Overuse Of Proton Pump Inhibitors Research Articles

Impact of large scale, multicomponent intervention to reduce proton pump inhibitor overuse in integrated healthcare system: difference-in-difference study

ObjectiveTo determine how a large scale, multicomponent, pharmacy based intervention to reduce proton pump inhibitor (PPI) overuse affected prescribing patterns, healthcare utilization, and clinical outcomes.DesignDifference-in-difference study.SettingUS Veterans Affairs Healthcare System,...

Associations between Proton-Pump Inhibitor Usage, Allergy, and Asthma: An Analysis of NHANES 2005–2006

Introduction: Acid suppression medications, such as proton-pump inhibitors (PPIs) and histamine-2 receptor antagonists, are commonly prescribed for the treatment of gastroesophageal reflux disease and other gastrointestinal disorders. However, concerns regarding potential long-term side effects are brought up by the overuse of PPIs. This study aimed to investigate the relationship between PPI usage, allergy, and asthma in the general US population. Methods: Data of individuals aged ≥20 years who had information on PPI use and questionnaires on allergy and asthma in the US National Health and Nutrition Examination Survey (NHANES) 2005–2006 were analyzed. Univariate and multivariable logistic regression analyses were performed to determine the associations between PPI use, prevalent allergy, and asthma. Results: A total of 4,481 participants (representing 198,543,007 US individuals after weighting) were included in the analyses. PPI use was not significantly associated with the presence of allergy or asthma in the general study population after adjustment. However, in females without steroid exposure, PPI use was significantly associated with increased odds of allergy (adjusted odds ratio [aOR] = 1.69, 95% confidence interval [CI]: 1.002–2.86), among which esomeprazole use was significantly associated with increased odds of allergy (aOR = 2.68, 95% CI: 1.30–5.54) and lansoprazole with increased odds of asthma (aOR = 3.44, 95% CI: 1.50–7.87) as compared to no PPI use. Duration of PPI use was not significantly associated with allergy or asthma. Conclusions: In US women without steroid exposure, PPI use is associated with increased likelihood of prevalent allergy and asthma.

The Impact of Sex on the Response to Proton Pump Inhibitor Treatment.

Proton pump inhibitor (PPI) treatment is responsible for substantial gastrin elevation secondary to reduced intragastric acidity. Due to the increasing global prevalence of PPI users, concerns have been raised about the clinical significance of continuous gastrin elevation and its potential long-term side effects. Hypergastrinemia secondary to PPIs has trophic effects on gastric mucosa, leading to enterochromaffin-like cell hyperplasia and gastric (fundic) polyp formation, and it is believed to provoke acid rebound following PPI withdrawal that induces PPI overutilization. Previous studies have found higher gastrin release following PPI therapy in females compared with males, and sex differences have also been demonstrated in pharmacokinetic parameters and dose requirements for acid reflux. It is conceivable that females might be at increased risk of PPI overuse, because they often receive higher milligram-per-kilogram doses. The prevalence of PPI use is more common among females, and the female sex is a risk factor for adverse drug reactions. This non-systematic review outlines the current knowledge of the impact of biological sex on the response to PPIs. The aim is to highlight the female sex as a potential risk factor that could be a step toward precision medicine and should be considered in future research on the response to PPI treatment.

Trends of Proton Pump Inhibitor Uses among Pharmaceutical Promotional Workers

Background: Proton pump inhibitors (PPIs) are one of the most frequently used drugs in the world for the management of gastric- acid related diseases. The aim of this study was to assess the trend of PPIs uses among the pharmaceutical promotional workers in Bangladesh. Methods: A questionnaire-based survey was conducted on pharmaceutical promotional workers from different regions in Bangladesh. The study data were collected which includes demographics, PPIs uses in terms of duration, dose, generics, symptoms for which they took PPIs and effects of PPIs on symptoms. Drugs or diseases that influenced the intake of PPIs were also recorded. Results: Among six hundred surveys issued for the study, 581 valid questionnaires were returned. Among the respondents 520 individuals (89.5%) were male and 61 individuals (10.5%) were female. Common indications for taking PPIs were abdominal discomfort (51.5%), vomiting (34.1%) and abdominal pain (24.6%). Two hundred seventy (48.56%) respondents had satisfactory relief of symptoms, 125 (22.48%) had symptoms reappeared after stopping PPIs and 77 (13.85%) had complete cure of symptoms. Most of the participants (42.60%) were on PPIs therapy for up to one year. Most of the participants (64.49%) took PPI once daily. Most of the participants (60.75%) started PPI by themselves. Esomeprazole (40.1%) and rabeprazole (30.1%) were the most frequently used PPIs. Conclusion: PPI is found to be a frequently used medication among pharmaceutical promotional workers. Further well-designed study with adequate work up may be designed to see misuse and overuse of PPI among workers of pharmaceutical sector as well as general population. Sir Salimullah Med Coll J 2023; 31: 41-46

