Prophylaxis Of Gastrointestinal Bleeding Research Articles

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

Proton pump inhibitors (PPIs) are the most commonly prescribed drugs for preventing upper gastrointestinal bleeding in critically ill patients. However, concerns have arisen about the possible harms of using PPIs, including potentially increased risk of pneumonia, Clostridioides difficile infection, and more seriously, an increased risk of death in the most severely ill patients. Triggered by the REVISE trial, which is a forthcoming large randomized trial comparing pantoprazole to placebo in invasively mechanically ventilated patients, we will conduct this systematic review to evaluate the efficacy and safety of PPIs versus no prophylaxis for critically ill patients. We will systematically search randomized trials that compared gastrointestinal bleeding prophylaxis with PPIs versus placebo or no prophylaxis in adults in the intensive care unit (ICU). Pairs of reviewers will independently screen the literature, and for those eligible trials, extract data and assess risk of bias. We will perform meta-analyses using a random-effects model, and calculate relative risks for dichotomous outcomes and mean differences for continuous outcomes, and the associated 95% confidence intervals. We will conduct subgroup analysis to explore whether the impact of PPIs on mortality differs in more and less severely ill patients. We will assess certainty of evidence using the GRADE approach. This systematic review will provide the most up-to-date evidence regarding the merits and limitations of stress ulcer prophylaxis with PPIs in critically ill patients in contemporary practice.

Evaluating physicians' awareness and prescribing trends regarding proton pump inhibitors: a cross-sectional study.

Introduction: Proton pump inhibitors (PPIs) are commonly used to treat acid-related disorders. Their appropriate use depends on the correct indications from the clinician. Owing to the high incidence of use and misuse, PPIs have been identified as an essential pharmacological class for developing deprescribing recommendations. Therefore, assessing physicians' knowledge and practice regarding PPI usage is critical for paving the way toward targeted recommendations and efforts. Objective: This study aimed to assess Syrian physicians' perceptions of proton pump inhibitors adverse effects, their benefit in upper gastrointestinal bleeding (UGIB) prophylaxis, and how these perceptions are related to PPI prescription practice. Methods: A cross-sectional study was performed using a web-based questionnaire distributed among Syrian physicians in internal medicine between 28 November and 23 December 2022. The questionnaire assessed perceptions and experiences of PPIs, concerns about specific adverse effects, and their effectiveness for UGIB prophylaxis, in addition to the different scenarios used to determine the best practice for appropriate treatment to manage minimal, mild, moderate, and high-risk UGIB patients. Results: A total of 473 participants completed the questionnaire, with median age ±SD was (28.46 ± 4.58), and most participants (83.3%) were residents. Approximately half of the participants (45.5%) agreed that discussion assistance was provided to continue or terminate PPIs properly. Only 8.9% were very familiar with published evidence of PPI adverse effects. Bone weakening and vitamin B12 deficiency were the most frequently reported side effects (81.8% and 79.7%, respectively). However, dementia (0.4%) and mortality (1.9%) were the least reported adverse effects. More than half of the participants (64%) perceived using PPIs to prevent upper GI bleeding. Non-trainee physicians were less knowledgeable about appropriate GERD management than resident physicians (p < 0.001). Conclusion: The study showed a gap between Syrian physicians' perceptions and practices regarding PPI use, which necessitates spreading awareness of updated guidelines for PPI usage and their side effects.

Real-world efficacy of antibiotic prophylaxis for upper gastrointestinal bleeding in cirrhotic patients in Japan.

Antibiotic prophylaxis is recommended for cirrhotic patients with upper gastrointestinal bleeding (UGIB). However, the frequency of bacterial infection in such patients has remarkably decreased over the decades, which has reduced the necessity for prophylaxis. Therefore, here we investigated the real-world adherence and effectiveness of antibiotic prophylaxis in cirrhotic patients with UGIB in Japan. This population-based study was conducted with a Japanese real-world database of the Health, Clinic, and Education Information Evaluation Institute. We enrolled cirrhotic patients who were hospitalized for UGIB between April 2010 and March 2020. After those who died within 24h and who had aspiration pneumonia at admission were excluded, 1232 patients were analyzed. Rates of 6-week mortality, in-hospital bacterial infection, 30-day readmission, and length of hospital stay were evaluated. Prophylactic antibiotics were prescribed in 142 (11.5%) patients. Multivariate analysis revealed that antibiotic prophylaxis was not significantly associated with either 6-week mortality or bacterial infection. After propensity score matching, the rates of 6-week mortality (7.2% vs. 8.4%, P = 0.810), bacterial infection (9.6% vs. 4.2%, P = 0.082), and 30-day unexpected readmission (7.2% vs. 7.8%, P = 1.000) were similar in patients with and without prophylaxis, whereas the median length of hospital stay was significantly longer in patients with prophylaxis (17days vs. 13days, P = 0.013). Under current real-world circumstances in Japan, prophylactic antibiotics were prescribed in only 11.5% of cirrhotic patients with UGIB and were not associated with better clinical outcomes.

