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de Roux Q, Disli Y, Bougouin W, Renaudier M, Jendoubi A, Merle JC, Delage M, Picard L, Sayagh F, Cherait C, Folliguet T, Quesnel C, Becq A, Mongardon N. Upper gastrointestinal bleeding on veno-arterial extracorporeal membrane oxygenation support. Ann Intensive Care 2024; 14:104. [PMID: 38958791 PMCID: PMC11222359 DOI: 10.1186/s13613-024-01326-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/29/2024] [Indexed: 07/04/2024] Open
Abstract
INTRODUCTION Patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support are at a high risk of hemorrhagic complications, including upper gastrointestinal bleeding (UGIB). The objective of this study was to evaluate the incidence and impact of this complication in V-A ECMO patients. MATERIALS AND METHODS A retrospective single-center study (2013-2017) was conducted on V-A ECMO patients, excluding those who died within 24 h. All patients with suspected UGIB underwent esophagogastroduodenoscopy (EGD) and were analyzed and compared to the remainder of the cohort, from the initiation of ECMO until 5 days after explantation. RESULTS A total of 150 V-A ECMO cases (65 after cardiac surgery and 85 due to medical etiology) were included. 90% of the patients received prophylactic proton pump inhibitor therapy and enteral nutrition. Thirty-one patients underwent EGD for suspected UGIB, with 16 confirmed cases of UGIB. The incidence was 10.7%, with a median occurrence at 10 [7-17] days. There were no significant differences in clinical or biological characteristics on the day of EGD. However, patients with UGIB had significant increases in packed red blood cells and fresh frozen plasma needs, mechanical ventilation duration and V-A ECMO duration, as well as in length of intensive care unit and hospital stays. There was no significant difference in mortality. The only independent risk factor of UGIB was a history of peptic ulcer (OR = 7.32; 95% CI [1.07-50.01], p = 0.042). CONCLUSION UGIB occurred in at least 1 out of 10 cases of V-A ECMO patients, with significant consequences on healthcare resources. Enteral nutrition and proton pump inhibitor prophylaxis did not appear to protect V-A ECMO patients. Further studies should assess their real benefits in these patients with high risk of hemorrhage.
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Affiliation(s)
- Quentin de Roux
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France.
- U955-IMRB, Equipe 03 "Stratégies pharmacologiques et thérapeutiques expérimentales des insuffisances cardiaques et coronaires", Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, Maisons-Alfort, France.
- Service d'Anesthésie-Réanimation et Médecine Péri-Opératoire, CHU Henri Mondor, 1 rue Gustave Eiffel, Créteil, 94000, France.
| | - Yekcan Disli
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Wulfran Bougouin
- Réanimation polyvalente, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, Massy, France
- AfterROSC research group, Paris, France
| | - Marie Renaudier
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Ali Jendoubi
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Jean-Claude Merle
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Mathilde Delage
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Lucile Picard
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Faiza Sayagh
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Chamsedine Cherait
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Thierry Folliguet
- Service de chirurgie cardiaque, Assistance Publique-Hôpitaux de Paris, DMU CARE, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France
| | - Christophe Quesnel
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France
| | - Aymeric Becq
- Service de gastro-entérologie, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France
| | - Nicolas Mongardon
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France
- U955-IMRB, Equipe 03 "Stratégies pharmacologiques et thérapeutiques expérimentales des insuffisances cardiaques et coronaires", Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, Maisons-Alfort, France
- AfterROSC research group, Paris, France
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Zhao JL, Tofani C, Infantolino A. An Updated Review and a Case Report: Stress Ulcer Prophylaxis. Cureus 2024; 16:e60811. [PMID: 38910681 PMCID: PMC11190804 DOI: 10.7759/cureus.60811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2024] [Indexed: 06/25/2024] Open
Abstract
After encountering a unique patient case, we revisit the updated literature on stress ulcer prophylaxis with more updated studies. A 47-year-old male came to the hospital and was found to have acute cholecystitis. After undergoing urgent cholecystectomy, the patient developed melena and a 6 mg/dL drop from 12.5 g/dL to 6.5 g/dL in hemoglobin. He was found to have a gastric ulcer and was started on a proton pump inhibitor, which posed the question of whether or not stress ulcer prophylaxis was indicated. Therefore, the pathophysiology of stress ulcer prophylaxis is refreshed, discussing the various mechanisms through which stress ulcers form in a clinical context. Then, the main risk factors and indications for stress ulcer prophylaxis are defined based on current literature, further investigating whether or not stress ulcer prophylaxis has shown benefit and protection in various patient groups. Additionally, this review discusses the adverse effects of stress ulcer prophylaxis, including dysbiosis, community-acquired pneumonia, nutritional deficiencies, drug interactions, and fractures. Finally, inappropriate stress ulcer prophylaxis and contributing factors to overutilization are discussed, and alternative approaches to prevent stress ulcer formation are covered, including early enteral nutrition. Overall, there are mixed conclusions on the effectiveness of stress ulcer prophylaxis in noncritical patients. There are many adverse effects and unnecessary costs associated with inappropriate administration, and many studies have found that it should be reserved for specific clinical indications.
