Pharmacoepidemiology of stress ulcer prophylaxis in the United States and Canada. J Crit Care. 2014;29:955-960. [PMID: 25081626 DOI: 10.1016/j.jcrc.2014.06.025]

Hospitalized patients on proton pump inhibitors for stress ulcer prophylaxis have a higher risk of Clostridioides difficile infection compared with those on histamine-2 receptor antagonists

BACKGROUND

Previous studies on Clostridioides difficile infection (CDI) in proton pump inhibitor (PPI) users generally enrolled a heterogeneous population and did not include a control group of histamine H2 receptor antagonists (H2RAs) users or adjust for confounding variables, such as previous antibiotics. It is uncertain whether hospitalized patients using PPIs for stress ulcer prophylaxis (SUP) are at a higher risk of CDI compared with those using H2RAs. This study aimed to compare the association between CDI and the usage of antisecretory drugs (ASDs): PPIs and H2RAs, for SUP among hospitalized patients, and the impact of the duration of their use on CDI.

METHODS

In this nationwide population-based cohort study using the Taiwan National Health Insurance Database, hospitalized patients using ASDs for SUP were identified between 2017 and 2018. A total of 63,266 and 69,269 individuals were included in the PPI and H2RA groups, respectively. The primary endpoint was a 90-day monitoring of CDI occurrence.

FINDINGS

The incidences of CDI were 1.6/10,000 and 0.5/10,000 person-days in the PPIs and H2RAs groups, respectively. After adjusting for confounding factors, the risk of infection in the PPIs group remained significantly higher than in the H2RAs group (hazard ratio (HR), 2.49; 95% confidence interval (CI), 1.63-3.81). In the subgroup analysis, during hospitalization, the risk of CDI for patients using high-risk antibiotics or admitted to the intensive care unit (ICU), as well as patients with immunodeficiency, using PPIs for SUP, was higher than using H2RAs. Furthermore, the risk of CDI was higher in patients using ASDs for durations >14 days than in those using them for <7 days (adjusted HR, 3.66; 95% CI, 2.34-5.75).

CONCLUSIONS

The risk of occurrence CDI for hospitalized patients using PPIs for SUP was higher than using H2RAs. It is recommended not to exceed 14 days of any gastric ASDs for SUP during hospitalization, especially for patients who have used high-risk antibiotics, have been admitted to the ICU, or have immunodeficiency.

Assessment of endocarditis prophylaxis knowledge and attitudes among healthcare practitioners in Tehran and Hamadan

BACKGROUND

Having knowledge of the dental procedures that necessitate endocarditis prophylaxis is of high importance. Therefore, the aim of the present study was to determine the knowledge level and attitudes of general medical and dental practitioners, dental specialists, and cardiologists in Tehran and Hamadan about endocarditis.

METHODS

This cross-sectional study was carried out on 420 general medical and dental practitioners, dental specialists, and cardiologists in Tehran and Hamadan provinces in 2015. The questionnaire used in this research consisted of three parts as follows: part one: information on cardiac diseases; part two: dental procedures requiring endocarditis prophylaxis; part three: antibiotic diet in endocarditis prophylaxis. Independent t-test, one-way ANOVA, and chi-square tests were conducted to analyze the data. All the analyses were performed in SPSS version 16.

RESULTS

The results showed that 86.7 had a relatively favorable and 10.5% of subjects had a favorable level of knowledge about endocarditis. Also, 58.6% of subjects had a poor attitude toward endocarditis prophylaxis. There was a significant relationship between knowledge and attitude, age, gender, and work experience (P < 0.001). There was a significant relationship between knowledge and attitude, and job groups; dental specialists had a more favorable knowledge and positive attitude than others (P < 0.001).

CONCLUSION

We recommended developing more practical training programs in dental schools on cardiac diseases, and dental procedures requiring endocarditis prophylaxis and antibiotic diets.

Society of Critical Care Medicine and American Society of Health-System Pharmacists Guideline for the Prevention of Stress-Related Gastrointestinal Bleeding in Critically Ill Adults

RATIONALE

Critically ill adults can develop stress-related mucosal damage from gastrointestinal hypoperfusion and reperfusion injury, predisposing them to clinically important stress-related upper gastrointestinal bleeding (UGIB).

OBJECTIVES

The objective of this guideline was to develop evidence-based recommendations for the prevention of UGIB in adults in the ICU.

DESIGN

A multiprofessional panel of 18 international experts from dietetics, critical care medicine, nursing, and pharmacy, and two methodologists developed evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guideline development including task force selection and voting.

METHODS

The panel members identified and formulated 13 Population, Intervention, Comparison, and Outcome questions. We conducted a systematic review for each question to identify the best available evidence, statistically analyzed the evidence, and then assessed the certainty of the evidence using the GRADE approach. We used the evidence-to-decision framework to formulate the recommendations. Good practice statements were included to provide additional guidance.

RESULTS

The panel generated nine conditional recommendations and made four good practice statements. Factors that likely increase the risk for clinically important stress-related UGIB in critically ill adults include coagulopathy, shock, and chronic liver disease. There is no firm evidence for mechanical ventilation alone being a risk factor. Enteral nutrition probably reduces UGIB risk. All critically ill adults with factors that likely increase the risk for stress-related UGIB should receive either proton pump inhibitors or histamine-2 receptor antagonists, at low dosage regimens, to prevent UGIB. Prophylaxis should be discontinued when critical illness is no longer evident or the risk factor(s) is no longer present despite ongoing critical illness. Discontinuation of stress ulcer prophylaxis before transfer out of the ICU is necessary to prevent inappropriate prescribing.

CONCLUSIONS

The guideline panel achieved consensus regarding the recommendations for the prevention of stress-related UGIB. These recommendations are intended for consideration along with the patient's existing clinical status.

Proton pump inhibitors for gastrointestinal bleeding prophylaxis in critically ill patients: A systematic review protocol

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.

Proton-Pump Inhibitors to Prevent Gastrointestinal Bleeding - An Updated Meta-Analysis

BACKGROUND

The goal of this systematic review was to examine the efficacy and safety of proton-pump inhibitors for stress ulcer prophylaxis in critically ill patients.

METHODS

We included randomized trials comparing proton-pump inhibitors versus placebo or no prophylaxis in critically ill adults, performed meta-analyses, and assessed certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations approach. To explore the effect of proton-pump inhibitors on mortality based on disease severity, a subgroup analysis was conducted combining within-trial subgroup data from the two largest trials and assessed credibility using the Instrument for Assessing the Credibility of Effect Modification Analyses.

RESULTS

Twelve trials that enrolled 9533 patients were included. Proton-pump inhibitors were associated with a reduced incidence of clinically important upper gastrointestinal bleeding (relative risk [RR], 0.51 [95% confidence interval (CI), 0.34 to 0.76]; high certainty evidence). Proton-pump inhibitors may have little or no effect on mortality (RR, 0.99 [95% CI, 0.93 to 1.05]; low certainty). Within-trial subgroup analysis with intermediate credibility suggested that the effect of proton-pump inhibitors on mortality may differ based on disease severity. Subgroup results raise the possibility that proton-pump inhibitors may decrease 90-day mortality in less severely ill patients (RR, 0.89; 95% CI, 0.80 to 0.98) and may increase mortality in more severely ill patients (RR, 1.08; 95% CI, 0.96 to 1.20]. Proton-pump inhibitors may have no effect on pneumonia and little or no effect on Clostridioides difficile infection (low certainty).

CONCLUSIONS

High certainty evidence supports the association of proton-pump inhibitors with decreased upper gastrointestinal bleeding. Proton-pump inhibitors may have little or no effect on mortality, although a decrease in mortality in less severely ill patients and an increase in mortality in more severely ill patients remain possible. (PROSPERO number CRD42023461695.).

