Indications For Stress Ulcer Prophylaxis Research Articles

Appropriateness and Cost of Prophylaxis Stress Ulcer for Inpatient in the Internal Medicine Department in a Government Hospital: A Cross-Sectional Study

Guidelines from the American Society of Health-System Pharmacists (ASHP) 1999 prohibit acid-suppressing therapy for stress ulcer prophylaxis (SUP) in patients who are not critically ill. Stress ulcer prophylaxis is not recommended in non-ICU patients with <2 risk factors. Inappropriate use of SUP can increase costs for patients. This study aims to evaluate the use and the cost of SUP. This research was a non-experimental observational study with a cross-sectional approach. Data was collected retrospectively using the consecutive sampling method with a random sampling technique on the medical records of inpatients in the internal medicine ward of Sleman Regional Public Hospital from January to December 2020, totaling 340 samples. The results showed that proton pump inhibitors were the most widely used acid-suppressing drugs, with 45.8%. Furthermore, the histamine-2 receptor antagonist was 42.6%, the sucralfate group was 7.4%, and the antacid group was 4.2%. Of 340 patients, 57 (16.8%) were in the proper indication based on the guidelines, and 283 (83.2%) were under the wrong indication for SUP. They were using SUP with the proper indication so that the therapy could save treatment costs by Rp. 19,933,582. There was a high prevalence of inappropriate SUP prescriptions among inpatients in the internal medicine department; if these drugs were given with the appropriate indications, they could save more on the prophylaxis cost. Clinician pharmacists should develop an effective intervention strategy to reduce inappropriate SUP drugs.

ESIMPLER: A Dynamic, Electronic Health Record-Integrated Checklist for Clinical Decision Support During PICU Daily Rounds.

Design, implement, and evaluate a rounding checklist with deeply embedded, dynamic electronic health record integration. Before-after quality-improvement study. Quaternary PICU in an academic, free-standing children's hospital. All patients in the PICU during daily morning rounds. Implementation of an updated dynamic checklist (eSIMPLER) providing clinical decision support prompts with display of relevant data automatically pulled from the electronic health record. The prior daily rounding checklist, eSIMPLE, was implemented for 49,709 patient-days (7,779 patients) between October 30, 2011, and October 7, 2018. eSIMPLER was implemented for 5,306 patient-days (971 patients) over 6 months. Checklist completion rates were similar (eSIMPLE: 95% [95% CI, 88-98%] vs eSIMPLER: 98% [95% CI, 92-100%] of patient-days; p = 0.40). eSIMPLER required less time per patient (28 ± 1 vs 47 ± 24 s; p < 0.001). Users reported improved satisfaction with eSIMPLER (p = 0.009). Several checklist-driven process measures-discordance between electronic health record orders for stress ulcer prophylaxis and user-recorded indication for stress ulcer prophylaxis, rate of venous thromboembolism prophylaxis prescribing, and recognition of reduced renal function-improved during the eSIMPLER phase. eSIMPLER, a dynamic, electronic health record-informed checklist, required less time to complete and improved certain care processes compared with a prior, static checklist with limited electronic health record data. By focusing on the "Five Rights" of clinical decision support, we created a well-accepted clinical decision support tool that was integrated efficiently into daily rounds. Generalizability of eSIMPLER's effectiveness and its impact on patient outcomes need to be examined.

Perforated gastric ulcer following perforated appendicitis

Abstract Stress ulcers and gastric ulcer perforations are rare in the pediatric population, and there is insufficient evidence to support routine stress ulcer prophylaxis in children. Our case is of a 13-year-old male who presented with appendicitis. He underwent laparoscopic appendectomy and was found to have perforated appendicitis. Postoperatively, he had a prolonged course secondary to ileus and was kept NPO. On postoperative day seven, he acutely worsened with pain and fever. A CT scan was performed to assess for abscess formation and significant free air and fluid was identified without abscess formation. Laparoscopy was performed. He was found to have a large perforated gastric ulcer along the lesser curvature. Conversion to laparotomy was undertaken secondary to poor visualization and significant enteric spillage. The perforation was repaired with a modified Graham patch. This represents a rare case of a perforated stress ulcer in a pediatric patient that was not critically ill and would not have met the most generally accepted indications for stress ulcer prophylaxis in children.