Effectiveness of Proton Pump Inhibitors as a Gastrointestinal Bleeding Prophylaxis in Intensive Care Unit: Systematic Review and Meta-Analysis

Introduction: GI bleeding is a serious illness that can lengthen the time spent in the Intensive Care Unit (ICU) and increase morbidity and death by up to four times. Proton Pump Inhibitors (PPIs) are agents commonly used in patients to prevent Gastrointestinal (GI) bleeding in ICU. However, nowadays, the use of PPIs to prevent GI bleeding is being concerned due to the emergence of various studies regarding the side effects caused by PPIs. We conducted a systematic review and meta-analysis to see the magnitude of the effectiveness and validate the safety of PPIs.&#x0D; Methods: We searched through PubMed, ScienceDirect, GARUDA Portal, Clinical Key, and Google Scholar databases to identify randomized controlled trials (RCTs) that compared the effects of PPI administration on the PPI and placebo groups in adults ICU patients.&#x0D; Results: From a total of 8 studies, this meta-analysis shows the effectiveness of PPIs as prophylactic GI bleeding significantly with p &lt; 0.0001, RR = 0.52 (95% CI 0.38-0.71). Regarding safety, PPIs did not significantly increase the risk of pneumonia (p = 0.30, RR = 1.31 (95% CI 0.78-2.20)); and C. difficile infection (p = 0.90, RR = 0.91 (95% CI 0.21-3.85); and it does not impact on the mortality event (p = 0.78; RR 1.01 (95% CI 0.93-1.10).&#x0D; Conclusions: PPIs reduce GI bleeding in ICU patients over the age of 18. PPIs are also safe to use as preventative GI bleeding with no increased risk of pneumonia and C. difficile infection. PPI does not, however, significantly affect the death rates.

Meta-analysis of the effectiveness of histamine-2 receptor antagonists as prophylaxis for gastrointestinal bleeding in intensive care unit patients

Background: The risk of upper gastrointestinal bleeding increases in critically ill patients admitted to an intensive care unit (ICU), with 50–77% mortality. Histamine-2 receptor antagonists (H2RAs) are frequently used to prevent gastrointestinal bleeding in ICU patients, but the tests on its effectiveness and safety are still conflicting. Objective: To determine the effectiveness and safety of H2RA in preventing gastrointestinal bleeding in ICU patients. Methods: Data on randomised controlled trials (RCTs) were collected from the MEDLINE database, ScienceDirect, ClinicalKey, and The Cochrane Library. Two investigators assessed the quality of the trials using the critical appraisal skills program (CASP) checklist for RCT studies, and fixed-effects meta-analysis was carried out using Review Manager software. Results: The 12 RCTs showed a reduced risk of gastrointestinal bleeding (RR = 0.40; 95% CI = 0.30 ‒ 0.53; I-square = 38%; p &lt;0.00001) and a decreased number of patients requiring blood transfusion in H2RA group (RR = 0.44; 95% CI = 0.23 ‒ 0.82; I-square = 8%; p = 0.01), and these effects were significantly different from the placebo group. However, there was no significant difference in mortality between the two groups (RR = 0.99; 95% CI = 0.74 ‒ 1.33; I-square = 0%; p = 0.96). Regarding its safety, the administration of H2RAs did not affect the incidence of nosocomial pneumonia (RR = 1.13; 95% CI = 0.82 ‒ 1.55; I-square = 30%; p = 0.46). A sensitivity analysis with a random-effects model was also performed on eight articles with a low risk of bias. The statistical analyses of eight and 12 articles showed the same results—that H2RAs significantly reduced the risk of gastrointestinal bleeding. Conclusion: H2RA proves effective and safe in reducing the incidence of gastrointestinal bleeding, but not reducing the mortality in ICU patients.