Stress Ulcer Prophylaxis in Mechanically Ventilated Patients With Acute Myocardial Infarction

Background

Proton pump inhibitors (PPIs) and histamine type 2-receptor blockers (H2Bs) are commonly used for stress ulcer prophylaxis among patients requiring invasive mechanical ventilation (IMV). Recent studies suggest an increased mortality associated with PPIs compared to H2Bs, but these studies poorly represent patients with cardiovascular disease or acute myocardial infarction (AMI).

Objectives

The aim of this study was to compare outcomes related to stress ulcer prophylaxis with PPIs compared to H2Bs in patients with AMI requiring IMV.

Methods

We queried the Vizient Clinical Data Base for adults aged ≥18 years admitted between October 2015 and December 2019 with a primary diagnosis of AMI and requiring IMV. Using multivariable logistic regression, we assessed for the association between stress ulcer prophylaxis and in-hospital mortality.

Results

Including 11,252 patients with AMI requiring IMV, 66.7% (n = 7,504) received PPIs and 33.3% (n = 3,748) received H2Bs. Age, sex, and the proportion of patients presenting with ST-segment elevation myocardial infarction or cardiogenic shock were similar between groups (all, P > 0.05). Compared to PPIs, patients receiving H2Bs had a lower mortality (41.5% vs 43.5%, P = 0.047), which was not statistically significant after multivariate adjustment (odds ratio 0.97; 95% confidence interval: 0.89-1.06, P = 0.49). In unadjusted and adjusted analyses, H2Bs use was associated with fewer ventilator days, less ventilator-associated pneumonia, and lower hospitalization cost but similar Clostridium difficile infections.

Conclusions

Among patients with AMI requiring IMV in this observation cohort study, there was no difference in mortality among patients receiving H2Bs vs PPIs for stress ulcer prophylaxis despite fewer ventilator days and lower ventilator-associated pneumonia in those receiving H2Bs.

REVISE: Re-Evaluating the Inhibition of Stress Erosions in the ICU: a randomised trial protocol

INTRODUCTION

The Re-Evaluating the Inhibition of Stress Erosions (REVISE) Trial aims to determine the impact of the proton pump inhibitor pantoprazole compared with placebo on clinically important upper gastrointestinal (GI) bleeding in the intensive care unit (ICU), 90-day mortality and other endpoints in critically ill adults. The objective of this report is to describe the rationale, methodology, ethics and management of REVISE.

METHODS AND ANALYSIS

REVISE is an international, randomised, concealed, stratified, blinded parallel-group individual patient trial being conducted in ICUs in Canada, Australia, Saudi Arabia, UK, US, Kuwait, Pakistan and Brazil. Patients≥18 years old expected to remain invasively mechanically ventilated beyond the calendar day after enrolment are being randomised to either 40 mg pantoprazole intravenously or an identical placebo daily while mechanically ventilated in the ICU. The primary efficacy outcome is clinically important upper GI bleeding within 90 days of randomisation. The primary safety outcome is 90-day all-cause mortality. Secondary outcomes include rates of ventilator-associated pneumonia, Clostridioides difficile infection, new renal replacement therapy, ICU and hospital mortality, and patient-important GI bleeding. Tertiary outcomes are total red blood cells transfused, peak serum creatinine level in the ICU, and duration of mechanical ventilation, ICU and hospital stay. The sample size is 4800 patients; one interim analysis was conducted after 2400 patients had complete 90-day follow-up; the Data Monitoring Committee recommended continuing the trial.

ETHICS AND DISSEMINATION

All participating centres receive research ethics approval before initiation by hospital, region or country, including, but not limited to - Australia: Northern Sydney Local Health District Human Research Ethics Committee and Mater Misericordiae Ltd Human Research Ethics Committee; Brazil: Comissão Nacional de Ética em Pesquisa; Canada: Hamilton Integrated Research Ethics Board; Kuwait: Ministry of Health Standing Committee for Coordination of Health and Medical Research; Pakistan: Maroof Institutional Review Board; Saudi Arabia: Ministry of National Guard Health Affairs Institutional Review Board: United Kingdom: Hampshire B Research Ethics Committee; United States: Institutional Review Board of the Nebraska Medical Centre. The results of this trial will inform clinical practice and guidelines worldwide.

TRIAL REGISTRATION NUMBER

NCT03374800.

Assessment of adherence to the national stress ulcer prophylaxis guidelines: A cross-sectional analysis

Background

Clinical guidelines support the use of stress ulcer prophylaxis (SUP) in patients at risk of gastrointestinal (GI) bleeding such as those with coagulopathy, renal replacement therapy, and mechanical ventilation. Despite the observed benefits of SUP, its overuse has been highly associated with serious adverse effects.

Objective

To assess the adherence to the national SUP guidelines in a tertiary hospital in Saudi Arabia.

Methods

A cross-sectional study was conducted using electronic health records at King Fahad Specialist Hospital (KFSH), Buraydah, Saudi Arabia. We collected the data from January 1st to December 31st, 2020. Adult patients aged 18 and older who received SUP prescriptions were included. Descriptive analysis was performed to assess the adherence to the guidelines and to explore the factors associated with SUP use in a hospital-based setting.

Results

A total of 424 patients were enrolled in this study. The median age of patients was 55.2 years old. Only 54% of patients were candidates for SUP. Internal medicine and surgery wards ranked the highest in prescribing SUP at 34.2% and 30.4%, respectively. The most common major criterion to start SUP was the concomitant use of two or more of these medications (anticoagulants, aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and antidepressants) followed by using NSAIDs or corticosteroids by older adult patients aged (≥65 years) or have GI bleeding history at 43.2% and 21.5%, respectively.

Conclusion

The observed overuse of anti-ulcer drugs (AUD) indicates a need for greater adherence to SUP guidelines. Areas of improvement can be implemented to ensure appropriate adherence to SUP guidelines to control the costs and avoid unnecessary anti-ulcer-related adverse effects.

Impact of Stress Ulcer Prophylaxis Discontinuation Guidance in Mechanically Ventilated, Critically Ill Patients: A Pre-Post Cohort Study

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.

The Association of Long-Term Use of Proton Pump Inhibitors and Histamine H2 Receptor Antagonists with Clinical Complications in Patients with Severe Sepsis

Objective. Proton pump inhibitors (PPIs) are commonly used to treat gastric acidity, and their frequent use may trigger various malfunctioning, such as cardiac, renal, and liver function failure. In the current study, we evaluated the association between the excessive use of the PPIs and the clinical complications of intensive care unit (ICU) septic patients. Methods. A total of 208188 patients were analyzed from 2016 to 2017 through the China Critical Care Sepsis Trial (CCCST) database. The characteristics of the study group and outcome of events from the PPI- and H2 blocker-using groups were reported. To get unbiased results, the data from the target trials were randomly assigned for PPI and H2 blocker groups. Result. The data revealed 43.34 excess deaths (95% confidence intensive (CI) 25.12 to 62.02) per 1000 patients in patients extensively consuming PPI drugs. The sepsis with chronic kidney disease attributed to deaths 21.36; 95% CI (9.34 to 23.23). However, comorbidities, including circulatory diseases (16.34; 95% CI 5.78 to 23.45), nervous system (2.08; 95% CI 1.56 to 6.34), mental disorders (1.87; 95% CI 1.65 to 2.95), genitourinary system (5.23; 95% CI 3.69 to 8.89), and infectious and parasitic disease (4.17; 95% CI 1.44 to 7.49), were also reported. Extensive use of the PPIs and H2 blockers was associated with esophageal adenocarcinoma, Barrett’s esophagus, neoplasms, and GI cancers. Conclusion. We conclude that the excessive use of PPI in sepsis patients triggers chronic kidney disease which has a higher clinical complication rate among others.

