Use Of Acid Suppression Therapy Research Articles

Use of Acid-Suppression Therapy and Odds of Migraine and Severe Headache in the National Health and Nutrition Examination Survey.

Headache is an adverse event associated with the use of proton pump inhibitors (PPIs). Recently, migraine has emerged more specifically as a potential adverse event with PPI use. The objectives of this work were to capitalize on existing data to evaluate the association between migraine and severe headache prevalence and use of acid-suppression therapy, including PPIs, H2 receptor antagonists (H2RAs), and generic antacids; to compare risk from PPIs vs H2RAs; and to assess for potential mitigation by a dietary factor affected by acid-suppression therapy. Data from adults in the 1999-2004 National Health and Nutrition Examination Survey were used for this cross-sectional analysis. Acid-suppression therapy use was identified from self-report confirmed by product packaging review. Respondents who endorsed migraine or severe headache in the past 3 months were classified in the migraine or severe headache group. Dietary intake of magnesium was determined using one 24-hour recall interview. Multivariable logistic regression models were generated to analyze the relationship between acid-suppression therapy use and migraine or severe headache, and an interaction test was conducted to evaluate whether migraine or severe headache prevalence differed in relation to nutritional magnesium intake across acid-suppression therapy users and nonusers. In 11,818 US adults, the use of acid-suppression therapy was associated with higher odds of migraine or severe headache for all types of acid-suppression therapy and use of any type, as compared with those who did not use acid-suppression therapy: use of PPIs (70% higher), H2RAs (40% higher), and generic antacids (30% higher). Differences between acid-suppression therapy were not significant. An interaction was observed for H2RA use and magnesium intake (p = 0.024). These observations in US adults agree with previous findings that migraine or severe headache is a potential adverse event of PPIs, the most efficacious and most frequently used type of acid suppressing medication, and further suggest that other classes of acid suppressing medications (H2RAs and generic antacids) may also be implicated for migraine and severe headache. Future prospective analyses are needed to investigate migraine risk associated with acid suppressing medications while current evidence is sufficient to evaluate patients with migraine in light of recent deprescribing advice for PPIs.

Regional differences in the use of proton pump inhibitors in children

Physiological gastroesophageal reflux in infancy is difficult to distinguish from reflux disease. International guidelines recommend restrictive use of acid suppression therapy for infants due to the lack of documented effect, but its use in infants and older children has increased in recent years. This study aims to describe change over time and geographic variation in the investigation and treatment of suspected gastroesophageal reflux disease. In aggregated data from the Norwegian Prescribed Drug Registry for the period 1.1.2007-31.12.2020, we examined regional differences in the number of proton pump inhibitors dispensed for children and adolescents. Data from the Norwegian Patient Registry were analysed to identify the use of 24-hour pH measurement and gastroscopy, which can support the suspicion of gastroesophageal reflux disease. The number of proton pump inhibitors dispensed in the first year of life increased and was highest in South-Eastern Norway Regional Health Authority, with 10.1 per 1000 children in 2007 and 54.7 per 1000 children in 2020 (relative risk 5.4, 95% confidence interval 4.6 to 6.4). The number dispensed in 2020 was 64% higher in South-Eastern Norway Regional Health Authority compared to Northern Norway Regional Health Authority and Central Norway Regional Health Authority. There was little change in the number of gastroscopies, but use of 24-hour pH measurement fell by 52% from 2016 to 2020. Use of proton pump inhibitors in infants has increased considerably despite the guidelines. Together with geographic variation, this may point towards overtreatment of physiological reflux in infants. Few investigations indicate that an increasing proportion are treated without supporting diagnostics.