The effects of pantoprazole vs. placebo on 1-year outcomes, resource use and employment status in ICU patients at risk for gastrointestinal bleeding: a secondary analysis of the SUP-ICU trial.

Patients in intensive care units (ICUs) are at risk of stress-related gastrointestinal (GI) bleeding and stress ulcer prophylaxis (SUP), including proton pump inhibitors, is widely used in the attempt to prevent this. In this secondary analysis of Stress Ulcer Prophylaxis in Intensive Care Unit (SUP-ICU) trial, we assessed 1-year outcomes in the pantoprazole vs. placebo groups. In the SUP-ICU trial, 3298 acutely admitted ICU patients at risk of GI bleeding were randomly allocated, stratified for site, to pantoprazole or placebo. In this secondary analysis, we assessed clinically important GI bleedings in ICU and 1-year mortality, health care resource use (e.g. readmission with GI bleeding, use of home care and general practitioner), health care costs, and employment status for the Danish participants using registry data. Among the 2099 Danish participants, 2092 had data in the registries; 1045 allocated to pantoprazole and 1047 to placebo. The number of clinically important GI bleedings in ICU was 1.9 percentage points [95% CI 0.3-3.5] lower in the pantoprazole group vs. the placebo group, but none of the 1-year outcomes differed statistically significantly between groups, including total health care costs (€1954 [-2992 to 6899]), readmission with GI bleeding (-0.005 admissions [-0.016 to 0.005]), 1-year mortality (-0.013 percentage points [-0.051 to 0.026]), and employment (-0.178weeks [-0.390 to 0.034]). Among ICU patients at risk of GI bleeding, pantoprazole reduced clinically important GI bleeding in ICU, but this did not translate into a reduction in 1-year mortality, health care resource use or improvements in employment status.

Comparison of proton pump inhibitors and histamine 2 receptor antagonists for stress ulcer prophylaxis in the intensive care unit

Proton pump inhibitors (PPIs), followed by histamine 2 receptor antagonists (H2RAs), are the most commonly used drugs to prevent gastrointestinal bleeding in critically ill patients through stress ulcer prophylaxis. The relative efficacy and drug-related adverse events of PPIs and H2RAs remain unclear. In this retrospective, observational, comparative cohort study, PPIs and H2RAs for stress ulcer prophylaxis in critically ill patients were compared using a common data model. After propensity matching, 935 patients from each treatment group (PPI or H2RA) were selected. The PPI group had a significantly higher 90-day mortality than the H2RA group (relative risk: 1.28; P = 0.01). However, no significant inter-group differences in the risk of clinically important gastrointestinal bleeding were observed. Moreover, there were no significant differences between the groups concerning the risk of pneumonia or Clostridioides difficile infection, which are known potential adverse events related to these drugs. Subgroup analysis of patients with high disease severity were consistent with those of the total propensity score-matched population. These findings do not support the current recommendations, which prefer PPIs for gastrointestinal bleeding prophylaxis in the intensive care unit.

The efficacy and safety of acid suppressants for gastrointestinal bleeding prophylaxis in cardiac care unit patients.

Background and AimConcerns regarding adverse events associated with proton pump inhibitors (PPIs) and histamine‐2 receptor antagonists (H2RAs) for gastrointestinal bleeding (GIB) prophylaxis in the intensive care unit have increased in recent years. Few studies have focused on acid suppressant use in the cardiac care unit (CCU) setting exclusively. We performed a cohort study to determine the efficacy and safety of acid suppressants for GIB prophylaxis in CCU patients.MethodsThis retrospective cohort study included adults who were admitted directly to the CCU for more than 2 days from January 1, 2014, to April 30, 2019. The Crusade score was calculated to evaluate the risk of GIB. The primary outcomes were clinically important gastrointestinal bleeding (CIGIB), hospital‐acquired pneumonia (HAP), and in‐hospital mortality.ResultsOf the 3318 patients enrolled, 2284 (68.8%) patients received PPIs, 515 (15.5%) received H2RAs, and 519 (15.7%) received no acid suppressants. After adjusting for potential confounders, utilization of PPIs (2.69, 95% confidence interval [0.62–11.73]) and H2RAs (1.41, 95% confidence interval [0.19–10.36]) were not associated with a lower risk of CIGIB than the control. Sensitivity analyses revealed that PPI use was an independent risk factor for in‐hospital mortality in patients over 75 years old, with an adjusted odds ratio of 4.08 (1.14–14.63). PPIs increased the risk of HAP in patients over 75 years old and in those with heart failure, with adjusted odds ratios of 2.38 (1.06–5.34) and 2.88 (1.34–7.28), respectively.ConclusionsProton pump inhibitors and H2RAs for GIB prophylaxis in CCU patients were not associated with a lower risk of CIGIB than the controls. PPI therapy is associated with increased risks of HAP and in‐hospital mortality in patients over 75 years old. PPIs may increase the risk of HAP in patients with heart failure.

