Stress Ulcer Prophylaxis Research Articles

As indicações da profilaxia de úlceras gástricas em pacientes pediátricos hospitalizados: uma revisão integrativa

OBJECTIVES: To determine the main indications for gastric ulcer prophylaxis in hospitalized pediatric patients and, through the analysis of scientific evidence, to point out the main complications of the indiscriminate use of this prophylaxis and to mention alternatives to the use of drugs in the prevention of stress ulcers. METHODS: We selected articles written in English and Portuguese, published between 2009 and 2019, which show the indications of stress ulcer prophylaxis in critically ill pediatric patients, as well as studies demonstrating the complications of gastric acid suppression therapy. The search was performed in the PubMed, LILACS and SciELO databases. RESULTS: In this integrative review, sixteen studies that met the previously established inclusion criteria were analyzed. Of the articles included in this study, four are prospective observational studies, eight are systematic reviews, seven with meta-analysis, two retrospective cohort studies, one case-control study, one expert-opinion guideline, and one case report. CONCLUSION: The indiscriminate use of stress ulcer prophylaxis is not recommended and should only be used when there is an accurate indication. However, even where therapy is recommended, the risk-benefit assessment should be assessed and caution should be exercised with acid-suppressing drugs, as this prophylaxis increases the risk of Clostridium difficile infection and pneumonia. It is also suggested the introduction of early enteral nutrition as an alternative to the use of gastric ulcer drug prophylaxis, as the evidence points to its efficacy in reducing adverse effects and maintaining gastric homeostasis.

Prevention of gastrointestinal bleeding in critically ill patients.

This review focuses on the current literature on the epidemiology and prevention of stress-induced clinically important gastrointestinal bleeding in ICU patients. The incidence of stress-induced clinically important gastrointestinal bleeding in critically ill patients seems to be decreasing. Observational studies and an exploratory randomized controlled trial suggest that early enteral nutrition may be effective in preventing gastrointestinal bleeding in patients who are not at high risk. Recent systemic reviews and meta-analyses indicate that proton pump inhibitors and H2 receptor antagonists are more effective than placebo in preventing clinically important gastrointestinal bleeding, especially in high-risk and very high-risk patients, but do not reduce mortality. Although observational data suggested an association of proton pump inhibitors and H2 receptor antagonists with Clostridium difficile infection and pneumonia, this association was not confirmed in randomized controlled trials. The incidence of stress-induced clinically important gastrointestinal bleeding in critically ill patients seems to have decreased over time. Even though stress ulcer prophylaxis in critically ill patients has been a research focus for decades, many questions remain unanswered, such as which groups of patients are likely to benefit and what pharmacologic agent is associated with the best benefit-to-harm ratio.

Pretreatment with intestinal trefoil factor alleviates stress-induced gastric mucosal damage via Akt signaling.

BACKGROUNDStress-related gastric mucosal damage or ulcer remains an unsolved issue for critically ill patients. Stress ulcer prophylaxis has been part of routine intensive care, but uncertainty and controversy still exist. Co-secreted with mucins, intestinal trefoil factor (ITF) is reported to promote restitution and regeneration of intestinal mucosal epithelium, although the mechanism remains unknown.AIMTo elucidate the protective effects of ITF on gastric mucosa and explore the possible mechanisms.METHODSWe used a rat model of gastric mucosal damage induced by water immersion restraint stress and lipopolysaccharide-treated human gastric epithelial cell line to investigate the potential effects of ITF on damaged gastric mucosa both in vivo and in vitro.RESULTSITF promoted the proliferation and migration and inhibited necrosis of gastric mucosal epithelia in vitro. It also preserved the integrity of gastric mucosa by upregulating expressions of occludin and zonula occludens-1. In the rat model, pretreatment with ITF ameliorated the gastric mucosal epithelial damage and facilitated mucosal repair. The protective effects of ITF were confirmed to be exerted via activation of Akt signaling, and the specific inhibitor of Akt signaling LY249002 reversed the protective effects.CONCLUSIONITF might be a promising candidate for prevention and treatment of stress-induced gastric mucosal damage, and further studies should be undertaken to verify its clinical feasibility.

Major publications in the critical care pharmacotherapy literature: 2019.