A Nomogram for Individualized Prediction of Stress-Related Gastrointestinal Bleeding in Critically Ill Patients with Primary Intracerebral Hemorrhage

PURPOSE

To establish and validate a nomogram model for predicting stress-related gastrointestinal bleeding in critically ill patients with primary intracerebral hemorrhage.

PATIENTS AND METHODS

From January 2018 to March 2021, we conducted a hospital-based study by screening eligible patients with acute intracerebral hemorrhage. Univariate and multivariate logistic regression analyses were performed to determine the predictors for stress-related gastrointestinal bleeding in patients with primary intracerebral hemorrhage. The nomogram was constructed on the basis of multivariate logistic model and was internally validated by bootstrap resampling. The discriminative performance of the nomogram was evaluated using the calibration and concordance index (C-index), which was equal to the area under the curve of receiver-operating characteristics. Hosmer-Lemeshow test was performed to check the model's goodness of fit. A decision curve analysis was used to assess its clinical utility.

RESULTS

A total of 410 patients were enrolled in this study. Stress-related gastrointestinal bleeding occurred in 115 patients (28.0%). Multivariate analysis demonstrated that gastric pH at admission [odds ratio (OR): 0.52, 95% confidence interval (CI): 0.41-0.66, P < 0.001], ICH volume (OR: 1.03, 95% CI: 1.02-1.05, P < 0.001) and sepsis (OR: 2.56, 95% CI: 1.54-4.25, P < 0.001) were independent predictors for stress-related gastrointestinal bleeding in critically ill patients with ICH. The nomogram including gastric pH at admission, ICH volume and sepsis presented good discrimination with C-index of 0.770 (95% CI: 0.716 to 0.822), which was confirmed to be 0.764 through bootstrapping validation. The calibration plot showed good agreement between the predicted and observed outcomes. The Hosmer-Lemeshow test showed a goodness-of-fit (Chi-Square = 8.085, DF = 8, P = 0.425). Decision curve analysis demonstrated that the nomogram was clinically beneficial.

CONCLUSION

The proposed nomogram based on gastric pH at admission, ICH volume and sepsis can accurately predict the risk of stress-related gastrointestinal bleeding in critically ill patients with primary intracerebral hemorrhage.

Physicians' knowledge, attitude, and prescribing behavior regarding stress ulcer prophylaxis in China: a multi-center study

Background

Perioperative patients are at risk of developing stress ulcers (SU), which can cause clinically important bleeding. Stress ulcer prophylaxis (SUP) is widely applied to the patients in Intensive care unit (ICU) as well as the general ward, so it may lead to overmedication. However, there have been no surveys regarding SUP knowledge or prescribing habits.

Objective

Our study assessed the knowledge, attitudes, and prescribing behavior of the surgeons toward perioperative patients regarding SUP and determined factors associated with low knowledge and high level of prescribing behaviors.

Methods

We performed a cross-sectional survey using questionnaires, randomly sampling 1266 surgeons on their current SUP practices.

Results

Proton pump inhibitors for SUP were used the most (94%); 43% used lansoprazole. Guideline awareness was inconsistent; the most familiar guideline was the National Medical Journal of China, and 46% were unaware of any guidelines. The predictors of low knowledge score regarding SUP in multivariable analysis were the hospital grade (p = 0.000), the type of hospital (p = 0.044), attendance at continuing education programs (p = 0.037), the awareness of clinical practice guidelines (CPGs) for SUP (p = 0.000). Twenty-one percent of physicians were high prescribers. High prescribing behavior was associated with hospital grade(p = 0.000), education level(p = 0.010) and attendance at continuing education programs (p = 0.000).

Conclusion

We found that most surgeons used SUP, primarily proton pump inhibitors. However, surgeons knew little about the SUP guidelines, which may lead to insufficient SUP knowledge and overmedication. In addition, hospital grade, the type of hospital and attendance at continuing education programs may also affect the low knowledge of SUP. Hospital grade, education level and attendance at continuing education programs may affect high prescribing behavior.

Do the types and routes of proton pump inhibitor treatments affect clostridium difficile in ICU patients? A retrospective cohort study

Background: : Proton pump inhibitors (PPI) are associated with Clostridium difficile infection (CDI). Impact of the route of administration is unknown.Research Design and Methods: Patients in Multiparameter Intelligent Monitoring in Intensive Care II database (MIMIC-II) from 2001 to 2008, >18 years old, admitted to medical, surgical, or cardiac ICUs were included. PPI exposures were omeprazole, esomeprazole, lansoprazole, and pantoprazole. PPI administration routes were oral or intravenous. Patients who received histamine receptor antagonists (H2RA) were the control arm. CDI was identified using ICD-9 diagnostic code 008.45. Multiple logistic regression analysis was performed to calculate odds ratios (OR).Results: The study included 16,820 patients (57% male) with a mean age of 63 (SD±17) years and hospitalization duration of 10.2 days (SD±11). Pantoprazole was the most common PPI (94%). CDI occurred in 2.4% and more in patients receiving PPIs than H2RAs (3.0% vs. 0.8%, p < 0.001). CDI prevalence increased with intravenous (95%CI = 1.69-3.39, OR 2.4) and oral (95%CI = 1.59-3.27, OR 2.3) PPI use compared to H2RAs. CDI prevalence was not associated with PPI route in the multivariable model (OR 1.07, 95%CI 0.86-1.34).Conclusions: Both intravenous and oral PPI use in the ICU were independently associated with CDI.

Drug dosing in the critically ill obese patient: a focus on medications for hemodynamic support and prophylaxis

Medications used for supportive care or prophylaxis constitute a significant portion of drug utilization in the intensive care unit. Evidence-based guidelines are available for many aspects of supportive care but drug doses listed are typically for patients with normal body habitus and not morbid obesity. Failure to account for the pharmacokinetic changes that occur with obesity can lead to an incorrect dose and treatment failure or toxicity. This paper is intended to help clinicians design initial dosing regimens in critically ill obese patients for medications commonly used for hemodynamic support or prophylaxis. A detailed literature search of medications used for supportive care or prophylaxis listed in practice guidelines was conducted with an emphasis on obesity, pharmacokinetics and dosing. Relevant manuscripts were reviewed and strategies for dosing are provided. For medications used for hemodynamic support, a similar strategy can be used as in non-obese patients. Similarly, medications for stress ulcer prophylaxis do not need to be adjusted. Anticoagulants for venous thromboembolism prophylaxis, on the other hand, require an individualized approach where higher doses are necessary.

Effects of daily treatment with acid suppressants for stress ulcer prophylaxis on risk of ventilator-associated events

OBJECTIVE

To estimate the effects of continuous daily treatment with different acid suppressants on the risk of ventilator-associated events in critically ill patients.

DESIGN

Retrospective cohort study.

PATIENTS

Adult critically ill patients who underwent mechanical ventilation for ≥3 days during an inpatient admission between January 2006 and December 2014.

METHODS

We estimated the 30-day cumulative risk ratios (RRs) for ventilator-associated events comparing daily proton pump inhibitor (PPI) versus daily histamine-2-receptor antagonist (H2RA) strategies while controlling for time-fixed and time-varying confounding and accounting for competing events.

RESULTS

Of 6,133 patients, on ventilation day 3, 58.8% received H2RAs, 26.1% received PPIs, and 4.1% received sucralfate. Patients frequently changed treatment throughout follow-up. Among 4,595 patients receiving PPIs or H2RAs on day 3, we found no differences in risk estimates for ventilator mortality and extubation alive comparing daily PPI versus daily H2RA strategies: RR, mortality, 1.03 (95% CI, 0.89-1.22); extubation alive, 1.00 (95% CI, 0.96-1.03). We found similar results after accounting for PPI dose. For possible ventilator-associated pneumonia (PVAP) and infection-related ventilator-associated complication (IVAC), point estimates were larger, but the 95% CIs crossed 1.0: RR PVAP, 1.25 (95% CI, 0.80-1.94); IVAC, 0.89 (95% CI, 0.64-1.17). The magnitude of effect estimates depended on PPI dose. The RR for PVAP, high-dose PPI versus H2RA, was 1.53 (95% CI, 0.82-2.51), and for low-dose PPI versus H2RA, the RR was 0.97 (95% CI, 0.47-1.63). For IVAC, high-dose PPI versus H2RA, the RR was 1.01 (95% CI, 0.66-1.42), and for low-dose PPI versus H2RA, the RR was 0.78 (95% CI, 0.50-1.11).