Current use of proton pump inhibitors and when to limit, stop or not start treatment

Proton pump inhibitors (PPIs) are potent inhibitors of gastric acid secretion that have changed treatment practice for gastric acid-related disorders. The major adequate indications for their use are treatment of gastro-esophageal reflux disease, peptic ulcers, eradication of Helicobacter pylori infection in combination with antibiotics and prophylaxis for patients on non-steroidal anti-inflammatory or antiplatelet drugs. Since their introduction, clinical success has been accompanied by widespread use of PPIs, which has steadily increased over the last decades without concomitant increase in the incidence of acid-related disorders. PPIs are now among the most widely prescribed class of medications worldwide and around 10% of Icelanders are current PPI users. This increase has been linked to PPI prescription without an indication, or continued use for longer duration than recommended. In recent years, concerns have been raised about PPI overuse and the associated increased risk of harm, not only in terms of increased costs but also the potential risk of physical dependence and long-term side effects of PPIs. The article is based on search in PubMed, the authors' own clinical experience and research, and is intended to provide practice advice on the use of PPIs with focus on appropriate prescription and deprescription of PPIs.

Patients' perspectives on a patient-oriented electronic decision support tool to reduce overuse of proton pump inhibitors (arriba-PPI): a qualitative study in primary care

BackgroundTo evaluate patients’ perspectives and their experiences with a consultation involving a computer-assisted and patient-centered discontinuation strategy (arriba-PPI tool) as part of a German multicenter study on reducing the prescription of proton pump inhibitors (PPIs).MethodsQualitative in-depth telephone interviews on proton pump inhibitors with patients who had received an arriba-PPI tool-based counseling by their general practitioner (GP). A random sample of 30 patients was taken from study participants. Interviews were conducted in 2020 and analyzed using a thematic qualitative text analysis.ResultsAlthough this was meant to be the key to shared decision making with regard to PPI reduction, study participants mostly did not recall the visual features of the tool. However, a few patients remembered them very clearly. Above all, patients appreciated a trustful relationship with the GP as well as comprehensive, individualized counseling.ConclusionApplication of the arriba-PPI tool can support the decision process but can also hinder the consultation process if the tool is not properly embedded in the consultation. GPs using the arriba-PPI tool to support the shared decision-making process should consider the patients’ and their own expectations on the benefit of the visual representation of the tool.

Awareness, attitude, and behavior regarding the use of proton pump inhibitors among healthcare providers, Al-Ahsa, Saudi Arabia

Objective: This study aimed to assess knowledge, attitude, and behavior of using proton pump inhibitors (PPIs) among healthcare providers. Methods: This was a cross-sectional study conducted in Al-Ahsa, Saudi Arabia between March and June, 2022 using a self-administrated questionnaire and including 300 medical professionals. Saudi healthcare providers, male or female, were included in this study. The questionnaire covered demographics, awareness, attitude, and behavior related to the use of PPIs. Results: According to the results, out of 300 participants, 33.1% were physicians, 33.4% were nurses, and 33.4% were pharmacists. Pharmacists demonstrated the greatest level of knowledge. Most participants (81.3%) answered that the main cause of PPI overuse was doctors, while others (18.7%) answered patients. The findings revealed that nurses, those who had bachelor's degrees, and those who were between the ages of 25 and 40 years, and who worked in primary healthcare had less knowledge. Conclusion: Medical professionals of Al-Ahsa were aware about the use of PPIs. Raising their level of knowledge and reducing their dependency on PPIs are necessary. The widespread abuse of PPI must be reduced by regular professional development programs and training for healthcare professionals.

Holistic management of symptomatic reflux: rising to the challenge of proton pump inhibitor overuse.