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Affiliation(s)
- Joy L Zhao
- Department of Gastroenterology and Hepatology, Sidney Kimmel Medical College, Philadelphia, USA
| | - Christina Tofani
- Division of Gastroenterology and Hepatology, Cooper University Hospital, Mount Laurel, USA
| | - Anthony Infantolino
- Division of Gastroenterology and Hepatology, Cooper University Hospital, Mount Laurel, USA
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3
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Reynolds PM, Wells L, Powell M, MacLaren R. Associated Mortality Risk of Proton Pump Inhibitor Therapy for the Prevention of Stress Ulceration in Intensive Care Unit Patients: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2023; 57:586-594. [PMID: 35648972 DOI: 10.1097/mcg.0000000000001723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 04/27/2022] [Indexed: 12/10/2022]
Abstract
GOALS The aim was to systematically evaluate risks and benefits of proton pump inhibitor (PPI) use for stress ulcer prophylaxis in the critically ill patient. BACKGROUND Whether PPIs increase mortality in the critically ill patient remains controversial. STUDY Systematic review and meta-analysis of randomized controlled trials (RCTs) and cohort studies with trial sequential analysis, Bayesian sensitivity analysis, and fragility index analysis. RESULTS A total of 31 studies in 78,009 critically ill adults receiving PPIs versus any comparator were included. PPI use was associated with an increased mortality risk in all studies [19.6% PPI vs. 17.5% comparator; RR: 1.10; 95% confidence interval (CI): 1.02-1.20; P =0.01], in the subgroup of RCTs (19.4% vs. 18.7%; RR: 1.05; 95% CI: 1.0-1.09, P =0.04), but not cohort studies (19.9% vs. 16.7%; RR: 1.12; 95% CI: 0.98-1.28, P =0.09). Results were maintained with a Bayesian sensitivity analysis (RR: 1.13; 95% credible interval: 1.035-1.227) and a fragility index analysis, but not sequential analysis ( P =0.16). RCTs with a higher baseline severity of illness revealed the greatest mortality risk with PPI use (32.1% PPI vs. 29.4% comparator; RR: 1.09; 95% CI: 1.04-1.14; P <0.001). PPI use reduced clinically important bleeding in RCTs (1.4% PPI vs. 2.1% comparator; RR: 0.67; 95% CI: 0.5-0.9; P =0.009) but increased bleeding in cohort studies (2.7% PPI vs. 1.2% comparator; RR: 2.05; 95% CI: 1.2-3.52; P =0.009). PPI use was not associated with a lower incidence of clinically important bleeding when compared with histamine-2 receptor antagonists (1.3% vs. 1.9%; RR: 0.59; 95% CI: 0.28-1.25, P =0.09). CONCLUSIONS This meta-analysis demonstrated an association between PPI use and an increased risk of mortality.