CONCLUSIONS

We estimated no effect of daily PPI versus daily H2RA on risk of mortality or extubation alive in critically ill patients. Further investigation with larger samples is warranted for PVAP and IVAC.

Therapeutic alternatives and strategies for drug conservation in the intensive care unit during times of drug shortage: a report of the Ontario COVID-19 ICU Drug Task Force

During the coronavirus disease (COVID-19) global pandemic, urgent strategies to alleviate shortages are required. Evaluation of the feasibility, practicality, and value of drug conservation strategies and therapeutic alternatives requires a collaborative approach at the provincial level. The Ontario COVID-19 ICU Drug Task Force was directed to create recommendations suggesting drug conservation strategies and therapeutic alternatives for essential drugs at risk of shortage in the intensive care unit during the COVID-19 pandemic. Recommendations were rapidly developed using a modified Delphi method and evaluated on their ease of implementation, feasibility, and supportive evidence. This article describes the recommendations for drug conservation strategies and therapeutic alternatives for drugs at risk of shortage that are commonly used in the care of critically ill patients. Recommendations are identified as preferred and secondary ones that might be less desirable. Although the impetus for generating this document was the COVID-19 pandemic, recommendations should also be applicable for mitigating drug shortages outside of a pandemic. Proposed provincial strategies for drug conservation and therapeutic alternatives may not all be appropriate for every institution. Local implementation will require consultation from end-users and hospital administrators. Competing equipment shortages and available resources should be considered when evaluating the appropriateness of each strategy.

Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: an updated systematic review and network meta-analysis of randomized trials

PURPOSE

Motivated by a new randomized trial (the PEPTIC trial) that raised the issue of an increase in mortality with proton pump inhibitors (PPIs) relative to histamine-2 receptor antagonists (H2RAs), we updated our prior systematic review and network meta-analysis (NMA) addressing the impact of pharmacological gastrointestinal bleeding prophylaxis in critically ill patients.

METHODS

We searched for randomized controlled trials that examined the efficacy and safety of gastrointestinal bleeding prophylaxis with PPIs, H2RAs, or sucralfate versus one another or placebo or no prophylaxis in adult critically ill patients. We performed Bayesian random-effects NMA and conducted analyses using all PEPTIC data as well as a restricted analysis using only PEPTIC data from high compliance centers. We used the GRADE approach to quantify absolute effects and assess the certainty of evidence.

RESULTS

Seventy-four trials enrolling 39 569 patients proved eligible. Both PPIs (risk ratio (RR) 1.03, 95% credible interval 0.93 to 1.14, moderate certainty) and H2RAs (RR 0.98, 0.89 to 1.08, moderate certainty) probably have little or no impact on mortality compared with no prophylaxis. There may be no important difference between PPIs and H2RAs on mortality (RR 1.05, 0.97 to 1.14, low certainty), the 95% credible interval of the complete analysis has not excluded an important increase in mortality with PPIs. Both PPIs (RR 0.46, 0.29 to 0.66) and H2RAs (RR 0.67, 0.48 to 0.94) probably reduce clinically important gastrointestinal bleeding; the magnitude of reduction is probably greater in PPIs than H2RAs (RR 0.69, 0.45 to 0.93), and the difference may be important in higher, but not lower bleeding risk patients. PPIs (RR 1.08, 0.88 to 1.45, low certainty) and H2RAs (RR 1.07, 0.85 to 1.37, low certainty) may have no important impact on pneumonia compared with no prophylaxis.

CONCLUSION

This updated NMA confirmed that PPIs and H2RAs are most likely to have a similar effect on mortality compared to each other and compared to no prophylaxis; however, the possibility that PPIs may slightly increase mortality cannot be excluded (low certainty evidence). PPIs and H2RAs probably achieve important reductions in clinically important gastrointestinal bleeding; for higher bleeding risk patients, the greater benefit of PPIs over H2RAs may be important. PPIs or H2RAs may not result in important increases in pneumonia but the certainty of evidence is low.

Trends and Outcomes of Gastrointestinal Bleeding Among Septic Shock Patients of the United States: A 10-Year Analysis of a Nationwide Inpatient Sample

Introduction

Gastrointestinal bleeding (GIB) complicating septic shock (SS) presents a therapeutic challenge in intensive care units. Large-scale data regarding utilization, length of stay, and cost outcomes of this association are lacking.

Methods

We queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample from 2003 to 2012, and identified all adult patients aged ≥18 years hospitalized for SS by the International Classification of Diseases, Ninth Revision (ICD-9) diagnostic code for SS and GIB. We compared the baseline characteristics and outcomes among patients with SS plus GIB to patients with SS without GIB.

Results

The weighted sample size from 2003 to 2012 was 119,684 admissions for SS. Among them, 6,571 (5.4%) patients were found to have a GIB. The mean age of the SS population with and without GIB was (mean/standard error of mean) [70.85 (0.43) vs. 67.43 (0.13) P < 0.001, respectively]. The incidence of GIB over the course of 10 years has remained stable; however, the mortality associated with GIB among SS patients is found to be declining especially from 2008 (59.2%) to 2012 (45.1%) (P < 0.01). Patients with SS and GIB compared to patients with SS and no GIB were found to have a longer length of stay [20.56 (0.61) vs. 15.76 (0.13) P < 0.001], higher mortality [54% vs. 45% P < 0.001], and higher admission costs in United States dollar ($) (mean/SEM) [$192,524.89 (7,378.20) vs. $142,688.55 (1,336.65) P < 0.001]. Univariate analysis demonstrated that comorbid conditions like peptic ulcer disease and cirrhosis had significant odds ratios {1.56 and 1.709, P = 0.016 and 0.046 respectively} for the occurrence of GIB with SS. Gastroesophageal reflux disease was found to be associated with a lower incidence of GIB [odds ratio: 0.57, P = 0.0008]. The cause of sepsis (pneumonia, urinary tract infection, or abdominal infections) was not a significant distinguishing factor for the incidence of GIB in SS.

Conclusion

GIB continues to affect the patients with SS admitted in intensive care units in the United States. We found an incidence of 5.4% of GIB in patients with SS, and it was associated with worse outcomes.

Gastrointestinal bleeding prophylaxis for critically ill patients: a clinical practice guideline

CLINICAL QUESTION

What is the role of gastrointestinal bleeding prophylaxis (stress ulcer prophylaxis) in critically ill patients? This guideline was prompted by the publication of a new large randomised controlled trial.

CURRENT PRACTICE

Gastric acid suppression with proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) is commonly done to prevent gastrointestinal bleeding in critically ill patients. Existing guidelines vary in their recommendations of which population to treat and which agent to use.

RECOMMENDATIONS

This guideline panel makes a weak recommendation for using gastrointestinal bleeding prophylaxis in critically ill patients at high risk (>4%) of clinically important gastrointestinal bleeding, and a weak recommendation for not using prophylaxis in patients at lower risk of clinically important bleeding (≤4%). The panel identified risk categories based on evidence, with variable certainty regarding risk factors. The panel suggests using a PPI rather than a H2RA (weak recommendation) and recommends against using sucralfate (strong recommendation).