Holistic management of symptomatic reflux: rising to the challenge of proton pump inhibitor overuse.

Appropriateness of Proton-Pump Inhibitor Usage among Hospitalized Patients in a Johor Government Hospital

Introduction: Proton pump inhibitors (PPIs) are potent and effective acid suppressant agents. There are emerging concerns that PPI overuse leads to escalating healthcare costs, drug-drug interactions, and adverse clinical outcomes. Exploring the appropriateness of PPI therapy among hospitalised patients in Malaysia is crucial. Thus, this study aims to determine the appropriateness of proton pump inhibitors utilisation in Sultan Ismail Hospital, Malaysia. Materials and Methods: This single-center retrospective cross-sectional study was conducted at a public tertiary hospital situated in the Johore state of Malaysia. Patients recruited were 12 years and above who had received PPI in January 2017. Medical information was reviewed from electronic medical records. Patients were classified into three subgroups based on indications adopted from evidence-based guidelines. Results: 422 patients were enrolled, 47.4% (n=200) fulfilled the Food Drug Administration (FDA) approved indications, 25.4% (n=107) had borderline indications, and 27.2% (n=115) had inappropriate PPI usage. Improper PPI therapy was observed with a similar fraction of patients in medical (24.5%, n= 58 ) and non-medical disciplines (30.8 %, n=57). Stress ulcer prevention in low-risk subjects and individuals with no apparent indication were reasons for PPI overuse. Conclusion: PPI overuse is prevailing in hospitalised adult patients. Promoting the awareness of guideline-based indications and adverse clinical events of PPI among clinicians is imperative in improving PPI prescribing.

Who gets prescriptions for proton pump inhibitors and why? A drug-utilization study with claims data in Bavaria, Germany, 2010\u20132018

PurposeThe German annual drug prescription-report has indicated overuse of proton pump inhibitors (PPIs) for many years; however, little was known about the characteristics of people using PPIs. This study aimed to provide comprehensive utilization data and describe frequencies of potential on- and off-label PPI-indications in Bavaria, Germany.MethodsClaims data of statutorily insured people from 2010 to 2018 were used. Defined daily doses (DDDs) of PPIs by type of drug, prevalence of PPI-use and DDDs prescribed per 1000 insured people/day were analyzed. For 2018, proportions of users and DDDs per 1000 insured people were calculated by age and sex. To elucidate changes in prescribing practices due to a suspected drug-drug interaction, we examined co-prescribing of clopidogrel and PPIs between 2010 and 2018. For PPI new users, sums of DDDs and frequencies of potential indications were examined.ResultsPPI prescribing increased linearly from 2010 to 2016 and gradually decreased from 2016 to 2018. In 2018, 14.7% of women and 12.2% of men received at least one prescription, and 64.8 DDDs (WHO-def.) per 1000 insured people/day were prescribed. Overall, omeprazole use decreased over the observation period and was steadily replaced by pantoprazole, especially when co-prescibed with clopidogrel. An on-label PPI-indication was not reported at first intake in 52.0% of new users.ConclusionsThe utilization of prescribed PPIs has decreased since 2016. However, a large proportion of new PPI-users had no documentation of a potential indication, and the sums of DDDs prescribed often seemed not to comply with guidelines.

Association of Proton Pump Inhibitors With Higher Risk of Cardiovascular Disease and Heart Failure

ObjectiveTo examine associations of cumulative exposure to proton pump inhibitors (PPIs) with total cardiovascular disease (CVD; composed of stroke, coronary heart disease, and heart failure [HF]) and HF alone in a cohort study of White and African American participants of the Atherosclerosis Risk in Communities (ARIC) study. MethodsUse of PPIs was assessed by pill bottle inspection at visit 1 (January 1, 1987 to 1989) and up to 10 additional times before baseline (visit 5; 2011 to 2013). We calculated cumulative exposure to PPIs as days of use from visit 1 to baseline. Participants (n=4346 free of total CVD at visit 5; mean age, 75 years) were observed for incident total CVD and HF events through December 31, 2016. We used Cox regression to measure associations of PPIs with total CVD and HF. ResultsAfter adjustment for potential confounding variables, participants with a cumulative exposure to PPIs of more than 5.1 years had a 2.02-fold higher risk of total CVD (95% CI, 1.50 to 2.72) and a 2.21-fold higher risk of HF (95% CI, 1.51 to 3.23) than nonusers. ConclusionLong-term PPI use was associated with twice the risk of total CVD and HF compared with nonusers. Our findings are in concordance with other research and suggest another reason to be cautious of PPI overuse.