Clinical practice guideline on gastrointestinal bleeding prophylaxis for critically ill patients: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine.

The Scandinavian Society of Anaesthesiology and Intensive Care Medicine Clinical practice Committee endorses the BMJ Rapid Recommendation Gastrointestinal bleeding prophylaxis for critically ill patients-a clinical practice guideline. The guideline serves as a useful decision aid for clinicians caring for critically ill patients, and can be used together with clinical experience to decide whether a specific critically ill patient may benefit from gastrointestinal bleeding prophylaxis.

The Gastrointestinal Tract in Intensive Care Medicine - Overview 2020

Gastrointestinal dysfunctions and failure are common clinical incidents in critically ill patients, which are recognized as both, primary and even more often as secondary diagnoses as consequence of an already existing disease or as a corollary of intensive care treatment. These functional complications may aggravate into life-threatening emergencies and are highly associated with prognosis and increased mortality.This article gives an overview about the pathophysiology, diagnostics and therapy of three very relevant current topics in intensive care medicine: prophylaxis and management of gastrointestinal bleeding, gastrointestinal motility and absorption disorders as well as different forms of liver dysfunctions.

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

Motivated by a new randomized trial (the PEPTIC trial) that raised the issue of an increase in mortality with proton pump inhibitors (PPIs) relative to histamine-2 receptor antagonists (H2RAs), we updated our prior systematic review and network meta-analysis (NMA) addressing the impact of pharmacological gastrointestinal bleeding prophylaxis in critically ill patients. We searched for randomized controlled trials that examined the efficacy and safety of gastrointestinal bleeding prophylaxis with PPIs, H2RAs, or sucralfate versus one another or placebo or no prophylaxis in adult critically ill patients. We performed Bayesian random-effects NMA and conducted analyses using all PEPTIC data as well as a restricted analysis using only PEPTIC data from high compliance centers. We used the GRADE approach to quantify absolute effects and assess the certainty of evidence. Seventy-four trials enrolling 39 569 patients proved eligible. Both PPIs (risk ratio (RR) 1.03, 95% credible interval 0.93 to 1.14, moderate certainty) and H2RAs (RR 0.98, 0.89 to 1.08, moderate certainty) probably have little or no impact on mortality compared with no prophylaxis. There may be no important difference between PPIs and H2RAs on mortality (RR 1.05, 0.97 to 1.14, low certainty), the 95% credible interval of the complete analysis has not excluded an important increase in mortality with PPIs. Both PPIs (RR 0.46, 0.29 to 0.66) and H2RAs (RR 0.67, 0.48 to 0.94) probably reduce clinically important gastrointestinal bleeding; the magnitude of reduction is probably greater in PPIs than H2RAs (RR 0.69, 0.45 to 0.93), and the difference may be important in higher, but not lower bleeding risk patients. PPIs (RR 1.08, 0.88 to 1.45, low certainty) and H2RAs (RR 1.07, 0.85 to 1.37, low certainty) may have no important impact on pneumonia compared with no prophylaxis. This updated NMA confirmed that PPIs and H2RAs are most likely to have a similar effect on mortality compared to each other and compared to no prophylaxis; however, the possibility that PPIs may slightly increase mortality cannot be excluded (low certainty evidence). PPIs and H2RAs probably achieve important reductions in clinically important gastrointestinal bleeding; for higher bleeding risk patients, the greater benefit of PPIs over H2RAs may be important. PPIs or H2RAs may not result in important increases in pneumonia but the certainty of evidence is low.