Letter from the Editor

Bariatric Surgical Practice and Patient CareVol. 18, No. 2 EditorialFree AccessLetter from the EditorDean J. MikamiDean J. MikamiDean J. Mikami, MD, FACS, Editor-in-Chief, Bariatric Surgical Practice and Patient Care, Professor of Surgery, Associate Chair of Clinical Affairs, Division Chief, General Surgery, Associate Program Director, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI 96813, USA E-mail Address: dmikami2@hawaii.eduDepartment of General Surgery, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA.Search for more papers by this authorPublished Online:15 Jun 2023https://doi.org/10.1089/bari.2023.29034.djmAboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Since our last issue, we have continued to receive high-quality articles from around the world. I again want to thank our dedicated peer review physicians, surgeons, and allied health professionals for their many hours of work. I also want to thank William F. Gourash, CRNP, PhD, Chih-Kun Huang, MD, and Melissa A. Kalarchian, PhD who will be rotating off our editorial board. Their many years of dedication to Bariatric Surgical Practice and Patient Care has moved the journal forward and we wish them the best in their future endeavors. I want to welcome two new members to the board at this time. Dr. Jennifer Schwartz is an assistant professor of surgery in the division of bariatric and minimally invasive surgery at the Yale School of Medicine. Dr. Schwartz earned her BS from Vanderbilt University and MD from SUNY Upstate Medical University.She then completed her general surgical residency and minimally invasive surgical fellowship at The Ohio State University Wexner Medical Center in Columbus, Ohio. Dr. Sara Martin del Campo who most recently received the 2022 Bariatric Surgery Top Doc designation. Sara E. Martin del Campo, MD, is a metabolic and bariatric surgeon with Swedish Weight Loss Services at First Hill and Issaquah. Dr. Martin del Campo is a board-certified general surgeon and fellowship-trained bariatric surgeon. She has studied clinical outcomes in surgery and has authored multiple peer-reviewed publications in the field, and she continues to participate on committees of many national societies, including the American Society for Metabolic and Bariatric Surgery and The Society of American Gastrointestinal and Endoscopic Surgeons.In this issue, we have a wide variety of articles from around the world. Our lead study is from Dr. Andrew Strong titled “Use of Acid Suppression Therapy Following Gastric Bypass and Sleeve Gastrectomy a Long-Term Follow up.” Bariatric Surgical Practice and Patient Care continues to hold a strong international presence as we have publications from six different countries represented in this issue.In closing, I hope you consider publishing your next study in Bariatric Surgical Practice and Patient Care. The journal is always open to innovative ways of improving the reader's experience. Please feel free to contact me if you have any suggestions that could improve our journal.Sincerely,FiguresReferencesRelatedDetails Volume 18Issue 2Jun 2023 InformationCopyright 2023, Mary Ann Liebert, Inc., publishersTo cite this article:Dean J. Mikami.Letter from the Editor.Bariatric Surgical Practice and Patient Care.Jun 2023.65-65.http://doi.org/10.1089/bari.2023.29034.djmPublished in Volume: 18 Issue 2: June 15, 2023PDF download

Use of Acid Suppressive Therapy Following Gastric Bypass and Sleeve Gastrectomy at Long-Term Follow-Up

Background: Earlier studies demonstrate that increased gastroesophageal reflux disease (GERD) symptoms following sleeve gastrectomy (SG) may necessitate initiation or dose escalation of acid suppressive therapy (AST). The relationship between GERD and AST use following Roux-en-Y gastric bypass (RYGB) is less clear. Methods: This is a retrospective study of patients undergoing primary SG or RYGB at tertiary care hospital from 2004 to 2014. Inclusion criteria were patients older than 18 years of age with employee health insurance at the study institution and at least 3 years of follow-up. The use of AST, defined as either proton pump inhibitor or selective H2 blockers, was compared pre- and postoperatively. Results: A total of 356 patients were identified, including 104 (29.2%) who has SG and 252 who had RYGB (70.8%). Similar proportions of patients had GERD before SG (54.8%) and RYGB (49.6%, p = 0.37). Long-term outcomes were compared at a median follow-up time period of 164 months (IQR, 119–215). The proportion of patients using AST increased following RYGB (21.0% preop vs. 34.1% postop, p < 0.05) including 54 (21.4%) patients with de novo postoperative use. Following SG, the proportion of patients using AST increased from 19.2% to 38.5% (p < 0.05), including 28 (26.9%) patients with de novo use. Similar proportions of patients were using AST following RYGB and SG (p > 0.05). Conclusion: This study confirms prior evidence of SG as a potentially refluxogenic operation, with many patients needing AST at long-term follow-up. However, it also demonstrates a similar proportion of patients requiring AST following RYGB. Although the current study is unable to delineate the reasons for this, prospective investigation into AST use after RYGB is warranted.