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Affiliation(s)
- Paul M Reynolds
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver, CO
| | - Lauren Wells
- PGY2 Emergency Medicine Pharmacy Resident, Froedtert and the Medical College of Wisconsin, Wauwatosa, WI
| | | | - Robert MacLaren
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver, CO
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4
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Borthwick M, Granholm A, Marker S, Krag M, Lange T, Wise MP, Bendel S, Keus F, Guttormsen AB, Schefold JC, Wetterslev J, Perner A, Møller MH. Associations between enteral nutrition and outcomes in the SUP-ICU trial: Protocol for exploratory post hoc analyses. Acta Anaesthesiol Scand 2023; 67:481-486. [PMID: 36636785 DOI: 10.1111/aas.14194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/01/2023] [Indexed: 01/14/2023]
Abstract
Critically ill patients are at risk of gastrointestinal (GI) bleeding. Counter measures to minimise this risk include the use of pharmacological stress ulcer prophylaxis (SUP). The effect of enteral nutrition as SUP on GI bleeding event rates is unknown. There are conflicting data describing the effect of co-administration of enteral nutrition with pharmacological SUP, and there is substantial variation in practice. We aim to conduct an exploratory post hoc analysis to evaluate the association of enteral nutrition with clinically important GI bleed rates in ICU patients included in the SUP-ICU trial, and to explore any interactions between enteral nutrition and pharmacologic SUP on patient outcomes. The SUP-ICU trial dataset will be used to assess if enteral nutrition is associated with the outcomes of interest. Extended Cox models will be used considering relevant competing events, including treatment allocation (SUP or placebo) and enteral nutrition as a daily time-varying covariate, with additional adjustment for severity of illness (SAPS II). Results will be presented as adjusted hazard ratios for treatment allocation and enteral nutrition, and for treatment allocation and enteral nutrition considering potential interactions with the other variable, all with 95% confidence intervals and p-values for the tests of interaction. All results will be considered as exploratory only. This post hoc analysis may yield important insights to guide practice and inform the design of future randomised clinical trial investigating the effect of enteral nutrition on GI bleeding.
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Affiliation(s)
- Mark Borthwick
- Departments of Pharmacy and Critical Care, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Anders Granholm
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Søren Marker
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Mette Krag
- Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Intensive Care, Holbaek Hospital, Holbaek, Denmark
| | - Theis Lange
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
- Centre for Statistical Science, Peking University, Beijing, China
| | - Matt P Wise
- Department of Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Stepani Bendel
- Department of Intensive Care Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Frederik Keus
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Anne Berit Guttormsen
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, University of Bern, Bern, Switzerland
| | - Jørn Wetterslev
- Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
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Reynolds PM, Stefanos S, MacLaren R. Restrictive resuscitation in patients with sepsis and mortality: A systematic review and meta-analysis with trial sequential analysis. Pharmacotherapy 2023; 43:104-114. [PMID: 36625778 PMCID: PMC10634281 DOI: 10.1002/phar.2764] [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: 09/28/2022] [Revised: 11/11/2022] [Accepted: 12/04/2022] [Indexed: 01/11/2023]
Abstract
STUDY OBJECTIVE Although fluid resuscitation is recommended by the Society of Critical Care Medicine Surviving Sepsis Campaign Guidelines, risks of volume overload persist.The objective of this systematic review is to assess the effects of a restrictive fluid resuscitation approach in the septic patient both during and after the initial resuscitation period (30 ml/kg). DESIGN A systematic review and meta-analysis with trial sequential analysis (TSA) of randomized controlled trials was conducted. Two blinded reviewers independently assessed and included studies that evaluated adult patients with sepsis involving a comparator group with an effective restrictive fluid resuscitation approach. The primary outcome was mortality. Secondary outcomes included rates of acute kidney injury (AKI), renal replacement therapy (RRT), ventilator days, intensive care unit (ICU) and hospital length of stay (LOS), duration of vasopressor therapy, and limb (or digital) ischemia. SETTING PubMed and Medline databases were queried for the search. PATIENTS A total of eight trials in 2375 patients were included. INTERVENTION Effective restrictive fluid resuscitation compared with standard of care. MEASUREMENTS AND MAIN RESULTS The risk of bias was high in six studies and low in two studies, and all studies implemented fluid restriction after a 30-ml/kg infusion of fluids. Fluid restriction did not significantly reduce mortality in all studies compared to usual care (37% vs. 40% with usual care; risk ratio [RR] 0.90, 95% confidence interval [CI] 0.76-1.06, p = 0.23, I2 = 24%) or by TSA findings. There were no significant differences in rates of AKI or RRT (5 studies), LOS in ICU (4 studies) or hospital (3 studies), duration of vasopressor therapy (6 studies), or incidence of limb or digital ischemia (3 studies). However, fluid restriction significantly reduced ventilator days as evaluated in seven studies (mean difference - 1.25 days, 95% CI -1.92 to -0.58 days, p = 0.0003, I2 = 90%). CONCLUSION This study demonstrated that a restrictive resuscitation strategy in sepsis resulted in no difference in mortality but may reduce ventilator days. Larger randomized trials are required to determine the optimal management of fluids in patients with sepsis.