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

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

Outcomes of Prophylactic Pantoprazole in Adult Intensive Care Unit Patients Receiving Dialysis: Results of a Randomized Trial

Background: Intensive care unit (ICU) patients with acute kidney injury requiring renal replacement therapy (RRT) are considered at high risk of gastrointestinal (GI) bleeding and stress ulcer prophylaxis (SUP) is often prescribed. We aimed to assess the incidence of GI bleeding and effects of SUP in these patients. Methods: We assessed GI bleeding in ICU patients receiving RRT at baseline (and at any time in the ICU) and effects of prophylactic pantoprazole versus placebo in the international SUP in the ICU (SUP-ICU) trial. All analyses were conducted according to a published protocol and statistical analysis plan. Results: Data of 3,291 acutely admitted adult ICU patients with one or more risk factors for GI bleeding randomized to pantoprazole or placebo intravenously once daily during ICU stay (until ICU discharge, death, or a maximum of 90 days) were analyzed. Some 20 out of 258 (7.8%, 95% CI 4.5–11.1%) and 52 out of 568 (9.2%, 95% CI 6.8–11.6%) of the patients receiving RRT at baseline and at any time in ICU, respectively, developed clinically important GI bleeding in the ICU. We did not observe statistically significant differences in the intervention effect (pantoprazole vs. placebo) in the proportion of patients with clinically important GI bleeding, clinically important events, infectious adverse events, use of interventions to stop GI bleeding, or 90-day mortality in patients with versus without RRT at baseline. Conclusions: In adult ICU patients receiving RRT at baseline, we observed high incidences of clinically important GI bleeding, but did not observe effects of pantoprazole versus placebo in this subgroup.

Gastrointestinal symptoms, gastrointestinal bleeding and the role of diet in patients with autoimmune blistering disease: a survey of the International Pemphigus and Pemphigoid Foundation.

Autoimmune blistering diseases are a group of severe mucocutaneous conditions that typically require the use of prolonged corticosteroids and immunosuppression. Properly managing associated comorbidities is an integral part of these patients' care. The frequency of gastrointestinal symptoms, particularly gastrointestinal bleeding in these patients, is not known. Likewise, the effect of diet on disease is unknown. To determine the incidence of gastrointestinal comorbidities and the role of diet in patients with autoimmune blistering disease. We distributed an e-survey to patients with autoimmune blistering disease utilizing the International Pemphigus and Pemphigoid Foundation's listserv. The incidence of gastrointestinal symptoms and gastrointestinal bleeding were recorded, as were foods avoided and those noted to be beneficial in patients' disease. Historical incidences in the general population were used as controls. A total of 200 responses were collected. 30.3% of patients experienced gastroesophageal reflux following treatment of their autoimmune blistering disease, with 51.7% utilizing some form of gastrointestinal symptomatic treatment. The incidence of gastrointestinal bleeding following an autoimmune blistering diagnosis was 2.1%, which remained significant despite correction for non-steroidal anti-inflammatory use (NSAID), but not corticosteroid use. 65.2% of patients reported dietary limitations because of their autoimmune blistering disease. Significant intolerances after correction for multiple comparisons included alcohol, citrus and spicy foods. Greater than 10% of patients reported improvements in their disease with vegetables and dairy. Gastrointestinal comorbidities are common in patients with autoimmune blistering diseases, with gastrointestinal bleeding occurring in 2.1% of patients following a diagnosis of autoimmune blistering disease. While further work is needed to determine the relative risk of routine gastrointestinal prophylaxis in this population, gastrointestinal bleeding prophylaxis should be considered in patients receiving corticosteroids, particularly those taking NSAIDs. Dietary limitations are additionally frequent in this population. Patients should be cautious of alcohol, citrus and spicy foods.

Prescribing of proton pump inhibitors for gastrointestinal bleeding prophylaxis in the Lebanese outpatient setting: patterns, compliance with guidelines and risks.