To summarize selected meta-analyses and trials related to critical care pharmacotherapy published in 2019. The Critical Care Pharmacotherapy Literature Update (CCPLU) Group screened 36 journals monthly for impactful articles and reviewed 113 articles during 2019 according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria. Articles with a 1A grade, including three clinical practice guidelines, six meta-analyses, and five original research trials are reviewed here from those included in the monthly CCPLU. Clinical practice guidelines on the use of polymyxins and antiarrhythmic drugs in cardiac arrest as well as meta-analyses on antipsychotic use in delirium, stress ulcer prophylaxis (SUP), and vasoactive medications in septic shock and cardiac arrest were summarized. Original research trials evaluated delirium, sedation, neuromuscular blockade, SUP, anticoagulation reversal, and hemostasis. This clinical review and expert opinion provides summary and perspectives of clinical practice impact on influential critical care pharmacotherapy publications in 2019.

Are we missing tracks while prescribing proton pump inhibitors? - An opinion from clinicians cross sectional hospital based questionnaire study

Introduction: Poton pump inhibitors are the main stage standard therapy for various gastrointestinal disorders such as upper gastrointestinal disorders, GERD, dyspepsia and peptic ulcer disease.1 The availability of PPIs as an OTC drug and it's over utilization in multiple disease backgrounds with or without symptoms has subjected patients to a potential risk such as parietal cell hypertrophy and hypergastrinemia leading to rebound acid secretion.2 Studies have shown that between 40% to 65% of prescriptions for a PPI fail to have an appropriate indication.3 Inapt stress ulcer prophylaxis (SUP) in hospital wards and in the clinical OPDs, and failure to discontinue SUP prior to hospital discharge has amplified this risk.4 Aim: To analyse the views, opinion and judgement of every clinicians in our hospital regarding PPI prescription and factors they consider while prescribing and their views to decrease misuse of the same. Materials and Methods: This is a cross-sectional, opinion deriving, hospital based questionnaire study where mostly physicians of all specialities were interviewed with a pre-structured questionnaire containing 14 questions. Results: 93 respondents of multi-speciality background had variety of opinion about the practice of the PPIs in our hospital. 24.7% of them treat 31-40 patients per month on average with genuine gastrointestinal symptoms which mandate the use of proton pump inhibitors evidently. 50% of the practitioners told they will prescribe for patient satisfaction and patients request for gastric tablets. 46.7% of the practitioners didn’t think of deprescribing PPIs in asymptomatic patients. Nearly 70% of them were either not sure or had any idea about the deprescribing PPI use. Keywords: Proton pump inhibitors, Prescription practice, Deprescribing guidelines, Long term effects.

The Use and Misuse of Proton Pump Inhibitors: An Opportunity for Deprescribing

Proton pump inhibitors (PPIs) are proven medications of choice for gastroesophageal reflux disease (GERD), acid-related disorders, erosive esophagitis, Barrett esophagus, prevention of gastrointestinal bleeding while on nonsteroidal anti-inflammatory drugs, eosinophilic esophagitis, peptic ulcer disease, stress ulcer prophylaxis in critically ill patients, and other indications. Best practice guidelines from several sources on the appropriate indications and duration of PPI therapy have been summarized for easy assimilation. Individualized decision with regard to PPI use is illustrated by case vignettes; best approaches are provided.The significant increase in use of PPIs for ill-defined indications over the years, associated adverse outcomes with long-term use, and consequent increase in health care costs have drawn much attention. Adverse outcomes due to PPI therapy may be categorized as unrelated or related to gastric acid inhibition. Examples of outcomes unrelated to acid inhibition include allergic reactions, acute interstitial nephritis, chronic kidney disease, poor cardiovascular outcomes, dementia, and drug interactions; consequences of acid inhibition include gastrointestinal infections, pneumonia, nutrient deficiencies, fractures, spontaneous bacterial peritonitis, and small intestinal bacterial overgrowth.Provider awareness regarding best practice guidelines on PPI use and imparting pertinent education to patients may be the rational approach to safe and effective PPI therapy. In individuals in whom the drug is not indicated, efforts at deprescribing the PPI may be attempted following discussion with the patient. Approaches include stopping the drug, reducing the dose or using “on-demand” therapy after completing the course of treatment for the specific indication. Barriers to successful deprescribing exist. Follow-up is recommended for recurrence of manifestations; in the event of recurrence, the PPI may need to be re-instituted.PPIs are valuable, irreplaceable drugs in the prevention and treatment of certain disorders for specific durations of time. Evidence nevertheless suggests that excessive and inappropriately prolonged use of PPIs is associated with a broad range of adverse effects. Education of provider and patient, stewardship, and motivation are key to appropriate use of PPIs for the right indications. Key implications for practice are offered.