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Affiliation(s)
- Paul M Reynolds
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
- Department of Clinical Pharmacy, Denver VA Medical Center, Aurora, Colorado, USA
| | - Sylvia Stefanos
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
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6
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Meng R, Chen LR, Zhang ML, Cai WK, Yin SJ, Fan YX, Zhou T, Huang YH, He GH. Effectiveness and Safety of Histamine H2 Receptor Antagonists: An Umbrella Review of Meta-Analyses. J Clin Pharmacol 2023; 63:7-20. [PMID: 36039014 DOI: 10.1002/jcph.2147] [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: 06/16/2022] [Accepted: 08/24/2022] [Indexed: 12/15/2022]
Abstract
Histamine H2 receptor antagonists (H2RAs) were widely used to inhibit gastric acid secretion, but its association with adverse events remains controversial and unclear. We conducted an umbrella review of meta-analyses to systematically assess the quality and credibility of the correlations between H2RA use with the risk of adverse outcomes through searching 4 major databases from inception to April 30, 2022. Forty-six individual meta-analyses were identified, including 29 meta-analyses of observation studies with 32 unique outcomes and 19 meta-analyses of randomized controlled trials with 3 unique outcomes for comparing the H2RA versus non-H2RA group. A Measurement Tool to Assess Systematic Reviews 2 rating for the included meta-analyses showed that 4 of 46 meta-analyses were assigned as high scores, 3 were assigned as "moderate," and 25 were assigned as low scores. Grading of Recommendations Assessment, Development and Evaluation assessment for combined results demonstrated that 6 outcomes were rated as "moderate," 9 outcomes were rated as "low," and 17 outcomes were rated as "very low." We confirmed significant associations of H2RA use with pneumonia, peritonitis, necrotizing enterocolitis, Clostridium difficile infection, liver cancer, gastric cancer, and hip fracture diseases. No associations for colorectal cancer, melanoma, kidney cancer, lung cancer, or common reproductive system cancer or renal, neurological, and cardiovascular system diseases were observed. We found a variety of evidence for the associations between H2RAs and adverse outcomes, which would give clinicians more positive guidance on prescription of H2RAs in clinical practice.
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Affiliation(s)
- Rui Meng
- Department of Clinical Pharmacy, 920th Hospital of Joint Logistics Support Force of People's Liberation Army, Kunming, China.,Kunming Medical University, Kunming, China
| | - Li-Rong Chen
- Department of Clinical Pharmacy, 920th Hospital of Joint Logistics Support Force of People's Liberation Army, Kunming, China
| | - Man-Li Zhang
- Department of Clinical Pharmacy, 920th Hospital of Joint Logistics Support Force of People's Liberation Army, Kunming, China.,Kunming Medical University, Kunming, China
| | - Wen-Ke Cai
- Department of Cardio-Thoracic Surgery, 920th Hospital of Joint Logistics Support Force of People's Liberation Army, Kunming, China
| | - Sun-Jun Yin
- Department of Clinical Pharmacy, 920th Hospital of Joint Logistics Support Force of People's Liberation Army, Kunming, China
| | - Yu-Xin Fan
- Department of Clinical Pharmacy, 920th Hospital of Joint Logistics Support Force of People's Liberation Army, Kunming, China
| | - Tao Zhou
- Department of Clinical Pharmacy, 920th Hospital of Joint Logistics Support Force of People's Liberation Army, Kunming, China
| | - Yan-Hua Huang
- Department of Clinical Pharmacy, 920th Hospital of Joint Logistics Support Force of People's Liberation Army, Kunming, China
| | - Gong-Hao He
- Department of Clinical Pharmacy, 920th Hospital of Joint Logistics Support Force of People's Liberation Army, Kunming, China
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Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, Lee G, Maragakis LL, Powell K, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 43:687-713. [PMID: 35589091 PMCID: PMC10903147 DOI: 10.1017/ice.2022.88] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard Branson
- Department of Surgery, University of Cincinnati Medicine, Cincinnati, Ohio
| | - Kelly Cawcutt
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew Crist
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric C Eichenwald
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda R Greene
- Highland Hospital, University of Rochester, Rochester, New York
| | - Grace Lee
- Stanford University School of Medicine, Palo Alto, California