To determine patterns of proton pump inhibitor (PPIs) prescribing for gastrointestinal bleeding prophylaxis (GIBP) in the Lebanese outpatient setting, to assess their compliance with guidelines for approved GIBP indications and to delineate independent factors that are associated with non-compliance. A community-based multicentre cross-sectional study was conducted. Eligible patients were those who presented to the community pharmacy setting with a PPI prescription for GIBP. Prescriptions were reviewed by a clinical pharmacist to ascertain their compliance with guidelines approved for GIBP indications. Several variables were tested to determine independent factors that were associated with guidelines non-compliance. Of the 720 reviewed PPI prescriptions, 297 (41.25%) were found to be compliant with guidelines approved for GIBP indications. The presence of two or more comorbid conditions, prescribing initiated by a primary care physician, patients taking three or more medications, and prescribing of NSAIDs including low-dose aspirin were found to be independent factors that were significantly associated with PPI prescribing non-compliance (P≤0.05). PPIs were also inappropriately coprescribed with corticosteroids (102 (24.1%)), selective serotonin reuptake inhibitors (SSRIs) (48 (11.4%)), amoxicillin-clavulanic acid (20 (4.7%)) and bisphosphonates (13 (3.1%)) for GIBP. This study demonstrated that PPIs were appropriately prescribed for GIBP in less than the half of the study patients. The need for improvement of clinical practice in this regard is therefore indispensable since inappropriate prescribing is costly and put the patient at risk for adverse health outcomes. Strategies to alter inappropriate prescribing may include education, guidelines awareness and decision support systems.

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

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

Comparative Efficacy and Safety of Antiulcer Drugs for Stress Ulcer Prophylaxis (SUP) in Critically Ill Patients: A Systematic Review and Network Meta-Analysis

Background: Stress ulcers can affect the prognosis of critically ill patients. However, is stress ulcer prophylaxis (SUP) necessary for critically ill patients? What is the best choice of SUP? There are no specific answers to these two questions. The aim of our study was to conduct a conventional pairwise meta-analysis to assess the effects of SUP versus no prophylaxis and to perform a network meta-analysis to evaluate the efficacy and safety of antiulcer drugs for SUP in adult critically ill patients. Methods: We searched the Cochrane Central Register of Controlled Trials in the Cochrane Library, EMBASE, MEDLINE, CINAHL, and the Web of Science using a combination of MeSH and text words relevant to SUP, critically ill patients, adults, proton pump inhibitors (PPIs), histamine-2-receptor antagonists (H2RAs), sucralfate, and antacids, together with randomized controlled trials from the date of database inception to July 5, 2017. We extracted relevant information using a predefined data extraction form and assessed the risk of bias using the Cochrane risk of bias tool. Our primary outcome was the incidence of gastrointestinal (GI) bleeding. The secondary outcome was all-cause mortality and the risk of pneumonia. Findings: A total of 73 randomized controlled trials, with a total of 10,509 adult critically ill patients, were identified in our study. In the pairwise meta-analysis, we found a statistically significant difference between SUP and no prophylaxis for GI bleeding (RR 0·45, 95% CI 0·38 to 0·53) but no statistically significant differences in mortality (RR 0·96, 95% CI 0·84 to 1·10) or the risk of pneumonia (RR 1·15, 95% CI 0·91 to 1·46). In a 5-node network meta-analysis, pooled effect sizes suggested that, compared to no prophylaxis, all interventions were associated with reduced GI bleeding. Additionally, compared to PPIs (RR 0·60, 95% CI 0·47 to 0·76) and H2RAs (RR 0·77, 95% CI 0·67 to 0·88), sucralfate was associated with a reduction in pneumonia. In an 11-node network meta-analysis, omeprazole was significantly more effective than cimetidine, ranitidine, and sucralfate in preventing GI bleeding, while compared to omeprazole, pantoprazole and ranitidine, sucralfate was associated with a decreased risk of pneumonia. In terms of mortality, the combined results showed no statistically significant differences in any comparisons. Interpretation: SUP is necessary for preventing GI bleeding in adult critically ill patients. We recommend sucralfate as a better choice for SUP in adult critically ill patients. Funding: This study was supported by grants from the National Natural Science Foundation of China (No. 81402462, 81571871 and 81770276) and the Yuweihan Fund for Distinguished Young Scholars. Declaration of interests: We declare no competing interests.

Primary Prophylaxis for Gastrointestinal Bleeding in Children With Biliary Atresia and Portal Hypertension Candidates for Liver Transplantation: A Single-Center Experience