Impact of concomitant gastroesophageal reflux disease symptomology on prognosis and pulmonary function of chronic hypersensitivity pneumonitis.

Comorbid risk factors in chronic hypersensitivity pneumonitis (CHP) are poorly characterised. Gastroesophageal reflux disease (GERD) is linked to interstitial lung diseases like idiopathic pulmonary fibrosis (IPF), but its association and treatment in CHP is less understood. This study aims to understand the role and prevalence of GERD in CHP, plus the effect of GERD treatment on lung function and mortality. A tertiary referral centre panel was retrospectively reviewed for 214 patients diagnosed with CHP based on clinical history, bronchoalveolar lavage fluid analysis, imaging and histopathology. GERD diagnostic criteria included symptomology, acid suppressive therapy use and diagnostic testing. CHP patients with GERD (n = 89) and without GERD (n = 125) were compared via descriptive statistical analysis. Pulmonary function, GERD diagnosis plus treatment and other comorbidities were evaluated against CHP outcomes. Respective differences between diagnosis and study termination dates in the GERD population versus without GERD for functional vital capacity (FVC) were - 1 L vs - 2.5 L, diffusing capacity of the lungs for carbon monoxide (DLCO) were - 2 mL/min/mmHg versus - 1 mL/min/mmHg, per cent alive at the time of study 88% versus 81%, median date of survival 574.5 versus 850 and supplemental oxygen requirement 41% versus 37%. GERD prevalence was higher in CHP patients relative to the general population. No statistical significance was found between survival curves, oxygen requirement, smoking history, FVC, or DLCO. GERD could be a harmful comorbidity in CHP though may not necessarily affect survival or functional outcomes. This aligns with previous IPF studies, though remains controversial. Further research is needed regarding this association and treatment benefit.

Initiation of acid suppression therapy for laryngomalacia

ObjectiveEvidence supporting the use of acid suppression therapy (AST) for laryngomalacia (LM) is limited. The objective of this study was to determine if outpatient-initiated AST for LM was associated with symptom improvement, weight gain, and/or avoidance of surgery. MethodsA retrospective cohort was reviewed at a tertiary-care children's hospital. Patients were included if they were diagnosed with LM at ≤6 months of age, seen in an outpatient otolaryngology clinic between 2012 and 2018, and started on AST. Primary outcomes were improvement of airway and dysphagia symptoms, weight gain, and need for surgery. Severity was assessed by symptom severity. ResultsOf 2693 patients reviewed, 199 met inclusion criteria. Median age of diagnosis was 4 weeks (range: 0–29 weeks). LM was classified as mild/moderate (71.4%) and severe (28.6%) based on symptom severity. Severity on flexible fiberoptic laryngoscopy (FFL) was not associated with clinical severity. Weight percentile, airway symptoms, and dysphagia symptoms improved within the cohort. In total, 26.1% underwent supraglottoplasty (SGP). In multivariate analysis, only severe LM on FFL was predictive of SGP (OR: 7.28, 95%CI: 1.91–27.67, p = .004). ConclusionClinical symptom severity did not predict response to AST raising the question of utility of AST in LM. Severity of LM based on FFL, not clinical severity, was associated with decision to pursue SGP. Prospective randomized trials are needed to better understand the role of AST in LM. Level of evidenceLevel 3.

Patients, Prescribers, and Institutional Factors Associated with Inappropriate Use of Acid Suppressive Therapy in Medical Wards: An Experience of a Single-Center in Saudi Arabia.