| | - Lisa L Maragakis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Krista Powell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gregory P Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Kathleen Speck
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah S Yokoe
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sean M Berenholtz
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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8
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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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9
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Impact of clinical pharmacists on adherence to stress ulcer prophylaxis protocol in critically ill Egyptian patients: a comparative study. DRUGS & THERAPY PERSPECTIVES 2021. [DOI: 10.1007/s40267-020-00786-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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10
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Major publications in the critical care pharmacotherapy literature: 2019. J Crit Care 2020; 62:197-205. [PMID: 33422810 DOI: 10.1016/j.jcrc.2020.12.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 12/07/2020] [Accepted: 12/20/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE To summarize selected meta-analyses and trials related to critical care pharmacotherapy published in 2019. MATERIALS AND METHODS The Critical Care Pharmacotherapy Literature Update (CCPLU) Group screened 36 journals monthly for impactful articles and reviewed 113 articles during 2019 according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria. RESULTS Articles with a 1A grade, including three clinical practice guidelines, six meta-analyses, and five original research trials are reviewed here from those included in the monthly CCPLU. Clinical practice guidelines on the use of polymyxins and antiarrhythmic drugs in cardiac arrest as well as meta-analyses on antipsychotic use in delirium, stress ulcer prophylaxis (SUP), and vasoactive medications in septic shock and cardiac arrest were summarized. Original research trials evaluated delirium, sedation, neuromuscular blockade, SUP, anticoagulation reversal, and hemostasis. CONCLUSION This clinical review and expert opinion provides summary and perspectives of clinical practice impact on influential critical care pharmacotherapy publications in 2019.
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Madhuvu A, Endacott R, Plummer V, Morphet J. Ventilation bundle compliance in two Australian intensive care units: An observational study. Aust Crit Care 2020; 34:327-332. [PMID: 33268313 PMCID: PMC8205301 DOI: 10.1016/j.aucc.2020.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 11/15/2022] Open
Abstract
Background The ventilation bundle has been used in adult intensive care units to decrease harm and improve quality of care for mechanically ventilated patients. The ventilation bundle focuses on prevention of specific complications of mechanical ventilation; ventilator-associated pneumonia, sepsis, barotrauma, pulmonary oedema, pulmonary embolism, and acute respiratory distress syndrome. The Institute for Healthcare Improvement ventilation bundle consists of five structured evidence-based interventions: head of the bed elevation at 30–45°; daily sedation interruptions and assessment of readiness to extubate; peptic ulcer prophylaxis; deep vein thrombosis prophylaxis; and daily oral care with chlorhexidine. Objectives The objective of the study was to evaluate the use of the ventilation bundle in two intensive care units in Victoria, Australia. Methods This is a 3-month prospective observational study in two intensive care units. Patient medical records were reviewed on days 3, 4, and 5 of mechanical ventilation using a prevalidated ventilation bundle checklist. Results A total of 96 critically ill patients required mechanical ventilation for more than 2 d. Patients had a mean age of 64.50 y (standard deviation = 14.89), with an Acute Physiology, Age, Chronic Health Evaluation (APACHE) III mean score of 79.27 (standard deviation = 27.11). The mean ventilation bundle compliance rate was 88.3% on the three consecutive mechanical ventilation days (day 3 = 79.4%, day 4 = 91.1%, and day 5 = 96.7%). There was a statistically significant difference in the mean APACHE III score between patients who had head of bed elevation and those without head of bed elevation, on days 3 (p = <0.001) and 4 (p = 0.007). Conclusion The ventilation bundle elements were used in Australian intensive care units. The likelihood of having all ventilation bundle elements on day 3 was low if the patient's APACHE III score was high. However, the ventilation bundle compliance rate increased with mechanical ventilation days.