BackgroundCirrhosis for biliary atresia (BA) is associated with risk of gastrointestinal bleeding (GB) from gastroesophageal varices due to portal hypertension. Primary prophylaxis of GB is controversial in children who are candidates for liver transplantation (LT). The aim of the study was to define the management of gastroesophageal varices and to identify the benefit of primary prophylaxis for GB in BA children waiting for LT. MethodsA retrospective single-center study including all BA children listed for LT in 2008–2016. Clinical, endoscopical, and biochemical data were analyzed. ResultsOf 82 children, 50 (61%) did not receive primary prophylaxis and did not present any episode of bleeding, 16 (19.5%) underwent primary prophylaxis, and 16 (19.5%) presented spontaneous GB and received secondary prophylaxis. Children without primary prophylaxis and GB were younger than patients with primary prophylaxis and those with GB (7.7 years [range, 4.1–37.9 years] vs 11.2 years [range, 5.1–43 years]; P = .03 vs 10.7 years [range, 6.9–39.9 years], respectively; P = .004). Seventy-five percent of GB occurred in children older than 8 months. Fifteen (93.8%) children with GB presented esophageal varices (grade III = 10 [62.5%]) and 10 (62.5%) required endoscopic treatments, consisting mainly of sclerotherapy. Median time to LT was similar for children with or without bleeding (2 months [range, 0–17.7 months] vs 2.2 months [0–17.9 months], respectively; P = .89). After 45.5 months (range, 13.7–105.5 months) of follow-up, the overall patient survival was 97.6%. At the intention-to-treat analysis, the survival rate was 100% for patients without bleeding episode and 87.5% for children with GB (P = .16). ConclusionsDespite the risk of GB being not clinically predictable in children with BA waiting for LT, our experience suggests that primary prophylaxis of GB might be unnecessary in children younger than 6 months, while it should be considered in older children. Thus, the occurrence of GB does not delay the timing of transplantation.

Prescription Pattern of Proton Pump Inhibitors at Hospital Admission and Discharge

Background: Proton pump inhibitors (PPI) have reportedly been used in inappropriate clinical settings, often leading to an increased risk of adverse effects, drug interactions, and costs. Aim: The aim of this study was to evaluate the adequacy of PPI prescription in an internal medicine ward. Methods: The discharged home inpatients of a segment in the medicine department of a central hospital in the first trimester of 2017 were evaluated; those who died or were transferred to another unit were excluded. Data on gender, age, admission, and discharge therapy and diagnoses which could support PPI use were collected from clinical records. Statistical analysis was performed using Microsoft Excel 2013® and IBM SPSS Statistics 20®. Results: A total of 318 hospitalizations were included, corresponding to 301 patients; 171 (56.8%) were female and the average age was 75.4 ± 14.6 years. Among the 318 hospitalizations, 148 patients (46.5%) were on PPI at admission and 175 (55%) at discharge, the majority of them without indication (n = 91, 61.5% vs. n = 109, 62.3%). The main inappropriate indication was anticoagulation alone (n = 33, 36.3% vs. n = 43, 39.4%). There was indication for PPI therapy in 93 (29.2%) of the cases at admission and 111 (34.9%) at discharge, mostly for prophylaxis of gastrointestinal bleeding in high-risk patients (n = 82, 88.2% vs. n = 96, 86.5%). Among those with indication, 57 (61.3%) were medicated at admission versus 66 (59%) at discharge. The association between PPI therapy and an indication for its prescription was lost by the time of discharge (p = 0.245). Conclusions: PPI prescription is not in agreement with existing recommendations, which is why it should be revised at hospital discharge. The primary indication for PPI therapy is the prophylaxis of gastrointestinal bleeding in high-risk patients and the main inappropriate indication is prophylaxis in low-risk patients. A large proportion of the patients indicated for PPI use were discharged without prescription.

Mortality of severe septic patients between physician's high and low care volumes

BackgroundPatients with severe sepsis frequently require intensive care unit (ICU) admission and different ICU care models may influence their outcomes. The mortality of severe septic patients between physician's high and low care volume remains unclear. MethodsWe analyzed the data from a three-year prospective observation study, which was performed in an adult medical ICU of Chung Gung Memorial Hospital, Keelung. The data included initial bundle therapies based on the Surviving Sepsis Campaign (SSC) guidelines for patients with severe sepsis. ResultsClinical data of total 484 patients with severe sepsis were recorded. Cox regression model showed that physician's care volume was an independent factor for lowering mortality in ICU patients with severe sepsis (hazard ratio 0.708; 95% confidence interval 0.514–0.974; p = 0.034). Patients treated by high care volume physician had four out of nine bundle therapies that were significantly higher in percentage following the SSC guidelines. These four therapies were renal replacement therapy, administration of low-dose steroids for septic shock, prophylaxis of gastro-intestinal bleeding, and control of hyperglycemia. ConclusionHigh care volume physician may decrease mortality in ICU patients with severe sepsis through fitting bundle therapies for sepsis.