PurposeTo identify factors associated with inappropriate acid-suppressive therapy (AST) use in hospitalized medical ward patients.Patients and MethodsThis was a combined retrospective cohort study reviewing the electronic medical records of medical ward in a secondary university hospital between January 2018 and July 2019, in addition to prescriber surveys about AST knowledge. We included adult patients (≥18 years old) admitted to the medical ward who received at least one dose of AST during their hospitalization. Statistical analyses included descriptive statistics and logistic regression.ResultsA total of 335 patients were included. Most of the patients were female (66.6%), with a mean age of 42.37 ± 17.72 years; 76% (n=256) of the study subjects were prescribed AST for an inappropriate indication. Patients who were not receiving any home medications associated with high bleeding risk had higher odds of being prescribed AST inappropriately (OR, 4.06; 95% CI, 1.09–13.8). A total of 27 physicians completed the prescriber survey, and the average prescriber’s knowledge score was 46.8 ± 15.6%. This score did not differ by the prescriber’s position.ConclusionThis study demonstrated the overuse of AST in the medical ward. Therefore, improving providers’ awareness about AST and implementing an AST stewardship program in institutions is necessary to limit this long-lasting issue.

Assessing risk factors, mortality, and healthcare utilization associated with Clostridioides difficile infection in four Latin American countries

BackgroundClostridioides difficile infection (CDI) is the most common cause of healthcare-associated infections in Western countries. Risk factors, mortality, and healthcare utilization for CDI in Latin America are poorly understood. This study assessed risk factors and burden associated with nosocomial CDI in four Latin American countries. MethodsThis retrospective, case-control study used databases and medical records from 8 hospitals in Argentina, Brazil, Chile, and Mexico to identify nosocomial CDI cases from 2014 − 2017. Cases were patients aged ≥18 years with diarrhea and a positive CDI test ≥72 h after hospital admission. Two controls (without diarrhea; length of hospital stay [LOS] ≥3 days; admitted ±14 days from case patient; shared same ward) were matched to each case. CDI-associated risk factors were assessed by univariate and multivariable analyses. CDI burden (LOS, in-hospital mortality) was compared between cases and controls. ResultsThe study included 481 cases and 962 controls. Mean age and sex were similar between cases and controls, but mean Charlson comorbidity index (4.3 vs 3.6; p < 0.001) and recent hospital admission (35.3% vs 18.8%; p < 0.001) were higher among cases. By multivariable analyses, CDI risk was associated with prior hospital admission within 3 months (odds ratio [OR], 2.08; 95% CI: 1.45, 2.97), recent antibiotic use (ie, carbapenem; OR, 2.85; 95% CI: 1.75, 4.64), acid suppressive therapy use (OR, 1.71; 95% CI: 1.14, 2.58), and medical conditions (ie, renal disease; OR, 1.48; 95% CI: 1.19, 1.85). In-hospital mortality rate (18.7% vs 6.9%; p < 0.001) and mean overall LOS (33.5 vs 18.8 days; p < 0.001) were higher and longer, respectively, in cases versus controls. ConclusionAntibiotic exposure, preexisting medical conditions, and recent hospital admission were major risk factors for CDI in Argentina, Brazil, Chile, and Mexico. CDI was associated with increased in-hospital risk of death and longer LOS. These findings are consistent with published literature in Western countries.

Determining proton pump inhibitor prescription dispensing patterns and adherence to STOPP criteria for Nova Scotia Seniors Pharmacare Program beneficiaries.

Proton pump inhibitors (PPIs) are often prescribed potentially inappropriately. The screening tool of older person's potentially inappropriate prescriptions (STOPP) for therapeutic dose PPIs has been adapted to examine PPI discontinuation, dose reduction, or switching to Histamine-2 Receptor Antagonist (H2RA) after 60 days. The objectives of the present study were to (1) describe the use of acid suppression therapy (PPIs and H2RAs) 60 and 90 days after a new PPI dispensing, (2) assess predictors of lack of adherence to adapted STOPP criteria for PPI use, and (3) assess PPI dispensing over time. This was a retrospective cohort study of beneficiaries of the Nova Scotia Seniors Pharmacare (NSSP) aged 66 years or older who were newly dispensed a PPI between January 1, 1997 and March 31, 2011. The main outcome measure was adherence to the adapted STOPP criteria, which was analyzed using logistic regression. A total of 14,453 participants were included: 89.8% beginning on standard dose and 10.2% beginning on high-dose PPI. Of those beginning on high-dose PPI, 26.4% were dispensed high-dose PPI at day 60 and 30.2% were dispensed high-dose PPI at day 90. Predictors of lack of adherence to our adapted STOPP criteria included age ≥86 years, rural residence, and hospitalization within 1 year prior to cohort entry. Many PPI prescriptions dispensed for NSSP beneficiaries fail to adhere to the STOPP criteria. Predictors of lack of adherence to the adapted STOPP criteria were identified.