Reducing Overuse of Proton Pump Inhibitors for Stress Ulcer Prophylaxis and Nonvariceal Gastrointestinal Bleeding in the Hospital: A Narrative Review and Implementation Guide.

Proton pump inhibitors (PPIs) are among the most commonly used medications in the world; however, these drugs carry the risk of patient harm, including acute and chronic kidney disease, Clostridium difficile infection, hypomagnesemia, and fractures. In the hospital setting, PPIs are overused for stress ulcer prophylaxis and gastrointestinal bleeding, and PPI use often continues after discharge. Numerous multifaceted interventions have demonstrated safe and effective reduction of PPI use in the inpatient setting. This narrative review and the resulting implementation guide summarize published interventions to reduce inappropriate PPI use and provide a strategy for quality improvement teams.

Use of proton pump inhibitors: An exploration of awareness, attitude and behavior of health care professionals of Riyadh, Saudi Arabia

Background & ObjectivesOne of the broadly talked about class of medications for their extravagantly expanded abuse is proton pump inhibitors (PPIs). In spite of the fact that, they are known to be profoundly useful, it is accounted for several adverse manifestations. Health care professionals can assume an essential part in controlling its irrational use. The purpose of this study was to explore the knowledge, attitude and behavior of health care professionals of Riyadh region of Saudi Arabia on the use of PPIs by a cross-sectional study design. MethodsThe study data was obtained through a validated self-administered questionnaire covering knowledge (20 items), attitude (8 items) and behavior (6 items). Furthermore, demographic questions were placed to decide their effect on the intended three domains. The results were analysed by descriptive analysis and affirmed by multinomial regression method using SPSS-IBM 25. ResultsOf 414 surveyors, 121 (31%), 182 (44%) and 103 (25%) were doctors, pharmacist and nurses, respectively. Average age of participants' was 33.96 ± 8.37 years. Both doctors and pharmacist showed better degree of information (13.17/20 and 13.25/20) and good attitude (6.66/8 and 6.9/8) towards PPI use compared to nurses. Altogether higher extent of knowledge score showed by highly educated individuals, middle age groups and those with more practicing experience. The reliance on the utilization of PPI is less among pharmacist and nurses when compared to doctors. The outcome of the regression analysis exhibited that the odds of having low knowledge is more in young and bachelor degree holders. Interpretation & ConclusionHealthcare professionals in the Riyadh area are generally positive about the use of PPIs. However, increasing their level of knowledge and reducing their reliance on PPIs must be strengthened. Frequent professional development programs and trainings for healthcare professionals are needed to minimize widespread PPI overuse.

Stress ulcer prophylaxis use in critical care units at public hospitals in Johannesburg, South Africa.

Background Stress ulcer prophylaxis (SUP) is part of the management of critically ill patients in intensive care units (ICUs). However, inappropriate use of these drugs has important clinical implications such as ventilator-associated pneumonia and Clostridium difficile-associated gastrointestinal tract infections. The overuse of proton pump inhibitors (PPIs) as SUP is a rapidly growing problem globally. Objectives To describe the use of SUP in three selected ICUs in Johannesburg, South Africa (SA). Methods A retrospective, descriptive, contextual study design was used. Data were collected from ICU records of adult patients admitted into these units during the study period (1 August 2013 - 31 October 2013). Results A total of 174 patients were included in the study. Of these, 156 were on SUP and only 38.5% (n=60/156) were appropriately treated with SUP according to the American Society of Health-System Pharmacists guidelines. There was an inappropriate use of SUP in over 50% of those who were treated. The most frequently prescribed SUP was histamine-2 receptor antagonist (H2RA) (51.3%; n=80/156), followed by PPIs (30.8%; n=48/156), sucralfate (17.3%; n=27/156), and a combination of PPI and H2RA (0.6%; n=1/156). Conclusion The study demonstrated overuse of SUP. The most commonly used drug for SUP was H2RA and not PPIs. This study demonstrates that the problem of SUP overuse internationally also exists locally. The development of local guidelines may help to improve the practice of SUP in SA. Contributions of the study This study showed overuse of SUP and should encourage doctors to critically evaluate why they prescribe SUP and whether it is really indicated. This should help in the adoption of practices towards appropriate use of SUP.