HOW THIS GUIDELINE WAS CREATED

A guideline panel including patients, clinicians, and methodologists produced these recommendations using standards for trustworthy guidelines and the GRADE approach. The recommendations are based on a linked systematic review and network meta-analysis. A weak recommendation means that both options are reasonable.

THE EVIDENCE

The linked systematic review and network meta-analysis estimated the benefit and harm of these medications in 12 660 critically ill patients in 72 trials. Both PPIs and H2RAs reduce the risk of clinically important bleeding. The effect is larger in patients at higher bleeding risk (those with a coagulopathy, chronic liver disease, or receiving mechanical ventilation but not enteral nutrition or two or more of mechanical ventilation with enteral nutrition, acute kidney injury, sepsis, and shock) (moderate certainty). PPIs and H2RAs might increase the risk of pneumonia (low certainty). They probably do not have an effect on mortality (moderate certainty), length of hospital stay, or any other important outcomes. PPIs probably reduce the risk of bleeding more than H2RAs (moderate certainty).

UNDERSTANDING THE RECOMMENDATION

In most critically ill patients, the reduction in clinically important gastrointestinal bleeding from gastric acid suppressants is closely balanced with the possibility of pneumonia. Clinicians should consider individual patient values, risk of bleeding, and other factors such as medication availability when deciding whether to use gastrointestinal bleeding prophylaxis. Visual overviews provide the relative and absolute benefits and harms of the options in multilayered evidence summaries and decision aids available on MAGICapp.

Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: systematic review and network meta-analysis

OBJECTIVE

To determine, in critically ill patients, the relative impact of proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), sucralfate, or no gastrointestinal bleeding prophylaxis (or stress ulcer prophylaxis) on outcomes important to patients.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials, trial registers, and grey literature up to March 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES AND METHODS

We included randomised controlled trials that compared gastrointestinal bleeding prophylaxis with PPIs, H2RAs, or sucralfate versus one another or placebo or no prophylaxis in adult critically ill patients. Two reviewers independently screened studies for eligibility, extracted data, and assessed risk of bias. A parallel guideline committee (BMJ Rapid Recommendation) provided critical oversight of the systematic review, including identifying outcomes important to patients. We performed random-effects pairwise and network meta-analyses and used GRADE to assess certainty of evidence for each outcome. When results differed between low risk and high risk of bias studies, we used the former as best estimates.

RESULTS

Seventy two trials including 12 660 patients proved eligible. For patients at highest risk (>8%) or high risk (4-8%) of bleeding, both PPIs and H2RAs probably reduce clinically important gastrointestinal bleeding compared with placebo or no prophylaxis (odds ratio for PPIs 0.61 (95% confidence interval 0.42 to 0.89), 3.3% fewer for highest risk and 2.3% fewer for high risk patients, moderate certainty; odds ratio for H2RAs 0.46 (0.27 to 0.79), 4.6% fewer for highest risk and 3.1% fewer for high risk patients, moderate certainty). Both may increase the risk of pneumonia compared with no prophylaxis (odds ratio for PPIs 1.39 (0.98 to 2.10), 5.0% more, low certainty; odds ratio for H2RAs 1.26 (0.89 to 1.85), 3.4% more, low certainty). It is likely that neither affect mortality (PPIs 1.06 (0.90 to 1.28), 1.3% more, moderate certainty; H2RAs 0.96 (0.79 to 1.19), 0.9% fewer, moderate certainty). Otherwise, results provided no support for any affect on mortality, Clostridium difficile infection, length of intensive care stay, length of hospital stay, or duration of mechanical ventilation (varying certainty of evidence).

CONCLUSIONS

For higher risk critically ill patients, PPIs and H2RAs likely result in important reductions in gastrointestinal bleeding compared with no prophylaxis; for patients at low risk, the reduction in bleeding may be unimportant. Both PPIs and H2RAs may result in important increases in pneumonia. Variable quality evidence suggested no important effects of interventions on mortality or other in-hospital morbidity outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019126656.

Stress Ulcer Prophylaxis in Neurocritical Care

Stress ulcer prophylaxis (SUP) with acid-suppressive drug therapy is widely utilized in critically ill patients following neurologic injury for the prevention of clinically important stress-related gastrointestinal bleeding (CIB). Data supporting SUP, however, largely originates from studies conducted during an era where practices were vastly different than what is considered routine by today's standard. This is particularly true in neurocritical care patients. In fact, the routine provision of SUP has been challenged due to an increasing prevalence of adverse drug events with acid-suppressive therapy and the perception that CIB rates are sparse. This narrative review will discuss current controversies with SUP as they apply to neurocritical care patients. Specifically, the pathophysiology, prevalence, and risk factors for CIB along with the comparative efficacy, safety, and cost-effectiveness of acid-suppressive therapy will be described.

The SUP-ICU Trial: Does It Confirm or Condemn the Practice of Stress Ulcer Prophylaxis?

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.

Gastrointestinal stress ulcer prophylaxis in the intensive care unit, where is the data?

Stress-induced gastrointestinal ulcers are common among patients admitted to the intensive care unit (ICU). These ulcers impose significant morbidity and mortality, therefore, stress ulcer prophylaxis (SUP) is a common clinical practice among healthcare providers dealing with these critically-ill patients. Several strategies for SUP have been suggested over the past four decades, with acid suppressive therapies being the most commonly used in the ICU. Whether SUP is effective and safe, or not, remains a topic of controversy. The data is still conflicting, and provision of a simple answer is not feasible at the present time. Recently, a large phase IV, multicenter, randomized clinical trial (SUP-ICU), negated the benefits (and harms) of proton pump inhibitors as SUP. This article reviews some of these controversies.

Sociedade Portuguesa de Cuidados Intensivos guidelines for stress ulcer prophylaxis in the intensive care unit

Critically ill patients are at risk of developing stress ulcers in the upper digestive tract. Agents that suppress gastric acid are commonly prescribed to reduce the incidence of clinically important stress ulcer-related gastrointestinal bleeding. However, the indiscriminate use of stress ulcer prophylaxis in all patients admitted to the intensive care unit is not warranted and can have potential adverse clinical effects and cost implications. The present guidelines from the Sociedade Portuguesa de Cuidados Intensivos summarizes the current evidence and gives six clinical statements and an algorithm aiming to provide a standardized prescribing policy for the use of stress ulcer prophylaxis in the intensive care unit.

Assessment of pharmacologic prophylaxis use against stress ulcer in the medical wards of University of Gondar Hospital

Background

Critically ill patients with moderate-to-severe physiologically stressful event are at high risk of developing stress ulcers. The use of pharmacological prophylaxis significantly reduces the incidence of stress ulcer in high-risk patients.

Objective

The aim of this study was to assess the use of pharmacological prophylaxis for stress ulcer in the medical wards of University of Gondar Hospital.

Methods

A cross-sectional study design was used. In total, 234 patients were selected through simple random sampling technique. The risk of stress ulcer development was assessed using Evidence-Based Medicine Guideline for stress ulcer prepared by Orlando Regional Medical Center. SPSS version 21 was used for data analysis.

Result

The most common acute risk factor to stress ulcer was coagulopathy (18.4%), followed by hypoperfusion (9.8%). The concomitant non-steroidal anti-inflammatory drug use (16.7%), mild-to-moderate brain or spinal cord injury (11.1%), and concomitant or recent corticosteroid use (9.4%) were frequently seen risk factors that necessitate administration of a prophylaxis. In total, 82 (35%) study participants were given stress ulcer prophylaxis, among which 52 (63.4%) were given without indication. The most commonly used drug class in the prevention of stress ulcer was proton pump inhibitors (76/82, 92.7%). In total, 43 (18.4%) study subjects were not given stress ulcer prophylaxis while there was clear indication. Patients with a long hospital stay and a diagnosis of central nervous system disorders had significant risk for inappropriate stress ulcer prophylaxis use.