Proton Pump Inhibitors, H2 Blocker Use, and Risk of Inflammatory Bowel Disease in Children.

Evidence suggests use of proton pump inhibitors (PPIs) and H2 blockers may provoke disease flares in individuals with established inflammatory bowel disease (IBD); however, there are no studies investigating the relationship of these medications with risk of developing pediatric IBD. The hypothesis was that use of acid suppression therapy in children might be associated with development of pediatric IBD. This was a nested case-control study of 285 Kaiser Permanente Northern California members, age ≤21 years diagnosed with IBD from 1996 to 2016. Four controls without IBD were matched to each case on age, race, and membership status at the case's index date. Disease risk scores (DRS) were computed for each subject. Odds ratios and 95% confidence intervals were calculated by using conditional logistic regression models adjusted for DRS. The children's mean age was 15.1 ± 2.6 years and 49.5% were female. Six cases (n = 3 Crohn's disease [CD], n = 3 ulcerative colitis [UC]) and 6 controls were prescribed PPIs and 10 cases (n = 7 CD, n = 3 UC) and 28 controls were prescribed H2 blockers. The OR for the association of at least 1 PPI or H2 blocker prescription with subsequent IBD was 3.6 (95% CI, 1.1-11.7) for PPIs and 1.6 (95% CI, 0.7-3.7) for H2 blockers. Early-life PPI use appears to be associated with subsequent IBD risk. These findings have implications for clinical treatment of children with gastrointestinal symptoms and warrant further investigation in a larger cohort.

THE ROLE OF ICU STRESS ULCER PROPHYLAXIS CHECKLIST IN IMPROVING ADHERENCE TO PROPHYLAXIS GUIDELINES IN ICU SETTING: A QUALITY IMPROVEMENT PROJECT

SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: Stress ulcer prophylaxis (SUP) is a well-established intervention in modern day intensive care unit (ICU). Nonetheless, the use of acid suppressive therapy is not a benign treatment. Some reported side effects include pneumonia and Clostridium difficile infection. We studied if a simple checklist would improve the appropriate use of SUP. METHODS: The study was conducted during a month rotation with house-staff serving as their own controls. The first two weeks, house-staff provided usual care. For the second two weeks, house-staff were provided with education and a checklist containing the hospital SUP guidelines. We collected demographic data, appropriate SUP use, and whether SUP was continued upon transfer out of ICU. We compared the preintervention and postintervention groups. RESULTS: Complete data was available for 110 subjects. 10 subjects were excluded due to death or admission with upper GI bleeding. The baseline characteristics are summarized in Table 1. We observed the rate of appropriate use of SUP increased from 65.4% to 82.2% after the intervention (P value 0.06). The rate of appropriate continuation of SUP after ICU discharge increased from 74.3% to 78.3% (P value 0.7). CONCLUSIONS: Although not statistically significant, this quality improvement project demonstrates that the use of an ICU checklist provided to the house-staff at the beginning of the ICU rotation shows a trend towards improved rate of appropriate use of SUP in the ICU. CLINICAL IMPLICATIONS: A simple checklist can improve the appropriate use of SUP in the ICU and potentially reduce adverse events and cost of care. DISCLOSURES: No relevant relationships by Ahmad Abu Homoud, source=Web Response No relevant relationships by Majdi Al Nabulsi, source=Web Response No relevant relationships by Zeina AlMajthoub, source=Web Response No relevant relationships by Sherene Fakhran, source=Web Response no disclosure on file for Aiman Tulaimat

A603 Long-term use of acid suppression therapy does not differ between gastric bypass and sleeve gastrectomy patients

Gastroesophageal reflux disease (GERD) is common in patients with obesity and different bariatric procedures have different effects on the symptoms. There is little long-term data regarding acid suppression therapy (AST: proton pump inhibitor or H2-blocker) use after bariatric surgery.