Proton Pump Inhibitors and Oncologic Treatment Efficacy: A Practical Review of the Literature for Oncologists.

Proton pump inhibitors (PPIs) are the most commonly used anti-acid drugs worldwide, including among cancer patients. However, drug-drug interactions between PPIs and other agents may lead to decreased drug absorption with possible reduced therapeutic benefit, or even increased toxicity. Unfortunately, only scarce data exist regarding the safety of concomitant PPI use with anti-cancer agents. We aim at reviewing current evidence on this possible interaction by dividing anti-cancer agents by class. Until further data is available, we encourage healthcare providers to limit unnecessary PPI overuse.

Adverse Effects Associated with Proton Pump Inhibitor Use.

Proton pump inhibitors (PPIs) marked a before and after in the management of gastric acid‐related disorders since their introduction to the market in 1989. Due to a novel, highly effective mechanism of action blocking the last converging step of gastric acid secretion by parietal cells and very few and mostly tolerable side effects, these drugs quickly displaced other pharmacological compounds such as H2 antagonists as the first treatment choice for peptic ulcer disease, gastroesophageal ulcers, Zollinger-Ellison syndrome, nonsteroidal anti-inflammatory drug-associated ulcers, and eradication of Helicobacter pylori, leading to an exponential increase in their prescription up to now. However, widespread PPI use has led to emerging evidence of long-term adverse effects not described previously, including increased risk of kidney, liver, and cardiovascular disease, dementia, enteroendocrine tumors of the gastrointestinal tract, susceptibility to respiratory and gastrointestinal infections, and impaired absorption of nutrients. Although the evidence published thus far has not established strong correlations, it has been relevant enough to raise new questions about PPIs’ safety profile and reconsideration of their clinical indications. Hence, the aim of this review is to evaluate the association between PPI use and the risk of serious adverse effects given increasing concerns about the overuse of PPIs in the general population.

Epidemiological Study Assessing the Overuse of Proton Pump Inhibitors in Lebanese Population.

BACKGROUND Proton pump inhibitors (PPIs) are the most potent gastric agents for most acid-related disorders. Their effectiveness has led to their overutilization, leading to potential risks on patients and significant economic implications. The aim of this study was to determine the frequency of PPI overuse in Lebanon. Hence, the economic impact of this overutilization, if proven to be present, can be inferred. METHODS An epidemiological descriptive cross-sectional study was conducted in pharmacies all around Lebanese governorates over a 1-year period, using questionnaires handed out to 1000 participants coming to buy PPIs. Subjects taking PPIs for inappropriate indications or in inappropriate dosages or durations were considered abusing PPIs. PPIs are indicated for multiple gastric disorders and for prophylaxis of gastrointestinal injury when taking gastro-toxic medications. RESULTS 71.4% of subjects were overusing PPIs. Approximately 25 million US dollars were being wasted annually. Three categories of overuse were inferred (indication, dosage, and duration). Gastro protection was the most common reason for taking PPIs. Demographic variables and doctors’ prescriptions did not influence PPI overuse. CONCLUSION PPIs are massively overused in Lebanon, leading to a huge burden on the health care system. Adhering to evidence-based guidelines and educational programs is highly recommended to enhance the quality and efficiency of prescriptions.

Overuse of proton pump inhibitors in nursing homes: An Italian multicenter observational study.

To examine the prevalence of residents receiving proton pump inhibitors (PPIs) for evidence-based indications in a large sample of Italian nursing homes (NHs) and to assess the predictors of potentially inappropriate prescriptions. This study was conducted in a sample of Italian long-term care NHs. Information on drug prescription, diseases, and socio-demographic characteristics of NH residents was collected three times during 2018. Appropriate use of PPI was defined in accordance with the strongest evidence-based indications and the Italian criteria for PPI prescription. Among the 2579 patients recruited from 27 long-term care NHs, 1177 (45.6%) were receiving PPIs; 597 (50.7%) were taking them for evidence-based indications. Corticosteroids, anticoagulants, and mean number of drugs were the most important predictors of inappropriate PPIs prescriptions. NH residents receiving ≥13 drugs had about 10 times the risk of receiving a PPI than those taking 0 to 4 drugs. Similarly, residents with more comorbidity had about 2.5 times the risk of receiving a PPI than those in better health. The prevalence of residents inappropriately treated with PPI in individual NHs varied widely, ranging from 22% to 63%. Number of drugs, comorbidity, corticosteroids, and anticoagulants are the most important predictors of the inappropriate use of PPI in NHs. The wide variability between NHs in the appropriate use of PPIs suggests the need for thorough drug review in this fragile and vulnerable population. Prescribing patterns linked to evidence-based guidelines and national recommendations are essential for rational, cost-effective use of PPIs.