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.

Benefit of an electronic medical record-based alarm in the optimization of stress ulcer prophylaxis

BackgroundThe use of stress ulcer prophylaxis (SUP) has risen in recent years, even in patients without a clear indication for therapy. AimTo evaluate the efficacy of an electronic medical record (EMR)-based alarm to improve appropriate SUP use in hospitalized patients. MethodsWe conducted an uncontrolled before-after study comparing SUP prescription in intensive care unit (ICU) patients and non-ICU patients, before and after the implementation of an EMR-based alarm that provided the correct indications for SUP. Results1627 patients in the pre-intervention and 1513 patients in the post-intervention cohorts were included. The EMR-based alarm improved appropriate (49.6% vs. 66.6%, p<0.001) and reduced inappropriate SUP use (50.4% vs. 33.3%, p<0.001) in ICU patients only. These differences were related to the optimization of SUP in low risk patients. There was no difference in overt gastrointestinal bleeding between the two cohorts. Unjustified costs related to SUP were reduced by a third after EMR-based alarm use. ConclusionsThe use of an EMR-based alarm improved appropriate and reduced inappropriate use of SUP in ICU patients. This benefit was limited to optimization in low risk patients and associated with a decrease in SUP costs.

A Successful Pharmacist-Based Quality Initiative to Reduce Inappropriate Stress Ulcer Prophylaxis Use in an Academic Medical Intensive Care Unit.

Stress ulcer prophylaxis (SUP) is often inappropriately utilized, particularly in critically ill patients. The objective of this study is to find an effective way of reducing inappropriate SUP use in an academic medical intensive care unit (ICU). Medical ICU patients receiving SUP were identified over a 1-month period, and their charts were reviewed to determine whether American Society of Health-System Pharmacists guidelines were followed. Inappropriate usage was calculated as inappropriate patient-days and converted to incidence per 100 patient-days. Two interventions were implemented: (1) Pharmacists reviewed indications for SUP on each patient during daily team rounds and daily medication reconciliation and (2) residents rotating on ICU services were educated on a bimonthly basis. Postintervention data were obtained in a similar fashion. Prior to intervention, the incidence of inappropriate SUP usage was calculated to be 26.75 per 100 patient-days (n = 1099 total patient-days). Total cost attributable to the inappropriate use was $2433. Post intervention, we were able to decrease the inappropriate incidence of SUP usage to 7.14 per 100 patient-days (n = 1149 total patient-days). In addition, total cost of inappropriate use was reduced to $239.80. Our study highlights an effective multidisciplinary approach to reduce the inappropriate use of SUP in an academic medical ICU. We were able to reduce the incidence of inappropriate use of SUP by 73.31% (P < .001). Furthermore, we were able to decrease the costs by approximately $2200/month.

The Downward Spiral of Acid Suppressive Therapy in Stress Ulcer Prophylaxis

Introduction: Acid suppressive therapy (AST) use for stress ulcer prophylaxis (SUP) have long been seen as medical lore even though well established guidelines on appropriate AST use exists. Studies on non-critically ill patients have shown that AST guidelines are not followed. AST is routinely misused, leading to inappropriate chronic use. Moreover, chronic proton pump inhibitor (PPI) use has complications such as enteric infections, pneumonia, osteoporosis and drug interactions. Critically ill patients have multiple factors that lead to increased morbidity and mortality, one of which is inappropriate medication uses. This study seeks to evaluate the common misuse of AST in critically ill patients, and identify associated risk factors. Methods: A retrospective study of 692 patients admitted to the critical care units (CCU) at an academic institution. Inclusion criteria were patients admitted to CCUs who were >18y/o, and started on AST. Study excluded patients admitted with GI bleed, transferred to an outside institution, or expired. Data collection include, APACHE score, AST at home, indications for AST based on ASHP guidelines, AST discontinued when no longer indicted, discharged on AST, and length of stay (LOS). Results: After applying exclusion criteria, 395 total patients were included. Common AST used are PPI at 42% and Histamine-2 receptor antagonists (H2RAs) at 58%. We found that 56% of patients started on AST had no indication for SUP. At the time of downgrade from CCUs, AST was inappropriately continued on 74% of total patients. Subsequently, 20% were eventually discharged newly on AST. Of those newly discharged on AST, 67% were inappropriate. Longer LOS was associated with being newly discharged on inappropriate AST. The average LOS was 8.3 days for patients inappropriately discharged on new AST compared to 5.9 days for appropriate new AST (p=0.0284, Kruskal-Wallis test). Conclusion: While there have been studies on inappropriate use of AST among general medical patients, our study found that critically ill patients are equally affected by inappropriate AST use. This data supports that in critically ill patients, where morbidity and mortality are the highest, there is common misconceptions leading to inappropriate medication use. PPIs alone account for $13.6 billion in sales and is the 3rd largest class of drugs in the United States. The recognition of inappropriate AST use in critically ill patients can help significantly reduce healthcare expenditures and improve high value care.