584: Impact of a Pharmacist-Managed Stress Ulcer Prophylaxis Protocol at a Large Academic Medical Center

Copyright © 2020 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Prevalence and Risk Factors for Inappropriate Continuation of Proton Pump Inhibitors After Discharge From the Intensive Care Unit

ObjectiveTo determine the prevalence and risk factors for inappropriate discharge on proton pump inhibitor (PPI) therapy started in the intensive care unit (ICU) for stress ulcer prophylaxis. Patients and MethodsThis was a retrospective cohort study of adults initiated on treatment with a PPI in any of 9 affiliated ICUs from January 1, 2014, to December 31, 2018. Patients were excluded if they had an appropriate long-term PPI indication. Logistic regression modeling was used to identify characteristics associated with discharge on treatment with an inappropriate PPI. ResultsOf 24,751 patients admitted to an ICU, 4127 were initiated on treatment with a new PPI, with 2467 (60%) lacking a long-term PPI indication. Of these 2467, a total of 1122 (45%) were continued on PPI therapy after transfer to the floor and 668 (27%) were discharged on PPI therapy. On multivariable analysis, risk factors for inappropriate discharge on PPI therapy included having an upper endoscopy (adjusted odds ratio [aOR], 1.70; 95% CI, 1.08-2.66), admission to the surgical compared with medical ICU (aOR, 2.03; 95% CI, 1.32-3.10), and discharge to a nursing home or rehabilitation facility (aOR, 1.43; 95% CI, 1.04-1.96; and aOR, 2.29; 95% CI, 1.62-3.24, respectively). ConclusionAmong patients started on treatment with a PPI in the ICU without an indication for outpatient PPI use, 27% (668 of 2467) were nonetheless discharged on PPI therapy. Medically complex and surgical ICU patients are at increased risk for receiving PPIs without appropriate documented indications, and careful review of medication lists at discharge should occur in these high-risk groups.

Prophylactic acid suppressants in children in the intensive care unit: a systematic review with meta-analysis and trial sequential analysis.

Critically ill children are at risk of stress-induced gastrointestinal ulceration. Acid suppressants are frequently used in intensive care units even though there is uncertainty about the benefits and harms. With this systematic review, we aimed to assess patient-important benefits and harms of stress ulcer prophylaxis (SUP) in children in intensive care. We conducted the review according to the PRISMA statement, the Cochrane Handbook, and GRADE, using conventional meta-analysis and trial sequential analysis (TSA). We included randomised clinical trials comparing SUP with histamine-2-receptor antagonists or proton pump inhibitors vs placebo/no prophylaxis in children admitted for intensive care. Primary outcomes were all-cause mortality and overt gastrointestinal bleeding. Secondary outcomes were serious adverse events, hospital-acquired pneumonia, Clostridium difficile enteritis, myocardial ischemia, acute kidney injury and quality of life. We included a total of seven trials (n=504) with eight trial comparisons. We found no statistically significant difference in all-cause mortality (relative risk (RR) 1.43, 95% confidence interval (CI) 0.86-2.37), overt gastrointestinal bleeding (RR 0.75, 95% CI 0.42-1.35) or hospital-acquired pneumonia (RR 1.18, 95% CI 0.77-1.82) between SUP vs placebo/no prophylaxis. No trials reported on remaining secondary outcomes. TSA was unable to draw firm conclusions for all outcomes and certainty of evidence for all outcomes was "very low." We found no difference in all-cause mortality, overt gastrointestinal bleeding or hospital-acquired pneumonia in children in intensive care receiving acid suppressants compared with placebo/no prophylaxis. However, the quantity and quality of evidence was very low with no firm evidence for benefit or harm.

Deprescribing: A Tool to Optimize Medications Across the Continuum of Care

Deprescribing: A Tool to Optimize Medications Across the Continuum of Care

Impact of clinical pharmacists on adherence to stress ulcer prophylaxis protocol in critically ill Egyptian patients: a comparative study