421 Improving Proton Pump Inhibitor Prescribing Practices in an Academic Safety Net Primary Care Clinic: Quality Improvement Project

INTRODUCTION: Proton Pump Inhibitors (PPI) overuse in both inpatient and outpatient settings have increased drastically over the last 2 decades. Overuse of PPIs continues despite evidence based guidelines and prolonged PPI use carries serious adverse effects. The aim of this quality improvement (QI) is to reduce the percentage of patients inappropriately prescribed PPIs between the ages of 40-75 years from a baseline rate of 80% to < 60% within 1 year at ECMC internal medicine clinic (IMC). METHODS: We used the Plan-Do-Study-Act (PDSA) model and performed a root cause analysis to identify barriers for the reduction of inappropriate use of PPIs. The major barriers included system, provider and patient-based barriers including lack of electronic medical record (EMR) alerts, gaps in knowledge in both the provider and the patient, fear of discontinuation of the PPI. QI team included nursing and ancillary staff, residents, attending physicians, social worker. Outcome measure was to reduce the percentage of patients inappropriately prescribed PPIs from 80% to < 60% in 1 year. Process measures included measuring the percentage of patients who are appropriately referred to GI clinic for an EGD and the percentage of patients on PPI who have their GERD assessed during the clinic including assessment for alarm symptoms. Balancing measures included potential increase in patient wait times in the clinic and esophagogastroduodenoscopy (EGD) wait time. The major interventions included (1) creating a customized EMR template; (2) provider education; (3) tracking continuity of care visits and medication reconciliation; (4) patient education; (5) assessing barriers and response to discontinuation; (6) Pocket guides for physician education. RESULTS/OUTCOME MEASURES: Average rates of PPI discontinuation were 51.1% (n = 92/180), resulting into 30.0% inappropriate chronic PPI use from the baseline rates of 80% within 1 year. Process measures: The total percentage of patients on long term PPI use who had an EGD was recorded as 51.1% which improved from the baseline of < 30%. The EGD completion rates in eligible patients was 43.6% from baseline of < 20%. CONCLUSION: We exceeded the goal, achieved >50% reduction in inappropriate use of chronic PPI use within 1 year. Lack of automated medical decision support tool was identified as the biggest barrier. Optimization of EHR and education to QI team members were crucial for the success of this QI. Future directions include enhancing patient engagement and spread to other clinics.

Sepsis in Patients With Cirrhosis Awaiting Liver Transplantation: New Trends and Management.

Bacterial infections are more frequent and severe in patients with advanced liver disease and, therefore, in liver transplant candidates. The increased risk of infection in these patients parallels the severity of the immune dysfunction associated with cirrhosis, which is related to systemic inflammation and progressive immunodeficiency. Other factors contribute to this risk, such as genetic polymorphisms, proton pump inhibitor overuse, the numerous invasive procedures and hospitalizations these patients go through, or the immunosuppressive effects of malnutrition or alcohol abuse. Bacterial infections have a great impact on disease progression and significantly increase mortality rates before and after liver transplantation. Mechanisms leading to organ failure in sepsis are associated not only with the hemodynamic derangement but also with an excessive inflammatory response triggered by infection. Furthermore, prophylactic and empirical antibiotic treatment strategies in patients with cirrhosis are being modified according to the growing prevalence of multidrug-resistant bacteria in the past decade. Also, new criteria have been introduced for the diagnosis of sepsis and septic shock. These new definitions have been validated in patients with cirrhosis and show a better accuracy to predict in-hospital mortality than previous criteria based on systemic inflammatory response syndrome. Accurate prophylaxis and early identification and treatment of bacterial infections are key to reducing the burden of sepsis in patients with cirrhosis awaiting liver transplantation.