Acid Suppression Therapy and Symptom Improvement (or Lack Thereof) in Children

* Abbreviations: GER — : gastroesophageal reflux H2RA — : histamine H2-receptor antagonist HR — : hazard ratio PPI — : proton pump inhibitor Acid suppression therapy, in the form of histamine H2-receptor antagonists (H2RAs) and proton pump inhibitors (PPIs), is a common treatment in pediatrics for management of gastroesophageal reflux (GER). Symptoms commonly associated with GER in younger children include frequent emesis, back arching, fussiness, and discomfort. GER symptoms are reported in 10.3% of all children, with symptoms even more commonly noted in individuals <2 years old.1 At 4 months of age, 67% of children have daily regurgitation. Parents report a perceived problem with GER in 23% of 6-month-old infants.2 This high rate of concern results in GER being a common complaint in outpatient and inpatient settings. Combined with the ready availability of acid suppression therapy, this has led to increased prescribing of both H2RAs and PPIs in both infants and older children.3,4 Acid suppression therapy has been previously viewed as benign; however, recent research has revealed that these medications may carry risk. In this issue of Pediatrics , Malchodi et al5 assessed possible long-term adverse effects from use of acid suppression therapy. … Address correspondence to Mary Boruta, MD, Department of Pediatrics, Duke University Medical Center, DUMC 102375, Durham, NC 27710. E-mail: mary.boruta{at}duke.edu

Educational intervention can improve appropriateness of acid suppression therapy in hospitalized geriatric patients

ABSTRACTBackground: Inappropriate use of acid suppression (AST) therapy may lead to unnecessary harms, especially in the geriatric population. Despite this, AST remains one of the most commonly prescribed medications in the hospital. Therefore, we aimed to assess its prevalence and create educational intervention to improve the appropriateness of inpatient acid suppression therapy.Methods: Using a time-series design, we established a historical control by performing a retrospective chart. Accepted indications for AST were based on those endorsed by the USA Food and Drug Administration and literature review. Inclusion criteria were: (1) age ≥ 65; (2) acid suppression therapy-initiated in the hospital; and (3) patients admitted to the medicine teaching services. We then created an educational intervention, which consisted of lectures and distribution of information pocket cards to residents. Data was collected for two months after the intervention. We used a two-tail fisher exact test and student’s t-test to analyze our results.Results: 65% of geriatric patients were inappropriately placed on acid suppression therapy, for which 13% were discharged without further indications. After the educational intervention, the inappropriate use of acid suppression therapy decreased to 45% (P < 0.05).Conclusion: There is a significant overuse of AST in hospitalized geriatric patients. Educational interventions are one potential method that may help improve the appropriateness of acid suppression therapy for elderly inpatients.

Evaluation of the clinical impact of concomitant acid suppression therapy in colorectal cancer patients treated with capecitabine monotherapy.