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Affiliation(s)
- Auxillia Madhuvu
- School of Nursing and Midwifery, Monash University, McMahons Road, Frankston, Victoria, Australia; Monash Health, Dandenong Hospital, 135 David Street, Dandenong, Victoria, Australia.
| | - Ruth Endacott
- School of Nursing and Midwifery, Monash University, McMahons Road, Frankston, Victoria, Australia; Plymouth University/Royal Devon and Exeter Hospital Clinical School, Drake Circus, Plymouth, Devon, PL4 8AA, United Kingdom
| | - Virginia Plummer
- School of Nursing and Midwifery, Monash University, McMahons Road, Frankston, Victoria, Australia; School of Nursing and Healthcare Professions, Federation University, Berwick, Victoria, Australia
| | - Julia Morphet
- School of Nursing and Midwifery, Monash University, McMahons Road, Frankston, Victoria, Australia; Monash Health, Dandenong Hospital, 135 David Street, Dandenong, Victoria, Australia
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Dargent A, Jacquier M, Rozencwajg S, Andreu P, Quenot JP. Stress ulcer prophylaxis in ICU patients: Answers and questions from the PEPTIC trial. Anaesth Crit Care Pain Med 2020; 39:175-177. [PMID: 32147580 DOI: 10.1016/j.accpm.2020.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Auguste Dargent
- Médecine Intensive Réanimation, Hôpital Édouard-Herriot, 69003 Lyon, France
| | - Marine Jacquier
- Service de Médecine Intensive Réanimation, CHU Dijon-Bourgogne, 21000 Dijon, France
| | - Sacha Rozencwajg
- Service de Réanimation Chirurgicale, CHU Bichat-Claude-Bernard, 75018 Paris, France; Junior Group of the French Society of Anaesthesia and Intensive Care Medicine (Groupe Jeunes de la SFAR), 75016 Paris, France
| | - Pascal Andreu
- Service de Médecine Intensive Réanimation, CHU Dijon-Bourgogne, 21000 Dijon, France
| | - Jean-Pierre Quenot
- Service de Médecine Intensive Réanimation, CHU Dijon-Bourgogne, 21000 Dijon, France; INSERM, U1231, Équipe Lipness, Université Bourgogne-Franche-Comté, 21000 Dijon, France; INSERM, CIC-EC 1432, Faculté des sciences de la santé, 21000 Dijon, France.
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Abstract
PURPOSE OF REVIEW Stress ulcer prophylaxis in critically-ill patients has been a subject of extensive research, with multiple clinical trials attempting to study the best method of stress ulcer prophylaxis with the least adverse effects. Until recently, pharmacologic prophylaxis has prevailed as the primary choice for the prevention of stress ulcers but recent clinical studies have attempted to evaluate the role of enteral nutrition in stress ulcer prophylaxis. RECENT FINDINGS The incidence of stress ulcers that result in clinically important gastrointestinal bleeding (CIGIB) has drastically decreased over the last two decades. Furthermore, in the current era CIGB in the ICU does not seem to be associated with an increased mortality. Multiple recent clinical studies aimed to evaluate the role of proton pump inhibitors (PPIs) in patients who tolerate enteral nutrition in the ICU. SUMMARY The results of multiple recent clinical studies call for re-evaluation of the routine use of PPIs in critically ill patients who tolerates enteral nutrition in the ICU. Despite the promising preliminary results, definitive recommendations need larger clinical trials that are powered to evaluate any added benefits of using PPI in critically ill patients who tolerate enteral nutrition given the low incidence of CIGB in the current era.
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Antonelli M, Martin-Loeches I, Dimopoulos G, Gasbarrini A, Vallecoccia MS. Clostridioides difficile (formerly Clostridium difficile) infection in the critically ill: an expert statement. Intensive Care Med 2020; 46:215-224. [PMID: 31938827 DOI: 10.1007/s00134-019-05873-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 11/16/2019] [Indexed: 02/07/2023]
Abstract
Clostridioides difficile (formerly Clostridium difficile) infection (CDI) represents a worrisome condition, often underestimated, with severe clinical presentations, frequently requiring intensive care unit (ICU) admission. The aim of the present expert statement was to give an overview of the management of CDI in critically ill patients, for whom CDI represents a redoubtable problem, in large part related to the use and abuse of antibiotics. The available knowledge about pathophysiology, risk factors, diagnosis and treatment concerning critical care patients affected by CDI has been reviewed, even though most of the existing information come from studies performed outside the ICU and the evidence on several issues in this specific context is scarce. The adoption of potential preventive and therapeutic strategies aimed to stem the phenomenon were discussed, including the faecal microbiota transplantation. This possibility could represent a highly interesting option in critically ill patients, but current evidence is limited and future well designed studies are needed. A special insight on the specific challenges that the ICU physicians may face caring for the critically ill patients with CDI was also proposed.