Stress Ulcer Prophylaxis in Hospitalized Patients, Subsequent Use in Primary Care, and Physicians' Opinions About Acid-Suppressive Therapy.

Stress ulcer prophylaxis (SUP) is not indicated in most hospitalized patients. This study determined the prevalence of the use of proton pump inhibitors (PPI) and histamine receptor 2 blockers (H2B) in hospitalized patients, continued PPI/H2B use after discharge, and physicians' opinions about SUP. A retrospective electronic chart review, as well as a national survey of residents and faculty in primary care residency programs to determine the appropriateness of SUP. Of 753 charts reviewed, 332 hospitalized patients with outpatient follow-up were included; 303 of them had either PPI or H2B ordered during hospitalization, but only 120 patients had an indication for SUP. Stepwise logistic regression results showed patients with a history of PPI/H2B use were 16.6 times more likely to receive SUP (odds ratio 16.6; 95% confidence interval 2.2-124.7). In addition, a PPI/H2B indication also significantly predicted SUP use (odds ratio 5.1; 95% confidence interval 1.2-22.2). A total of 171 completed surveys were received: 73% residents and 27% faculty. Only 24% reported being aware of SUP guidelines; 17% reported using electronic health record order set suggestions for SUP. More than 90% of hospitalized patients received SUP; less than half of them had an indication for needing SUP. A large number of patients discharged on PPI/H2B continued to receive it in the outpatient setting at 6 months follow-up. Only 24% of physicians reported using SUP based on guidelines. Physician education and evidence-based validation of electronic health record order sets are potential areas for improvement.

Stress ulcer prophylaxis in the intensive care unit.

Stress ulcer prophylaxis (SUP) is considered standard of care in the majority of critically ill patients in the ICU. In this review, we will present the current evidence for the use of SUP in ICU patients, including data on the prevalence of gastrointestinal bleeding and the balance between benefits and harms of SUP. The prevalence of overt gastrointestinal bleeding in critically ill patients is in the area of 5%. Consistent risk factors for gastrointestinal bleeding have been identified, but indications for SUP vary considerably. SUP is used in three out of four critically ill patients, most frequently in the form of proton pump inhibitors. A recent systematic review of SUP vs. placebo or no prophylaxis in critically ill patients highlights the lack of evidence supporting the use of SUP. Importantly, data suggest potential harm, including increased risk of nosocomial infections and cardiovascular events. The prevalence of gastrointestinal bleeding in critically ill patients in the ICU is low, the prognostic importance is ambiguous, and SUP is widely used. The balance between benefits and harms of SUP is unknown, and clinical equipoise exists. High-quality randomized controlled trials and systematic reviews assessing benefits and harms of SUP in ICU patients are highly warranted.

Impact of a Multifaceted Intervention on Prescribing of Proton Pump Inhibitors for Stress Ulcer Prophylaxis in the Critically Ill