Conclusion

In this study, inappropriate use of prophylaxis for stress ulcer was common. The higher proportion of inappropriateness was due to the use of stress ulcer prophylaxis while there was no enough indication. We recommend future researchers to assess the cost and impact of inappropriate stress ulcer prophylaxis use, and the physicians should be adherent to the standard guidelines.

Gastrointestinal Bleeding in Patients With Acute Respiratory Distress Syndrome: A National Database Analysis

Background

The goal of our study was to determine the impact of gastrointestinal bleeding (GIB) on in-hospital outcomes among acute respiratory distress syndrome (ARDS) patients, and subsequently determine the potential risk factors for the development of GIB.

Methods

ARDS patients with and without GIB were identified using the National Inpatient Sample (2002 - 2012). Linear regression analysis was used to assess impact of GIB on in-hospital mortality, length of stay and total charges. Univariate logistic regression was used to determine associated odds ratios (OR) for causes of ARDS and common comorbid conditions.

Results

We identified 149,190 ARDS patients. The incidence of GIB was the highest among patients > 60 years (P < 0.001). GIB was associated with longer hospitalization days (7.3 days versus 11.9 days, P < 0.001), higher mortality (11% versus 27%, P < 0.001) and greater economic burden ($82,812 versus $45,951, P < 0.001). GIB was common in cirrhosis (OR: 8.3), peptic ulcer disease (OR: 3.7), coagulopathy disorders (OR: 3.003), thrombocytopenia (OR: 2.6), anemia (OR: 2.5) and atrial fibrillation (OR: 1.5). ARDS secondary to aspiration pneumonia (OR: 2.0), pancreatitis (OR: 2.0), sepsis (OR: 1.6) and community acquired pneumonia (OR: 0.8) was more likely to have GIB.

Conclusion

Our study demonstrates that GIB in ARDS patients is associated with significant increased mortality, hospitalization and health care cost.

Use of Enteral Nutrition for Gastrointestinal Bleeding Prophylaxis in the Critically Ill: Review of Current Literature

PURPOSE OF REVIEW

This review provides a comprehensive overview of the etiology of stress-related mucosal disease, current acid suppression therapy recommendations, and the role enteral nutrition may play in disease prevention.

RECENT FINDINGS

Recent literature indicates enteral nutrition may prevent complications of stress-related mucosal disease by increasing splanchnic blood flow, enhancing gastrointestinal motility, and promoting cellular immunity and integrity through local nutrient delivery. Stress-related mucosal disease is a common complication of hospitalization in the critically ill which may lead to overt gastrointestinal bleeding and enhanced mortality. High-risk patients have historically been prescribed acid suppression therapy, though enteral nutrition may also have a role in disease mitigation.

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.

Impact of targeted educational interventions on appropriateness of stress ulcer prophylaxis in critically ill adults

Background:

Acid suppression therapy (AST) is routinely used in critically ill patients to prevent stress-related mucosal bleeding (SRMB).

Objective:

Our objective was to determine the impact of a structured educational intervention on AST used for prevention of SRMB on appropriateness of AST.

Methods:

A single-center, retrospective, cohort study of appropriate use of AST in critically ill patients admitted to the medical intensive care unit (ICU) at an academic medical center between January to June of 2014 (no intervention) and January to June of 2015 (intervention) was conducted. The percentage of patients prescribed inappropriate AST, inappropriate AST at ICU transfer and hospital discharge, doses of inappropriate AST, and adverse effects associated with AST use were compared between periods using chi-square tests.

Results:

Patients in the intervention group (n=118) were 5 years older than patients in the no intervention group (n=101). AST was inappropriately initiated more frequently in the no intervention group (23% vs. 11%, p=0.012). Continuation of inappropriate AST at ICU transfer and hospital discharge was similar between groups (60% vs. 53%, p=0.277 and 18% vs. 14%, p=0.368, respectively).

Conclusion:

Patients had appropriate AST initiated and inappropriate AST withheld more frequently when formal education was provided. This low-cost intervention strategy can be implemented easily at institutions where pharmacists interact with physicians on rounding services and should be evaluated in institutions where interactions between pharmacists and physicians occur more frequently in non-rounding situations.

Withholding Pantoprazole for Stress Ulcer Prophylaxis in Critically Ill Patients: A Pilot Randomized Clinical Trial and Meta-Analysis

INTRODUCTION

A decreased frequency of upper gastrointestinal bleeding and a possible association of proton pump inhibitor use with Clostridium difficile and ventilator-associated pneumonia have raised concerns recently. The Reevaluating the Inhibition of Stress Erosions Pilot Trial determined the feasibility of undertaking a larger trial investigating the efficacy and safety of withholding proton pump inhibitors in critically ill patients.

METHODS

In 10 ICUs, we randomized adult ICU patients anticipated to be mechanically ventilated for greater than or equal to 48 hours to receive 40 mg of IV pantoprazole daily or placebo. We excluded patients who had acute or recent gastrointestinal bleed, used dual antiplatelet agents, had a medical condition requiring proton pump inhibitor treatment, or had already received more than one dose of acid suppression daily. Patients, families, clinicians, and research staff were blinded. We conducted a systematic review and meta-analysis of similar trials.

MAIN RESULTS

Ninety-one patients (49 pantoprazole and 42 placebo) from 10 centers in Canada, Saudi Arabia, and Australia were enrolled. All feasibility goals were met: 1) recruitment rate was 2.6 patients per month; 2) consent rate was 77.8%; and 3) protocol adherence was 97.7%. Upper gastrointestinal bleeding developed in 6.1% of patients in the pantoprazole group and 4.8% in the placebo group (p = 1.0). Ventilator-associated pneumonia developed in 20.4% of patients in the pantoprazole group and 14.3% in the placebo group (p = 0.58). C. difficile was identified in 4.1% pantoprazole patients and in 2.4% placebo patients (p = 1.0). We meta-analyzed five trials (604 patients) of proton pump inhibitors versus placebo; there was no statistically significant difference in the risk of upper gastrointestinal bleeding, infections, or mortality.

CONCLUSIONS

Our results support the feasibility of a larger trial to evaluate the safety of withholding stress ulcer prophylaxis. Although the results are imprecise, there was no alarming increase in the risk of upper gastrointestinal bleeding; the effect of proton pump inhibitors on ventilator-associated pneumonia and C. difficile remain unclear.

Preventive effect of prospective evaluation combined with graded prevention on stress ulcer in emergency patients

AIM

To evaluate the effect of prospective evaluation combined with graded prevention on the incidence of stress ulcer in emergency patients.

METHODS

From January 2011 to June 2013, 142 emergency patients treated at our hospital were included in a control group and given normal intervention, while 163 emergency patients treated from July 2013 to January 2016 at our hospital were included in an observation group and given prospective evaluation combined with graded intervention. The incidence of stress ulcer, bleeding time, length of stay and satisfaction rate were compared between the two groups.

RESULTS

The incidence of stress ulcer was significantly lower in the observation group than in the control group (13.49% vs 32.39%, P < 0.05). The bleeding time and hospital stay were significantly shorter in the observation group than in the control group (2.65 d ± 2.43 d vs 4.27 d ± 2.01 d, 17.44 d ± 8.67 d vs 22.67 d ± 7.95 d, P < 0.05). Of the 163 patients in the observation group, 97 were very satisfied, 57 were moderately satisfied, 4 were satisfied, and 5 were not satisfied with the intervention. Of the 142 patients in the control group, 59 were very satisfied, 55 were moderately satisfied, 18 were satisfied, and 10 were not satisfied with the intervention. The rate of satisfaction with the intervention was significantly higher in the observation group than in the control group (94.46% vs 80.27%, P < 0.05).