Standardized protocols can aid in appropriate prescribing of stress ulcer prophylaxis (SUP) in the intensive care unit (ICU). The study aimed to evaluate the impact of providing a physician’s education (PhyEd) versus a PhyEd + Clinical Pharmacist (PhyEd + CPh) approach on adherence to a SUP protocol and possible cost saving in the ICU. This was a quasi-experimental study. An evidence-based SUP protocol was developed by a clinical pharmacy team at an Egyptian ICU. Physicians were provided with educational sessions, information regarding the protocol, and latest SUP guidelines over a 1-month period. All adult patients admitted to one of the two ICU floors during the 6-month study period were eligible for inclusion. Patients admitted with an indication for acid suppressive therapy and those who stayed in the ICU for < 48 h were excluded. Patients were divided into two groups based on their ICU floor: PhyEd (1st floor) and PhyEd + CPh (2nd floor). Clinical pharmacists provided interventions regarding protocol adherence only for patients on the 2nd floor. A total of 177 patients were included. SUP protocol non-adherence, calculated as the percentage of inappropriate (i.e., did not meet all the criteria in the protocol) patient-days, was significantly lower in the PhyEd + CPh group than in the PhyEd group (64.7% vs 90.9%; p < 0.0001). Bleeding events were comparable in both groups. The total actual cost saved due to protocol adherence was $US149.44 ($US118.95 in the PhyEd + CPh group + $US30.49 in the PhyEd group). The estimated total cost saved due to protocol adherence was $US948.56. Clinical pharmacists’ daily interventions decreased non-adherence to the SUP protocol, and provided a significant decrease in hospital expenditures with no influence on adverse effects.

S1355 The Utility of Routine Use of Stress Ulcer Prophylaxis in Hospitalized Patients: A Retrospective Study in a Community-Based Hospital

S1355 The Utility of Routine Use of Stress Ulcer Prophylaxis in Hospitalized Patients: A Retrospective Study in a Community-Based Hospital

S1365 Inappropriate Continuation of Proton Pump Inhibitors Upon Discharge in Patients Who Received Stress Ulcer Prophylaxis

S1365 Inappropriate Continuation of Proton Pump Inhibitors Upon Discharge in Patients Who Received Stress Ulcer Prophylaxis

S0627 Incidence of Thrombocytopenia Between Proton Pump Inhibitors and Histamine-2 Receptor Antagonists in Critically Ill, Mechanically Ventilated Patients Receiving Stress-Ulcer Prophylaxis

S0627 Incidence of Thrombocytopenia Between Proton Pump Inhibitors and Histamine-2 Receptor Antagonists in Critically Ill, Mechanically Ventilated Patients Receiving Stress-Ulcer Prophylaxis

Proton Pump Inhibitors Versus Histamine-2 Receptor Antagonists Likely Increase Mortality in Critical Care: An Updated Meta-Analysis

BackgroundUpper gastrointestinal bleeding is common among the critically ill. Recently, the Proton Pump Inhibitors (PPIs) vs. Histamine-2 Receptor Blockers for Ulcer Prophylaxis Therapy in the Intensive Care Unit (PEPTIC) trial suggested PPIs might increase mortality. We performed an updated meta-analysis to further inform discussion. MethodsWe leveraged 2 recent systematic reviews to identify randomized controlled trials directly comparing PPIs and H-2 Receptor Antagonists (H2RAs) for stress ulcer prophylaxis in critically ill patients and reporting mortality. We extracted mortality data from each study and meta-analyzed them with the PEPTIC trial using a random effects model. ResultsOf 28,559 total patients, 14,436 (50.5%) were allocated to PPI and 14,123 to H2RAs (49.5%). Compared to H2RAs, the pooled relative risk for mortality was 1.05 (95% confidence interval 1.00-1.10) with an estimated risk difference for mortality of 9 additional deaths per 1000 patients exposed to PPI (95% confidence interval 0-18); heterogeneity was low (I2 = 0%; P = 0.826). ConclusionsStress ulcer prophylaxis with PPIs likely increases mortality compared to H2RAs. Whether stress ulcer prophylaxis is beneficial in critical care remains open to further study.

A Retrospective Cohort Analysis of the Use of Enteral Nutrition Plus Pharmacologic Prophylaxis or Enteral Nutrition Alone.