Background:: Lack of well-supported evidence clearly defining one agent as superior to the other for use in stress ulcer prophylaxis (SUP) has led to an array of treatment strategies. Studies comparing histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) have shown H2RAs to be non-inferior to PPIs at preventing clinically significant gastric bleeding. This, in addition to the decreased cost associated with H2RAs, has led to the adoption of H2RAs as the preferred agent for SUP at our institution. Objectives:: To evaluate the impact of developing a guideline and removing PPIs from computerized order entry PowerPlans on PPI prescribing for SUP in critically ill patients. Patients and Methods:: Members of the critical care service developed a guideline to direct SUP and removed pantoprazole from two critical care admission PowerPlans. In this interventional study with a historical control, adult patients admitted to the medical or surgical-trauma ICU and prescribed a PPI were evaluated during two time periods before and after the interventions. Patients were excluded if they were receiving a PPI for a reason other than SUP. Patients were assessed daily for an indication for SUP. These included mechanical ventilation, high dose steroids, and coagulopathy. Results:: A total of 92 and 60 patients were included in the pre- and post-intervention groups, respectively. PPI use for SUP was reduced from 38% in the pre-intervention group to 15.6% in the post-intervention group (P < 0.0001). PPI days adjusted for LOS were not different between the pre- and post-intervention groups (84% vs 86%, P = 0.5909). Of the total PPI days, 52.4% (95% CI 48.8 - 56.1) were classified as inappropriate because there was no indication, while the remaining 47.6% (95% CI 43.9 - 51.2) had an indication but should have received a H2RA. The total cost associated with guideline non-adherence was $1802. Conclusions:: Our multifaceted intervention reduced the number of days in which a PPI was prescribed for SUP in the overall ICU population; however, it did not impact the duration of PPI therapy. Patients either had no indication for SUP, or had an indication where less costly H2RAs could have been used. Additional opportunity exists to improve cost-effective prescribing of SUP for critically ill patients.

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

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. 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. 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. 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.

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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 but may be associated with complications including Clostridium difficile (CD) infection and nosocomial pneumonia (NP). Methods: A retrospective database analysis of ICU patients admitted to a 54 bed medical-surgical ICU between 07/2009 and 02/2013 was performed. Patients were identified based on the indications for SUP (duodenal ulcer, gastric ulcer, H. Pylori infection, erosive esophagitis, mechanical ventilation, coagulopathy, and gastroesophegeal reflux disease). Outcomes included development of GI bleed (GIB), CD infection, and NP up to 30 days. Either histamine receptor antagonists or proton pump inhibitors were prescribed for SUP. Results: The database contained 14,280 patients, out of which 12825 (89.8%) received SUP (SUP group) and 1455 (10.2%) did not (NSUP group). In the SUP group, 4360 (34%) had an indication for SUP, vs 37 (2.4%) of the patients in the NSUP group had an indication for SUP. GIB developed in 353 (2.8%) patients in the SUP group vs 6 (0.4%) patients in the NSUP group (Odds ratio [OR]= 7.0; 95% confidence interval [95% CI], 3.1 – 15.7, p < 0.0001). CD developed in 230 (1.8%) patients in the SUP group vs 14 (0.9%) patients in the NSUP group (OR= 1.9; 95% CI, 1.1 – 3.2, p = 0.02). NP developed in 71(0.6%) patients in the SUP group vs 2 (0.1%) patients in the NSUP group (OR= 4.0; 95% CI, 1.0 – 16.5, p = 0.05). Conclusions: Stress ulcer prophylaxis was prescribed for more patients than indicated and was associated with an increased incidence of Clostridium difficile infection and nosocomial pneumonia. The administration of SUP should be guided by established indications and undergo continuous quality assessment to prevent overutilization.

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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.

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Introduction: Current guidelines regarding stress ulcer prophylaxis (SUP) recommend prophylaxis in specific and limited situations. Pharmacological SUP, especially with proton pump inhibitors (PPI), may be overused in the medical intensive care unit (MICU). The objective of this study was to evaluate the appropriate use of SUP in adult medical critically ill patients upon admission and discharge. Methods: This was a retrospective, chart review of 100 adult critically ill patients admitted to the MICU from July 2011 to June 2012. Inclusion criteria were: age ≥ 18 years old, admission to the MICU for at least 48 hours, and administration of SUP. Patients diagnosed with a variceal bleed, active peptic ulcer disease, acute gastrointestinal (GI) bleed based on endoscopic exam or chart notation, Zöllinger-Ellison syndrome, or requiring a histamine-2 receptor antagonist (H2RA) for management of an allergic reaction were excluded. Appropriateness of SUP therapy was assessed using the ASHP 1999 SUP guidelines and was evaluated upon admission and discharge, respectively. Descriptive statistics were used to characterize hospital SUP practices and examine the frequency of patients receiving SUP appropriately upon admission to the MICU and at discharge from the MICU. Results: Out of one hundred patients that were enrolled, 86 (95.6%) patients received SUP appropriately. Ninety percent of patients were mechanically ventilated, which was the primary indication for SUP. There were 69 patients (69%) transferred from the MICU to a lower level of care. Of those patients, prescribers discontinued SUP therapy appropriately for only 14 patients. Of the 55 remaining patients who received a SUP agent, 48 (87.3%) received it appropriately based on current recommendations supported by 1999 ASHP guidelines on SUP and primary literature. An additional finding was that of 53 patients who received a PPI, 27 (50.9%) did not meet hospital criteria for receiving a PPI as first-line therapy. Conclusions: A majority of patients received SUP appropriately on admission and discharge from the MICU. However, over half of the patients who received PPI therapy did not meet hospital criteria for receiving a PPI first line. This occurred despite having a team of healthcare professionals caring for the patient which is concerning. The collected data suggest that our hospital may be overprescribing PPIs for patients who could have received H2RAs instead. Based on these findings, further education to the clinicians will be provided.