Capecitabine is an oral chemotherapeutic agent used in colorectal cancer. Two prior studies found a negative impact with the concomitant use of proton pump inhibitor agents during treatment with capecitabine in patients with early colorectal and gastroesophageal cancers. To determine if there is a clinical impact of the concomitant use of capecitabine and acid suppression therapy in patients with local and metastatic colorectal cancer. This was a single-center retrospective cohort study of adult patients with colorectal cancer on capecitabine monotherapy between 2011 and 2017. Progression-free survival (PFS) and overall survival were compared between patients on acid suppression therapy and those not on acid suppression therapy. A total of 70 patients were included. Patients on acid suppression therapy at capecitabine initiation (21%) had decreased progression-free survival versus those not on acid suppression therapy (HR 2.24, 95% CI 1.06-4.41, p = 0.035), after adjusting for disease severity and age. Acid suppression therapy use was associated with a numerical decrease in overall survival (HR 1.86, 95% CI 0.81-3.91, p = 0.14). In patients on any concomitant acid suppression therapy (25%), there was a decreased rate of progression-free survival (HR 6.21, 95% CI 2.56-14.32, p = 0.0001) but not overall survival (HR 1.64, 95% CI 0.68-3.54, p = 0.25) versus those without concomitant acid suppression therapy, after adjusting for age and disease severity. Concurrent use of acid suppression therapy and capecitabine was associated with decreased progression-free survival, and there was a trend towards decreased overall survival. Due to the demonstrated potential of decreased efficacy, concurrent use of proton pump inhibitors or histamine 2 receptor antagonists should be avoided in colorectal cancer patients on treatment with capecitabine monotherapy.

Predictors of therapeutic failure among patients with acute brucellosis treated by dual therapy with doxycycline‐rifampin

To determine the frequency of therapeutic failure among patients with acute and subacute brucellosis and to explore the predictors of failure. The study included 213 consecutive, naïve patients with acute and subacute brucellosis. All participants underwent clinical evaluation, chest radiography, stool microscopic examination and interferon-gamma release assay. Patients received the WHO-recommended therapy of doxycycline 200 mg/day and rifampin 900 mg/day, for 6 weeks. Mean age of the study population was 39.8 ± 12.2 years; 64.8% of them were males. The therapeutic failure rate was 16.4%. Adverse effects were reported by 13.1%. Multivariate analysis of factors associated with therapeutic failure revealed latent tuberculosis infection (LTBI) (OR 3.1, 95% CI, 1.9-24.6, P: 0.009), ascariasis (OR 2.6, 95% CI 1.5-17.9, P: 0.012), and the use of acid suppressive therapy (OR 2.1, 95% CI 1.2-19.5, P: 0.037) as the predictors of therapeutic failure. The prevalence of therapeutic failure among the Egyptian patients with acute/subacute brucellosis is increasing. Predictors of therapeutic failure are LTBI, ascariasis, and the use of acid suppressive therapy.

Acid Suppression to Prevent Gastrointestinal Bleeding in Patients With Ventricular Assist Devices

BackgroundThe high incidence of gastrointestinal bleeding (GIB) in patients with ventricular assist devices (VAD) is well known, but there is limited evidence to support the use of proton pump inhibitors (PPIs) or histamine receptor antagonists (H2RA) for preventing GIB in patients with VAD. Materials and methodsThe surgical ICU and VAD databases within a large regional academic cardiac mechanical support and transplant center were queried for patients who underwent VAD implantation between 2010 and 2014. An observational cohort study was conducted to identify which acid suppressing drug regimen was associated with the fewest number of GIB events within 30 d after VAD implantation: PPI, H2RA, or neither. Secondary outcomes included timing, etiology, and location of GIB. Multivariable logistic regression was used to compare treatment cohorts to GIB. Odds ratios, 95% confidence intervals, and P-values were reported from the model. ResultsOne hundred thirty-eight patients were included for final analysis, 19 of which had a GIB within 30 days of VAD implantation. Both H2RA and PPI use were associated with reduced GIB compared with the cohort with no acid suppressive therapy. In the multivariate analysis, the PPI cohort showed a statistically significant reduction in GIB (Odds ratio 0.18 [95% confidence interval 0.04-0.79] P = 0.026). ConclusionsUsing PPI postoperatively in patients with new VAD was associated with a reduced incidence of GIB. Given that GIB is a known complication after VAD placement, clinicians should consider the use of acid suppressive therapy for primary prevention.