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Affiliation(s)
- Massimo Antonelli
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
- Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, St James Street, Dublin 8, Dublin, Ireland
- Hospital Clinic, IDIBAPS, Universidad de Barcelona, Ciberes, Barcelona, Spain
| | - George Dimopoulos
- Critical Care Department, ATTIKON University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonio Gasbarrini
- Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Sole Vallecoccia
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
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The Phylogeny and Biological Function of Gastric Juice-Microbiological Consequences of Removing Gastric Acid. Int J Mol Sci 2019; 20:ijms20236031. [PMID: 31795477 PMCID: PMC6928904 DOI: 10.3390/ijms20236031] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 11/24/2019] [Accepted: 11/25/2019] [Indexed: 12/15/2022] Open
Abstract
Gastric juice is a unique combination of hydrochloric acid (HCl), lipase, and pepsin. Acidic gastric juice is found in all vertebrates, and its main function is to inactivate microorganisms. The phylogenetic preservation of this energy-consuming and, at times, hazardous function (acid-related diseases) reflects its biological importance. Proton pump inhibitors (PPIs) are one of the most widely used drugs in the world. Due to the reduced prevalence of Helicobacter pylori infection as well as the increased use of inhibitors of gastric acid secretion, the latter has become the most important cause of gastric hypoacidity. In the present manuscript, we review the microbiological consequences of removing gastric acidity. The resulting susceptibility to infections has not been studied extensively, and focus has mainly been restricted to bacterial and parasitic agents only. The strongest evidence concerning the relationship between hypochlorhydria and predisposition to infections relates to bacterial infections affecting the gastrointestinal tract. However, several other clinical settings with increased susceptibility to infections due to inhibited gastric acidity are discussed. We also discuss the impact of hypochlorhydria on the gut microbiome.
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Zhou X, Fang H, Xu J, Chen P, Hu X, Chen B, Wang H, Hu C, Xu Z. Stress ulcer prophylaxis with proton pump inhibitors or histamine 2 receptor antagonists in critically ill adults - a meta-analysis of randomized controlled trials with trial sequential analysis. BMC Gastroenterol 2019; 19:193. [PMID: 31752703 PMCID: PMC6873751 DOI: 10.1186/s12876-019-1105-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 10/30/2019] [Indexed: 02/08/2023] Open
Abstract
Background Proton pump inhibitors (PPI) and histamine 2 receptor antagonists (H2RA) have been widely used as stress ulcer prophylaxis (SUP) in critically ill patients, however, its efficacy and safety remain unclear. This study aimed to assess the effect of SUP on clinical outcomes in critically ill adults. Methods Literature search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane database of clinical trials for randomized controlled trials (RCTs) that investigated SUP, with PPI or H2RA, versus placebo or no prophylaxis in critically ill patients from database inception through 1 June 2019. Study selection, data extraction and quality assessment were performed in duplicate. The primary outcomes were clinically important gastrointestinal (GI) bleeding and overt GI bleeding. Conventional meta-analysis with random-effects model and trial sequential analysis (TSA) were performed. Results Twenty-nine RCTs were identified, of which four RCTs were judged as low risk of bias. Overall, SUP could reduce the incident of clinically important GI bleeding [relative risk (RR) = 0.58; 95% confidence intervals (CI): 0.42–0.81] and overt GI bleeding (RR = 0.48; 95% CI: 0.36–0.63), these results were confirmed by the sub-analysis of trials with low risk of bias, TSA indicated a firm evidence on its beneficial effects on the overt GI bleeding (TSA-adjusted CI: 0.31–0.75), but lack of sufficient evidence on the clinically important GI bleeding (TSA-adjusted CI: 0.23–1.51). Among patients who received enteral nutrition (EN), SUP was associated with a decreased risk of clinically important GI bleeding (RR = 0.61; 95% CI: 0.44–0.85; TSA-adjusted CI: 0.16–2.38) and overt GI bleeding (RR = 0.64; 95% CI: 0.42–0.96; TSA-adjusted CI: 0.12–3.35), but these benefits disappeared after adjustment with TSA. Among patients who did not receive EN, SUP had only benefits in reducing the risk of overt GI bleeding (RR = 0.37; 95% CI: 0.25–0.55; TSA-adjusted CI: 0.22–0.63), but not the clinically important GI bleeding (RR = 0.27; 95% CI: 0.04–2.09). Conclusions SUP has benefits on the overt GI bleeding in critically ill patients who did not receive EN, however, its benefits on clinically important GI bleeding still needs more evidence to confirm.