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Introduction: Stress ulcer prophylaxis (SUP) may be provided using proton pump inhibitors (PPIs) or histamine receptor antagonists (H2RAs). Data suggest PPIs may increase the risk of ventilator-associated pneumonia (VAP) in cardiac surgery critically ill patients. A lack of increased risk has been found in critically ill trauma patients. It is unknown whether PPIs for SUP are associated with increased infectious complications in the general critical care population. Methods: A retrospective chart review of patients admitted to the intensive care unit (ICU) from June 2008 to June 2010 was performed. Institutional Review Board approval was obtained prior to data collection. Patients were included if they received an intravenous PPI or H2RA. Cardiac surgery, pregnancy, active gastrointestinal bleeding, recent diagnosis of pneumonia, and immunosuppression were exclusion criteria. The primary objective was incidence of VAP. Secondary endpoints included development of bacteremia, urinary tract infection, Clostridium difficile infection, and gastrointestinal bleeding. Statistical analysis was performed using Pearson chi-square and independent t-tests, when appropriate. Results: A total of 281 patients were included in the analysis: 134 received PPIs and 147 H2RAs. Baseline characteristics were similar between groups. The most common admitting diagnosis was sepsis/septic shock. A majority of the subjects had an appropriate indication for SUP (70.9% vs. 65.3% in the PPI and H2RA groups, p=0.37). The mean duration of SUP was 6.6 days for the PPI group and 5.6 for the H2RA group (p=0.17). ICU and hospital length of stay were prolonged in the PPI group 9.42 days vs. 7.65 days (p=0.08) and 22.92 days vs. 16.73 days (p=0.002), respectively. Mortality rates were similar between the PPI and H2RA group, 15.7% vs. 23.1% (p=0.13). The incidence of VAP was 6% in the PPI group and 4.8% in the H2RA group (p=0.79). Development of bacteremia (17.9% vs. 15.6%), urinary tract infection (13.4% vs. 18.4%), and Clostridium difficile infection (9% vs. 8,8%) was similar between the two groups (p=NS). There were no episodes of gastrointestinal bleeding recorded in any subject in the study. Conclusions: These data suggest there is no significant difference in development of VAP between the use of PPIs and H2RAs for SUP in the general critical care population. Additionally, there does not seem to be a difference in other infectious complications associated with these classes of drugs.

The Role of Physician Knowledge and the Inappropriate Initiation of PPI Therapy for Stress Ulcer Prophylaxis in the ICU: Presidential Poster