Limiting the Inappropriate Use of Acid Suppression Therapy for Stress Ulcer Prophylaxis in Hospitalized Patients at Cleveland Clinic Florida: A Quality Improvement Project

Introduction: The use of acid suppression therapy (AST) for stress ulcer prophylaxis (SUP) has been recommended in a specific patient population in the intensive care unit (ICU) setting. This population includes patients with mechanical ventilation longer than 48 hours, coagulopathy, multi-organ failure, shock, thermal or major trauma, neurologic trauma, and history of upper gastrointestinal (GI) bleed, peptic ulcer, or erosive gastritis in the past year. However, AST is often misused to include patients without indication for SUP. The overuse of AST increases hospital cost and potential adverse side effects. Two of the most commonly uses ASTs are proton pump inhibitors (PPIs) and H2-blockers. The main objective of this quality improvement project was to decrease the inappropriate use of PPIs and H2-blockers for SUP in patients hospitalized at Cleveland Clinic Florida (CCF). Methods: We obtained the medical records of patients prescribed (PPIs) or H2 blockers during January 2016. We performed a retrospective chart review of the January 2016 patients and explored seven data variables: admitting diagnosis, AST prescribed, route of administration, whether AST was used for treatment of prophylaxis, appropriateness of AST use for prophylaxis, appropriateness of AST use for treatment, and number of doses administered. We performed the intervention in December of 2016 by removing the “GI prophylaxis” section on the general admission order set of our electronic medical records. We then collected data looking at the same variables in inpatients who received AST in January 2017. Our primary endpoint was the rate of inappropriate use of AST. We used measures of central tendency and Pearson Chi Square testing to compare the rates of inappropriate AST use in the preintervention and post-intervention groups. Results: 365 out of 939 (36%) patients admitted during January 2016 inappropriately received AST with PPIs or H2-blockers for SUP. In the post-intervention period (January 2017), 243 out of 945 (25.7%) patients received inappropriate PPIs or H2-blockers for SUP. This was statistically significant (p value <.0001). Conclusion: Acid suppression therapy for stress ulcer prophylaxis is frequently misutilized in hospitalized patients. This increases hospital costs and adverse events. More interventions should be performed to ensure the appropriate use of SUP, which would decrease resource expenditures without negatively impacting the quality of care patients receive.1097 Figure 1 No Caption available.

Decrease in the Inappropriate Use of Acid Suppression Therapy in the Geriatric Age Group by Educational Intervention

Inappropriate use of acid suppression therapy may lead to unnecessary harms, especially in the geriatric population. Despite this, acid suppression therapy remains one of the most commonly prescribed medications in the hospital. Therefore, we aimed to assess the prevalence of acid suppression therapy in a geriatric inpatient population and to create an educational intervention to improve the appropriateness of inpatient acid suppression therapy in this population. Using a time-series design, we established a historical control by performing a retrospective chart review on inpatient geriatric patients who were started on acid suppression therapy while in a teaching-based hospital. Accepted indications for acid suppression therapy were based on those endorsed by the US Food and Drug Administration and literature review. Inclusion criteria were: (1) age 65 years or older; (2) acid suppression therapy-initiated in the hospital; and (3) patients admitted to the medicine teaching services. Patients who were already on acid suppression drugs before their hospitalization were excluded. We then created an educational intervention, which consisted of lectures and distribution of information pocket cards to residents. Data were collected for 2 months after the intervention. We used a 2-tailed Fisher’s exact test and Student t test to analyze our results. Before our educational intervention, 65% of geriatric patients were inappropriately placed on acid suppression therapy, for which 13% were discharged without further indications. After the educational intervention, the inappropriate use of acid suppression therapy decreased to 45% (P < .001). In addition, there was a significant increase from 35% to 55% (P < .001) in the appropriate use of acid suppression therapy after the educational intervention. There is a significant overuse of acid suppression therapy in hospitalized geriatric patients. These agents are often continued at the time of the discharge, leading to potential harms and increased health care cost. Educational interventions are one potential method that may help improve the appropriateness of acid suppression therapy for elderly inpatients.

703 - Decrease in the Inappropriate Use of Acid Suppression Therapy in the Geriatric Age Group by Educational Intervention

703 - Decrease in the Inappropriate Use of Acid Suppression Therapy in the Geriatric Age Group by Educational Intervention