CONCLUSION

Prospective evaluation combined with graded prevention can significantly reduce the incidence of stress ulcer, shorten bleeding time and hospitalization time, and improve patient satisfaction in emergency patients.

Pantoprazole or Placebo for Stress Ulcer Prophylaxis (POP-UP): Randomized Double-Blind Exploratory Study

OBJECTIVES

Pantoprazole is frequently administered to critically ill patients for prophylaxis against gastrointestinal bleeding. However, comparison to placebo has been inadequately evaluated, and pantoprazole has the potential to cause harm. Our objective was to evaluate benefit or harm associated with pantoprazole administration.

DESIGN

Prospective randomized double-blind parallel-group study.

SETTING

University-affiliated mixed medical-surgical ICU.

PATIENTS

Mechanically ventilated critically ill patients suitable for enteral nutrition.

INTERVENTIONS

We randomly assigned patients to receive either daily IV placebo or pantoprazole.

MEASUREMENTS AND MAIN RESULTS

Major outcomes were clinically significant gastrointestinal bleeding, infective ventilator-associated complication or pneumonia, and Clostridium difficile infection; minor outcomes included overt bleeding, hemoglobin concentration profiles, and mortality. None of the 214 patients randomized had an episode of clinically significant gastrointestinal bleeding, three patients met the criteria for either an infective ventilator-associated complication or pneumonia (placebo: 1 vs pantoprazole: 2), and one patient was diagnosed with Clostridium difficile infection (0 vs 1). Administration of pantoprazole was not associated with any difference in rates of overt bleeding (6 vs 3; p = 0.50) or daily hemoglobin concentrations when adjusted for transfusion rates of packed red cells (p = 0.66). Mortality was similar between groups (log-rank p = 0.33: adjusted hazard ratio for pantoprazole: 1.68 [95% CI, 0.97-2.90]; p = 0.06).

CONCLUSIONS

We found no evidence of benefit or harm with the prophylactic administration of pantoprazole to mechanically ventilated critically ill patients anticipated to receive enteral nutrition. The practice of routine administration of acid-suppressive drugs to critically ill patients for stress ulcer prophylaxis warrants further evaluation.

Re-evaluating the Inhibition of Stress Erosions (REVISE): a protocol for pilot randomized controlled trial

INTRODUCTION

Clinicians routinely administer stress ulcer prophylaxis to mechanically ventilated patients in the intensive care unit (ICU), most commonly prescribing proton pump inhibitors (PPIs). However, the incidence of gastrointestinal (GI) bleeding from stress ulceration is low and recent observational studies suggest these agents may increase infections. Therefore, a large randomized clinical trial (RCT) is needed to inform modern practice. The aim of this multicenter pilot trial is to determine the feasibility of performing a large RCT to investigate the efficacy and safety of withholding intravenous pantoprazole.

METHODS AND ANALYSIS

We will include adult critically ill patients who have an anticipated duration of ventilation of >=48 hours. We will exclude patients with acute or recent GI bleeding, pregnancy, dual antiplatelet therapy, poor prognosis or intent to withdraw life support, or previous enrolment in this or a confounding trial. Following informed consent, patients will be randomized to receive the intervention of placebo (0.9% NaCl) or intravenous pantoprazole 40 mg daily. Patients, families, clinicians, data collectors, adjudicators of outcome and statisticians will be blind to allocation. The three primary feasibility outcomes are the informed consent rate, recruitment rate, and protocol adherence. Clinical outcomes include clinically important upper GI bleeding, ventilator-associated pneumonia (VAP), Clostridium difficile infection, length of stay and mortality in ICU and hospital.

ETHICS AND APPROVAL

This study has been approved by Health Canada, and research ethics board (REB) at each of the participating centers.

TRIAL REGISTRATION NUMBER

This trial was registered on 31 October 2014. The trial registration number is NCT02290327.

FUNDING

REVISE Pilot Trial is funded by Research Grant awarded by Physicians Services Incorporated, Dammam University Research Funds, Capital Health Authority Research Award Halifax, and Royal Adelaide Hospital Project Committee Grant.

Pneumonia prevention in intubated patients given sucralfate versus proton-pump inhibitors and/or histamine II receptor blockers

BACKGROUND

Ventilator-associated pneumonia (VAP) is a common cause of infectious morbidity and mortality in the intensive care unit (ICU). The type of stress-ulcer prophylaxis (SUP) given to ventilated patients may, in part, be responsible. We observed an increase in VAP as ventilator bundle compliance increased and a decrease in VAP when bundle compliance decreased. We reasoned that SUP which raises gastric pH such as proton-pump inhibitors (PPIs) and histamine II (H2) receptor antagonists as opposed to SUP which does not raise pH such as sucralfate (S) may be responsible and also may alter the causative bacteria.

MATERIALS AND METHODS

This is a single-center retrospective cohort analysis of all intubated, adult surgical patients admitted to the surgical ICU between January and June during the 3-y period 2012-2014. Demographics, APACHE II, Injury Severity Score, VAP occurrence, culprit bacteria, ventilator days, and ICU days were recorded based on the type of SUP given.

RESULTS

There were 45 instances of VAP in the 504 study patients, 33 in the PPI/H2 group, and 12 in the S group (P < 0.01). VAP per 1000 ventilator days were 10.2 for PPI/H2 and 3.7 for S (P < 0.01). Culprit bacteria were mostly Pseudomonas, gram-negative bacilli, and methicillin-resistant Staphylococcus aureus in PPI/H2 patients (n = 29) compared with oropharyngeal flora in S patients (n = 6; P < 0.001).

CONCLUSIONS

There was a substantial difference in VAP occurrence and in the culprit bacteria between S and PPI/H2 treated patients due perhaps to gastric alkalization.

Adherence to stress-related mucosal damage prophylaxis guideline in patients admitted to the Intensive Care Unit

Objective:

Concern about adverse effects of the inconsistent use of stress-related mucosal damage prophylaxis in intensive care unit (ICU) is increasing. Hence, this study was designed to prospectively evaluate the rate of inappropriate stress ulcer prophylaxis (SUP) administration upon ICU admission, at ICU discharge and determine the adherence to American Society of Health-System Pharmacists (ASHP) guideline during ICU stay.

Methods:

In this study, 200 patients were randomly selected from all ICU admissions during 9 months. Risk factors of stress ulcer were recorded daily during ICU stay and appropriateness of SUP administration was assessed according to the ASHP criteria.

Findings:

Of all 160 (80%) patients who received SUP, 44.4% did not have indication; and among 95 patients with an indication for SUP administration, 6.3% did not receive it upon ICU admission. Consequently, 77 (38.5%) of 200 patients received inappropriate prophylaxis on ICU admission. In addition, 53.5% of patients had appropriate adherence to ASHP guideline during all days of ICU stay (44% and 2.5% of patients received SUP more than 120% and <80% of appropriate SUP duration, respectively). Moreover, 81.2% were continued on inappropriate prophylaxis upon transfer from the ICU.

Conclusion:

We concluded that although SUP administration included both overutilization and underutilization in this ICU, but high prevalence of SUP overutilization caused unnecessary hospital costs, personal monetary burden, and may increase adverse drug reactions. Therefore, educating physicians and cooperation of clinical pharmacists regarding implementing standard protocols could improve patterns of SUP administration.

Efficacy and safety of proton pump inhibitors for stress ulcer prophylaxis in critically ill patients: a systematic review and meta-analysis of randomized trials

BACKGROUND

The relative efficacy and safety of proton pump inhibitors (PPIs) compared to histamine-2-receptor antagonists (H2RAs) should guide their use in reducing bleeding risk in the critically ill.