Purpose: Our objective was to calculate the rate of inappropriate PPI initiation in an academic ICU and the contributing role of the prescribing physicians' knowledge of stress ulcer prophylaxis (SUP), as established by the American Society of Health-System Pharmacists (ASHP). Secondary aims were to determine the subsequent rate of continuation of a PPI on hospital discharge, the rate of missed indications for starting SUP and the rate of gastrointestinal bleeding in patients not started on a PPI. Methods: A retrospective chart review of medical ICU patients on no acid suppression was conducted from January, 2012 to December 31, 2012. Demographics including age, sex, ethnicity, comorbidities, and ICU length of stay were collected. The rate of inappropriate PPI initiation, the subsequent rate of continuation of PPI on hospital discharge and the rate of bleeding in patients not started on a PPI were determined. A 10-question questionnaire about SUP based on ASHP guidelines was administered to prescribing physicians. Results: Of 477 total patients, 212 patients were excluded due to concurrent acid suppression therapy. One hundred seventy-seven patients were started on a PPI for SUP and 88 patients were not. The average age was 54 years, 56% of the patients were male, 54% were Caucasian, 39% were African-American, with an average ICU length of stay of 6.7 days. Of the 177 patients, 101 patients (57%) were inappropriately started on a PPI for SUP. However, only three of these patients were subsequently discharged from the hospital on a PPI. Of the 88 patients not begun on a PPI, no indications for SUP were missed and no incidents of gastrointestinal bleeding were reported. Fifty residents who staff the ICU responded correctly to only 42% of the questions for a knowledge deficit of 58% for SUP. Conclusion: Our study demonstrates that 57% of patients started on SUP were done so inappropriately. The questionnaire suggested that the major determinant was a lack of knowledge of ASHP guidelines. We believe that the inclusion of a PPI in the ICU admission order set leads to reflexive ordering. The rate of patient discharge on inappropriate PPI prescription was very low, likely due to a medication reconciliation program that requires documentation of an appropriate indication. Given the implications of PPI use on Clostridium difficile infection, pneumonia, and the associated incremental costs, we have proposed targeting this knowledge gap with each resident receiving laminated cards with ASHP guidelines, posting these on all ICU computers, and removing PPIs from the admission order set. Based on the outcomes of our intervention we hope to implement such targeted measures in other areas.

Inappropriate use of acid suppression therapy in Internal Medicine wards of a tertiary care teaching Hospital.

Objective: To assess appropriateness of prescription of acid suppressive therapy (AST) in Internal Medicine ward in a tertiarycare hospital. Methods: In this prospective observational study , weincluded all those patientswho were started on AST after admission in the internal medicine ward in a tertiary care hospital in Hyderabad ,Sindh ,Pakistan from May 1 to July 31, 2013 . All those patientswere excluded from the study who were alreadyon the AST therapy. Details were taken regarding age, sex, primary diagnosis, other morbidity, drug used for AST and indication for AST on a specifically designed proforma. The appropriatenessof AST was determined by widely accepted Food and drug authority (FDA) indications and American society of health system pharmacist (ASHP) guidelines. Results: We included300 Patients in our study. All patients, in our study, were given AST at the time of admission tothe medicine ward. 133 (44.33%) Patients were male and 167 (55.66%) were female, their mean age was 43.91±18.58 (mean ± SD). 53 (17.6%) Patients had a FDA approved indication.51 (17%) Patients received AST therapy for SUP (stress ulcer prophylaxis) Out of that 7 (2.3%) had an absolute indication for SUP, 44(14.8%) had 2 or more relative indications for SUP . 196 (65.3%)received AST without any appropriate indication. Omeparzolewas themost frequently used AST (55%), followed byranitidine (45%) Conclusion:Use of AST is mostly inappropriate inInternal medicinewards.Implementation of institutional protocols, evidence based medicine teaching during residency training, and frequent review of therapy by the attending consultant during ward rounds may be helpfulto promote appropriate use of AST in medicine wards.

Patterns of Use of Prophylaxis for Stress-Related Mucosal Disease in Patients Admitted to the Intensive Care Unit

Morbidity associated with stress ulcer-related bleeding, the cost of medications, and the possible complications associated with stress ulcer prophylaxis are important considerations when prescribing prophylaxis. We prospectively studied the prescription patterns for stress ulcer prophylaxis in patients admitted to our ICU. We prospectively recorded the indications for stress ulcer prophylaxis and prescription patterns for use based on the American Society of Healthcare Pharmacists criteria and other indications for 99 new intensive care unit (ICU) admissions to a tertiary referral center. In all 51 patients had no indication for stress ulcer prophylaxis, 32 had 1 indication, 14 had 2 indications, and 2 patients had 3 indications for receiving stress ulcer prophylaxis in the ICU. Eighty-two percent of patients without any indications received stress ulcer prophylaxis; 81% of patients with 1 indication, 79% of patients with 2 indication, and 50% of patients with 3 indications received stress ulcer prophylaxis. Overall, 53% of patients either received stress ulcer prophylaxis when none was indicated or did not receive stress ulcer prophylaxis when it was indicated. We also review the recent literature on stress-related mucosal disease and the use of prophylaxis for stress-related mucosal disease. Stress ulcer prophylaxis administration in this ICU is inconsistent and includes both underutilization and overutilization. Educating physicians and implementing hospital protocols could improve use patterns.