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Affiliation(s)
- Xiaoyang Zhou
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Hanyuan Fang
- Department of Emergency, Ningbo Yinzhou No.2 Hospital, Ningbo, 315000, Zhejiang, China
| | - Jianfei Xu
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Peifu Chen
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Xujun Hu
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Bixin Chen
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Hua Wang
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Caibao Hu
- Department of Intensive Care Medicine, Zhejiang Hospital, Hangzhou, 310000, Zhejiang, China.
| | - Zhaojun Xu
- Department of Intensive Care Medicine, HwaMei Hospital, University Of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China.
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Barletta JF, Buckley MS, MacLaren R. The SUP-ICU Trial: Does It Confirm or Condemn the Practice of Stress Ulcer Prophylaxis? Hosp Pharm 2019; 55:96-101. [PMID: 32214442 DOI: 10.1177/0018578719867687] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose: Stress ulcer prophylaxis (SUP) is routinely administered to critically ill patients for the prevention of stress ulcer-induced, clinically important bleeding (CIB). Recently, the value of SUP has been questioned due to the perceived decline in CIB and the potential for infectious complications secondary to acid suppressive therapy. The SUP-ICU trial is a large, randomized controlled trial comparing intravenous pantoprazole with placebo for the indication of SUP. It is hoped that this trial would answer many of the questions pertaining to the overall value of SUP. This article will provide an in-depth assessment of the SUP-ICU trial in the context of the overall body of literature in this area. Furthermore, applications for clinical practice and recommendations on the provision of SUP are provided. Summary: The SUP-ICU trial revealed no difference in the primary outcome of 90-day mortality with pantoprazole but lower rates of CIB were noted (which was a secondary outcome). Overall, these data provide important insight into the value of SUP along with other questions related to the provision of SUP such as the relationship between CIB and mortality, infectious complications, and enteral nutrition. Conclusions: The SUP-ICU trial is a landmark trial describing the value of SUP in a modern-day setting of intensive care unit (ICU) practice. The provision of SUP should be continued in high-risk patients. Future studies are ongoing that will add further insight to this routine practice.
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Leedahl DD, Personett HA, Nagpal A, Barreto EF. Prevention of Clostridium difficile Infection in Critically Ill Adults. Pharmacotherapy 2019; 39:399-407. [PMID: 30506900 DOI: 10.1002/phar.2200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The incidence and severity of Clostridium difficile infection (CDI) remain high across intensive care units in the United States despite national efforts to decrease this escalating health care burden. Most published literature and guidelines address treatment rather than prevention, yet this approach may be too downstream to limit morbidity and mortality from the disease and its complications. Mechanisms to prevent CDI successfully include reducing modifiable risk factors and minimizing horizontal transmission of C. difficile spores between patients and the health care environment. Because CDI prevention is characterized by a bundled approach, it is difficult to quantify the individual impact of any one element; however, a number of patient- and facility-level strategies can be considered for CDI prevention. Robust hygiene strategies, diagnostic and antimicrobial stewardship, and particular prophylaxis maneuvers such as continuation of oral vancomycin or fidaxomicin in the setting of systemic antibiotics have all demonstrated benefit. The preventive roles of deprescribing acid suppressants, routine use of probiotics, or early fecal microbiota transplantation remain unclear. The focus of this review is to summarize the evidence related to primary and secondary CDI prevention in critically ill adults and provide a concise implementation pathway for clinicians and policymakers.
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Affiliation(s)
- David D Leedahl
- Pharmacy Services, Sanford Medical Center, Fargo, North Dakota
| | | | - Avish Nagpal
- Infectious Diseases, Sanford Medical Center, Fargo, North Dakota
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
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Welchen Stellenwert haben Protonenpumpeninhibitoren im Rahmen der Prophylaxe von Stressulzerationen und stressassoziierten gastrointestinalen Blutungen bei Patienten auf Intensivstation? Med Klin Intensivmed Notfmed 2018; 114:350-354. [DOI: 10.1007/s00063-018-0515-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 11/16/2018] [Indexed: 12/23/2022]
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