METHODS

We searched the Cochrane library, MEDLINE, EMBASE, ACPJC, clinical trials registries, and conference proceedings through November 2015 without language or publication date restrictions. Only randomized controlled trials (RCTs) of PPIs vs H2RAs for stress ulcer prophylaxis in critically ill adults for clinically important bleeding, overt gastrointestinal (GI) bleeding, nosocomial pneumonia, mortality, ICU length of stay and Clostridium difficile infection were included. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess our confidence in the evidence for each outcome.

RESULTS

In 19 trials enrolling 2117 patients, PPIs were more effective than H2RAs in reducing the risk of clinically important GI bleeding (RR 0.39; 95 % CI 0.21, 0.71; P = 0.002; I (2) = 0 %, moderate confidence) and overt GI bleeding (RR 0.48; 95 % CI 0.34, 0.66; P < 0.0001; I (2) = 3 %, moderate confidence). PPI use did not significantly affect risk of pneumonia (RR 1.12; 95 % CI 0.86, 1.46; P = 0.39; I (2) = 2 %, low confidence), mortality (RR 1.05; 95 % CI 0.87, 1.27; P = 0.61; I (2) = 0 %, moderate confidence), or ICU length of stay (mean difference (MD), -0.38 days; 95 % CI -1.49, 0.74; P = 0.51; I (2) = 30 %, low confidence). No RCT reported Clostridium difficile infection.

CONCLUSIONS

PPIs were superior to H2RAs in preventing clinically important and overt GI bleeding, without significantly increasing the risk of pneumonia or mortality. Their impact on Clostridium difficile infection is yet to be determined.

Stress ulcer prophylaxis in the intensive care unit: an international survey of 97 units in 11 countries

BACKGROUND

Stress ulcer prophylaxis (SUP) may decrease the incidence of gastrointestinal bleeding in patients in the intensive care unit (ICU), but the risk of infection may be increased. In this study, we aimed to describe SUP practices in adult ICUs. We hypothesised that patient selection for SUP varies both within and between countries.

METHODS

Adult ICUs were invited to participate in the survey. We registered country, type of hospital, type and size of ICU, preferred SUP agent, presence of local guideline, reported indications for SUP, criteria for discontinuing SUP, and concerns about adverse effects. Fisher's exact test was used to assess differences between groups.

RESULTS

Ninety-seven adult ICUs in 11 countries participated (eight European). All but one ICU used SUP, and 64% (62/97) reported having a guideline for the use of SUP. Proton pump inhibitors were the most common SUP agent, used in 66% of ICUs (64/97), and H2-receptor antagonists were used 31% (30/97) of the units. Twenty-three different indications for SUP were reported, the most frequent being mechanical ventilation. All patients were prescribed SUP in 26% (25/97) of the ICUs. Adequate enteral feeding was the most frequent reason for discontinuing SUP, but 19% (18/97) continued SUP upon ICU discharge. The majority expressed concern about nosocomial pneumonia and Clostridium difficile infection with the use of SUP.

CONCLUSIONS

In this international survey, most participating ICUs reported using SUP, primarily proton pump inhibitors, but many did not have a guideline; indications varied considerably and concern existed about infectious complications.

Prevalence and outcome of gastrointestinal bleeding and use of acid suppressants in acutely ill adult intensive care patients

PURPOSE

To describe the prevalence of, risk factors for, and prognostic importance of gastrointestinal (GI) bleeding and use of acid suppressants in acutely ill adult intensive care patients.

METHODS

We included adults without GI bleeding who were acutely admitted to the intensive care unit (ICU) during a 7-day period. The primary outcome was clinically important GI bleeding in ICU, and the analyses included estimations of baseline risk factors and potential associations with 90-day mortality.

RESULTS

A total of 1,034 patients in 97 ICUs in 11 countries were included. Clinically important GI bleeding occurred in 2.6 % (95 % confidence interval 1.6-3.6 %) of patients. The following variables at ICU admission were independently associated with clinically important GI bleeding: three or more co-existing diseases (odds ratio 8.9, 2.7-28.8), co-existing liver disease (7.6, 3.3-17.6), use of renal replacement therapy (6.9, 2.7-17.5), co-existing coagulopathy (5.2, 2.3-11.8), acute coagulopathy (4.2, 1.7-10.2), use of acid suppressants (3.6, 1.3-10.2) and higher organ failure score (1.4, 1.2-1.5). In ICU, 73 % (71-76 %) of patients received acid suppressants; most received proton pump inhibitors. In patients with clinically important GI bleeding, crude and adjusted odds for mortality were 3.7 (1.7-8.0) and 1.7 (0.7-4.3), respectively.

CONCLUSIONS

In ICU patients clinically important GI bleeding is rare, and acid suppressants are frequently used. Co-existing diseases, liver failure, coagulopathy and organ failures are the main risk factors for GI bleeding. Clinically important GI bleeding was not associated with increased adjusted 90-day mortality, which largely can be explained by severity of comorbidity, other organ failures and age.

Stress-related mucosal disease in the critically ill patient

Bleeding from stress-related mucosal disease in critically ill patients remains an important clinical management issue. Although only a small proportion (1-6%) of patients admitted to an intensive care unit (ICU) will bleed, a substantial proportion exhibit clinical risk factors (mechanical ventilation for >48 h and a coagulopathy) that predict an increased risk of bleeding. Furthermore, upper gastrointestinal mucosal lesions can be found in 75-100% of patients in ICUs. Although uncommon, stress-ulcer bleeding is a severe complication with an estimated mortality of 40-50%, mostly from decompensating an underlying condition or multiorgan failure. Although the vast majority of patients in ICUs receive stress-ulcer prophylaxis, largely with PPIs, some controversy surrounds their efficacy and safety. Indeed, no single trial has shown that stress-ulcer prophylaxis reduces mortality. Some reports suggest that the use of PPIs increases the risk of nosocomial infections. However, several meta-analyses and cost-effectiveness studies suggest PPIs to be more clinically effective and cost-effective than histamine-2 receptor antagonists, without considerable increases in nosocomial pneumonia. To help clinicians use the most appropriate strategy for treatment of patients in the ICU, this Review presents the latest information on all aspects of stress-related mucosal disease.

Proton pump inhibitors increase the risk for hospital-acquired Clostridium difficile infection in critically ill patients

INTRODUCTION

Proton pump inhibitors (PPI) have been linked to Clostridium difficile infection (CDI) but there are few data specific to ICU patients. We evaluated duration of PPI exposure as a potential risk factor for hospital-acquired CDI in the ICU.

METHODS

This retrospective, case-control study was conducted using the Multiparameter Intelligent Monitoring in Intensive Care II database, a large publically available database of more than 35,000 ICU patients. Adult patients with CDI were identified using the ICD-9 code for Clostridium difficile listed as a secondary diagnosis. To be included, patients had to be present in an ICU for ≥ 48 hours prior to Clostridium difficile acquisition. These patients were then matched to patients without CDI using the ICD-9 primary diagnosis, age (+/-5 years) and SOFA score (+/-1). Successfully matched patients were reviewed for PPI exposure and other potential confounding variables for CDI. PPI exposure was characterized as short (<2 days) or long (≥ 2 days). Multivariate modeling was performed to identify independent risk factors for CDI.

RESULTS

There were 408 patients evaluated and 81% received a PPI. The percentage of patients who had a long exposure to PPIs was 83% in the CDI group compared to 73% with controls (P = 0.012). Upon inclusion of the following variables into a multivariate analysis (long PPI exposure, histamine-2-receptor antagonist administration, antibiotic administration, immunosuppression and study duration), long PPI exposure (odds ratio (OR) (95% confidence interval (CI) = 2.03 (1.23 to 3.36), P = 0.006) and antibiotic use (OR (95% CI) = 2.52 (1.23 to 5.18), P = 0.012) were identified as independent predictors of CDI.

CONCLUSIONS

Proton pump inhibitors are independent risk factors for the development of CDI in ICU patients. This risk is particularly exposed after two or more days of therapy.