Use of acid suppressive therapy in hospitalized non-critically ill patients

To assess the appropriateness of prescribing acid suppressive therapy (AST) in a general medicine service in a tertiary care hospital. In this retrospective observational study, we reviewed the inpatient records of all patients admitted to the general medical service in a tertiary care hospital in Beirut, Lebanon, from April 1 to May 31, 2011. Treatment with AST was considered appropriate if the patient had a specific indication or appropriate treatment purpose [e.g., gastro-esophageal reflux disease (GERD), peptic ulcer disease, dyspepsia, acute or suspected gastrointestinal (GI) bleeding]. Appropriate administration of stress ulcer prophylaxis (SUP) was derived from an internal guideline that is based on the American Society of Health System Pharmacists guidelines. Prophylaxis was considered appropriate if a patient had 1 absolute indication (coagulopathy or requiring mechanical ventilation), or 2 or more relative indications (sepsis, occult bleeding, use of high dose corticosteroids, recent use of non-steroidal anti-inflammatory drugs for more than 3 mo, renal or liver failure, enteral feeding and anticoagulant use). Of the 153 patient admissions during the study period, 130 patients (85%) were started on AST, out of which 11 (8.5%) had a diagnosis that supports the use of this therapy (GI bleed, gastritis and GERD), 16 (12.3%) had an absolute indication for SUP, 59 (45.4%) had 2 or more relative indications for SUP, and 44 (33.8%) received AST without an appropriate indication. In addition, one patient with an absolute indication for SUP and four with two or more relative indications did not receive AST. Rabeprazole was the most frequently used AST (59.2%), followed by omeprazole (24.6%), esomeprazole (11.6%) and ranitidine (4.6%). The dose of AST was appropriate in 126 patients (96.9%) and the route of administration was appropriate in 123 patients (94.6%). Fifteen of the admitted patients (10%) were discharged on AST, 7 of which (47%) did not have an appropriate indication. AST is overused in hospitalized non-critically ill patients and many patients are discharged on unnecessary AST which can increase cost, drug interactions and adverse events. Potential interventions include implementation of institutional protocols and prescriber education.

Audit on Practices of Stress Ulcer Prophylaxis in Intensive Care Unit Patients.

ABSTRACTBackgroundThis audit was aimed at studying current practices regarding the use of stress ulcer prophylaxis (SUP) in the Indian critical care setup, with the background aim of raising awareness regarding the use and indications of SUP in critically ill patients.Materials and methodsAfter registering the trial with the clinical trial registry, India, a structured audit questionnaire containing 26 questions pertaining to SUP was distributed through electronic media among clinicians working in the intensive care units (ICUs) across India. Responses obtained were statistically analyzed.ResultsThe questionnaire was sent to 550 clinicians. Only 197 responded, of whom 91.4% were anesthesiologists, 5.6% were physicians, and 3% were intensivists. The audit revealed that 33% respondents were unaware of the existing SUP guidelines and around 32% did not have protocols for SUP in their ICU. Sixty-nine percent of respondents felt that all ICU patients must receive SUP and 44.7% opined that it should be started on ICU arrival. Almost 94% knew that early enteral feeding is protective against stress ulceration. Only 24.9% responders agreed that there must be clear indications for SUP, and most of them were unaware of all the potential side effects. Once initiated, 43.7% respondents would stop prophylaxis when no indication was left, whereas 69 respondents would stop on ICU discharge.ConclusionThere is a lack of awareness regarding initiation, choice of agent, adverse effects as well as termination of SUP in ICU and guidelines for the same. Institutional protocols should be in place and steps need to be taken to prevent unwarranted use.How to cite this articleGupta D, Bhalotra AR, Singh R. Audit on Practices of Stress Ulcer Prophylaxis in Intensive Care Unit Patients. Indian J Crit Care Med 2020;24(3):160–167.