregivers. It is reassuring that a cross-sectional analysis of data from the National Ambulatory Medical Care Survey as well as a double-blinded, placebo-controlled trial report no safety concerns with PPIs, other than a possible small association with enteric infection. SUMMARY Most of the publicized serious putative adverse effects attributed to PPIs have been debunked in more recent and properly designed studies. Nevertheless, PPIs should be prescribed for valid indications and, when prescribed long-term, they should be used at the lowest effective dose and their ongoing need periodically assessed.
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Latest insights into the hot question of proton pump inhibitor safety - a narrative review. Dig Liver Dis 2020; 52:842-852. [PMID: 32513631 DOI: 10.1016/j.dld.2020.04.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 02/06/2023]
Abstract
Proton pump inhibitors (PPIs) are among the most widely prescribed medications worldwide and their use is continuously increasing. Although they have been shown to combine high therapeutic efficacy and good safety profile in many studies, in last years we have witnessed the publication of many articles reporting the possible association of long-term PPI therapy with important unexpected adverse events and these observations have created alarmism in both patients and physicians. However, the majority of these studies are observational, retrospective and prone to residual confounding. Also, the odds ratio values are generally comprised between 1 and 2 and therefore devoid of strong clinical relevance. As it is unlikely that prospective randomized trials will be ever done to reinforce these associations, we can only attempt to distinguish clear- from unclear-defined adverse events from the available literature. Nowadays we can reasonably exclude cardiovascular diseases, community-acquired pneumonia, all-cause mortality, dementia and bone fractures from PPI-related adverse events. However, physicians should be aware of the existence of possible risks when treating their patients, especially the elderly and frail ones, with long-term PPIs, which should be prescribed only to persons with defined indications and at lowest dose and duration.
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