Antibacterial activity of sucralfate versus aluminum chloride in simulated gastric fluid

A pilot study investigating the in vitro efficacy of sucralfate against common veterinary cutaneous pathogens

OBJECTIVE

To determine whether Cicalfate® (Avene), a commercially available skin cream, or its active ingredient - sucralfate - demonstrate in vitro antimicrobial effect against common veterinary cutaneous pathogens.

MATERIALS AND METHODS

Prospective study assessing in vitro susceptibility of standardised and clinical strains of common veterinary cutaneous pathogens to titrated concentrations of sucralfate in either saline solution (range 0∙2 to 200 mg/mL) or in Cicalfate® restorative cream solubilised in DMSO (range 0∙002 to 1 mg/mL). Minimum inhibitory concentrations were determined by broth dilution in accordance with Clinical and Laboratory Standards Institute guidelines.

RESULTS

Both solutions demonstrated in vitro inhibitory effects against strains of Proteus mirabilis, Pseudomonas aeruginosa, Staphylococcus aureus, Staphylococcus pseudintermedius, Escherichia coli and Enterococcus faecalis. Minimum inhibitory concentration ranges for susceptible bacteria tested in Cicalfate® solution and sucralfate solution were 0∙06 to 0∙25 mg/mL and 25 to 50 mg/mL, respectively. Sucralfate solution did not demonstrate antimicrobial effects against laboratory strains of S. aureus and E. faecalis and neither solution demonstrated antimicrobial effects against the clinical strain of P. aeruginosa. For organisms inhibited by sucralfate, Cicalfate® solution inhibited growth at lower sucralfate concentrations than sucralfate solution.

CLINICAL SIGNIFICANCE

The results of this pilot study suggest that Cicalfate® and sucralfate demonstrate in vitro antibacterial activity. Further in vitro and clinical studies are warranted to confirm these observations and determine their clinical utility in the treatment of superficial pyoderma.

Efficacy and safety of stress ulcer prophylaxis in critically ill patients: a network meta-analysis of randomized trials

PURPOSE

Stress ulcer prophylaxis (SUP) is commonly prescribed in the intensive care unit. However, data from systematic reviews and conventional meta-analyses are limited by imprecision and restricted to direct comparisons. We conducted a network meta-analysis of randomized clinical trials (RCTs) to examine the safety and efficacy of drugs available for SUP in critically ill patients.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Library Central Register of Controlled Trials through April 2017 for randomized controlled trials that examined the efficacy and safety of proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), and sucralfate for SUP in critically ill patients. No date or language restrictions were applied. Data on study characteristics, methods, outcomes, and risk of bias were abstracted by two reviewers.

RESULTS

Of 96 potentially eligible studies, we included 57 trials enrolling 7293 patients. The results showed that PPIs are probably more effective for preventing clinically important gastrointestinal bleeding (CIB) than H2RAs [odds ratio (OR) 0.38; 95% confidence interval (95% CI) 0.20, 0.73], sucralfate (OR 0.30; 95% CI 0.13, 0.69), and placebo (OR 0.24; 95% CI 0.10, 0.60) (all moderate quality evidence). There were no convincing differences among H2RA, sucralfate, and placebo. PPIs probably increase the risk of developing pneumonia compared with H2RAs (OR 1.27; 95% CI 0.96, 1.68), sucralfate (OR 1.65; 95% CI 1.20, 2.27), and placebo (OR 1.52; 95% CI 0.95, 2.42) (all moderate quality). Mortality is probably similar across interventions (moderate quality). Estimates of baseline risks of bleeding varied significantly across studies, and only one study reported on Clostridium difficile infection. Definitions of pneumonia varied considerably. Most studies on sucralfate predate pneumonia prevention strategies.

CONCLUSIONS

Our results provide moderate quality evidence that PPIs are the most effective agents in preventing CIB, but they may increase the risk of pneumonia. The balance of benefits and harms leaves the routine use of SUP open to question.

Sucralfate versus histamine 2 receptor antagonists for stress ulcer prophylaxis in adult critically ill patients: A meta-analysis and trial sequential analysis of randomized trials

PURPOSE

To determine the impact of using sucralfate versus H2RAs for SUP on patient important outcomes.

MATERIALS AND METHODS

We searched CENTRAL, MEDLINE, EMBASE, ACPJC, clinical trials registries, and conference proceedings through June 2016 for randomized controlled trials (RCTs) comparing sucralfate to H2RAs for SUP in adult critically ill patients.

RESULTS

21 RCTs enrolling 3121 patients met inclusion criteria. There was no significant difference between sucralfate compared to H2RAs in the risk of clinically important GI bleeding (risk ratio [RR] 1.19; 95% CI [confidence interval] 0.79, 1.80; P=0.42; I²=0%; low quality evidence). However, there was a statistically significant lower risk of ICU acquired pneumonia with sucralfate compared to H2RAs (RR 0.84; 95% CI 0.72, 0.98; P=0.03; I²=0%; moderate quality evidence). Sucralfate did not significantly affect the risk of death (RR 0.95; 95% CI 0.82, 1.10; P=0.51; I²=0%; high quality evidence), or duration of ICU stay in days (mean difference-0.39; 95% CI [-1.12, 0.34]; P=0.29; I²=0%; moderate quality evidence). Trial sequential analysis adjusted estimates were consistent with conventional estimates.

CONCLUSION

Moderate quality evidence suggests that sucralfate reduced ICU acquired pneumonia compared to H2RAs in adult critically ill patients, with no significant impact on GI bleeding or death.

Role of acid suppressants in intensive care medicine

Bleeding from stress-induced mucosal lesions continues to be a potential problem in critically ill patients, although its incidence has decreased dramatically over the past decade. Patients considered to be at risk are those with respiratory failure, coagulopathy, severe burns or tetraplegia. The most important cause of stress ulcer bleeding is tissue hypoxia. Provided that appropriate dosage regimens are administered, all agents approved for stress ulcer prophylaxis may reduce the incidence of overt as well as clinically important bleeding. However, the efficacy of stress ulcer prophylaxis does not correlate with the efficacy of gastric acid inhibition. Although numerous studies have demonstrated that an alkaline gastric juice is associated with gastric Gram-negative bacterial overgrowth, controversy remains over whether the pharmacological suppression of gastric acid in critically ill patients facilitates nosocomial pneumonia. The reasons for these divergent results are discussed, as is a possible association between gastric acid suppression and other systemic infections. Finally, several cost-effectiveness analyses performed over recent years have demonstrated that, in properly selected critically ill patients, stress ulcer prophylaxis is cost-effective.