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Abstract

Introduction: Critically ill patients may develop bleeding caused by stress ulceration (SU). Stress ulcer prophylaxis (SUP) is commonly used in the Intensive Care Unit (ICU) to prevent SU however, complications may include clostridium difficile (CD) infection and nosocomial pneumonia (NP). Whether a difference exists between proton pump inhibitors (PPI) and histamine 2 receptor antagonists (H2) remains unclear. Methods: A retrospective analysis of a database with patients admitted to a 54 bed medical-surgical ICU between 7/2009 and 2/2013 was performed. Patients were identified based on indications for SUP (duodenal ulcer, gastric ulcer, H. Pylori infection, erosive esophagitis, mechanical ventilation, coagulopathy, and gastroesophegeal reflux disease). Outcomes included the development of GI bleed (GIB), CD infection, NP and mortality up to 30 days. Results: The database contained 14,280 patients and the following patients were excluded: 3435 patients who were on acid suppression prior to admission, 1424 patients who did not receive SUP in the ICU, and 859 patients who received both H2 and PPI while in the hospital. This left 8562 patients; 3681 (43 %) in the PPI group and 4881 (57%) in the H2 group. SUP was indicated in 1190 patients (32.3 %) in the PPI group vs 1848 patients (37.8%) in the H2 group ( Odds ratio [OR] = 0.8; 95% confidence interval [CI], 0.7 – 0.9, p < 0.0001). GIB occurred in 174 patients (4.7 %) in the PPI group vs 53 patients (1.1 %) in the H2 Group (OR = 4.5, 95% CI, 3.3 – 6.2, p < 0.0001). CD infection occurred in 70 patients (1.9 %) in the PPI group vs 63 patients (1.3 %) in the H2 Group (OR = 1.5, 95% CI, 1.1 – 2.1, p = 0.02). NP occurred in 11 patients (0.29 %) in the PPI group vs 13 patients (0.26 %) in the H2 Group (OR = 1.1, 95% CI, 0.5 – 2.5, p = 0.8). The 30 day mortality was 6.0% (n=221) in the PPI group vs 3.7% (n=181) in the H2 Group (OR = 1.7, 95% CI, 1.4 – 2.0, p < 0.0001). Conclusions: The administration of a PPI compared to H2 for SUP was associated with an increase in GIB, CD infections, and mortality. The results of this study provide pilot data supporting the further study of PPI versus H2 blockers for ICU patients at risk for stress ulcers.