Background: Due to the risk of development of stress ulcers in intensive care unit (ICU) patients, pharmacologic prophylaxis is often utilized. However, some literature describes the use of enteral nutrition instead as stress ulcer prophylaxis. Methods: The purpose of this study is to determine if enteral nutrition is similar to pharmacologic stress ulcer prophylaxis (SUP) with enteral nutrition for reduction of gastrointestinal (GI) bleeding, perforation, or ulceration in ICU patients. This was a retrospective, single-center cohort study that took place at an academic medical center. Adult ICU patients receiving enteral nutrition who had a risk factor for stress-related mucosal damage were included. The primary outcome was the incidence of GI bleeding, perforation, or ulcer formation. Results: Overall, 167 patients were included in the study, 147 in the pharmacologic prophylaxis plus EN group (PPEN) and 20 in the enteral therapy only (EN) group. Of 167 patients included, 22 patients (21 in the PPEN group and 1 in the EN group) developed a primary outcome of GI bleeding, perforation, or ulceration (14.3% vs 5%, P = .4781). Patients in the PPEN group had a higher incidence of pneumonia (42.2% vs 15%, P = .0194), but no difference was seen between groups when patients with pneumonia present on admission were excluded (20.6% vs 10.5%, P = .5254). Conclusion: In this small cohort of patients, enteral nutrition alone is as effective as pharmacologic therapy in addition to enteral nutrition for the reduction of stress-related GI bleeding, perforation, and ulceration.

Reassessing the Use of Proton Pump Inhibitors and Histamine-2 Antagonists in Critically Ill Children: A Systematic Review and Meta-Analysis

To determine the associations of stress ulcer prophylaxis with gastrointestinal (GI) bleeding, nosocomial pneumonia (NP), mortality, and length of stay in the pediatric intensive care unit (PICU). We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies in the English language assessing the effects of proton pump inhibitors and histamine-2 receptor antagonists on patients in the PICU published before October 2018 from the PubMed, Embase, CINAHL, and Cochrane Central Register of Controlled Trials databases. A random-effects Mantel-Haenszel risk difference (MHRD) model was used to pool all the selected studies for meta-analysis. Primary outcomes were the incidences of GI bleeding and NP. Secondary outcomes included mortality and length of PICU stay. Seventeen studies (4 RCTs and 13 observational studies) with a total of 340 763 patients were included. The overall incidence of GI bleeding was 15.2%. There was no difference in the risk of GI bleeding based on stress ulcer prophylaxis status (MHRD, 5.0%; 95% CI, -1.0% to 11.0%; I2=62%). There was an increased risk of NP in patients who received stress ulcer prophylaxis compared with those who did not (MHRD, 5.3%; 95% CI, 3.5%-7.0%; I2=0%). An increased risk of mortality was seen in patients receiving stress ulcer prophylaxis (MHRD, 2.1%; 95% CI, 2.0%-2.2%; I2=0%), although this association was no longer found when 1 large study was removed in a sensitivity analysis. There was no statistically significant difference in length of PICU stay between the groups (standardized mean difference, 0.42days; 95% CI, -0.16 to 1.01days; I2=89.8%). Stress ulcer prophylaxis does not show a clear benefit in reducing GI bleeding or length of PICU stay. Observational studies suggest an increased risk of NP and mortality with stress ulcer prophylaxis, which remains to be validated in clinical trials.

Proton pump inhibitors versus histamine-2 receptor antagonists for stress ulcer prophylaxis during extracorporeal membrane oxygenation: a propensity score-matched analysis.

PurposePatients receiving extracorporeal membrane oxygenation (ECMO) generally receive proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) to avoid major gastrointestinal bleeding. Our aim was to compare outcomes between patients receiving PPIs and H2RAs for stress ulcer prophylaxis during ECMO.Materials and methodsWe performed a retrospective cohort study using the Japanese Diagnosis Procedure Combination Database, using data recorded from 1 July 2010 to 31 March 2017. We defined patients who received PPIs within 2 days after starting ECMO as the PPIs group and those who received H2RAs within 2 days after starting ECMO as the H2RAs group. We performed propensity score matching to compare outcomes. The primary outcomes were gastrointestinal bleeding requiring endoscopic haemostasis and in-hospital mortality. The secondary outcomes were red blood cell transfusion, hospital-acquired pneumonia and Clostridium difficile infection during hospitalisation.ResultsOf 11 328 eligible patients, 9738 received PPIs and 1590 received H2RAs. Propensity score matching created 1556 pairs. No significant differences were seen regarding endoscopic haemostasis (1.2% vs 0.8%; p=0.37), in-hospital mortality (53.0% vs 53.1%; p=0.94), red blood cell transfusion rates (91.4% vs 89.7%; p=0.11), hospital-acquired pneumonia (13.0% vs 12.4%; p=0.59) or C. difficile infection (0.1% vs 0.2%; p=0.32) between the PPIs and H2RAs groups, respectively.ConclusionWe found no differences in the evaluated outcomes between the PPIs and H2RAs groups. Both PPIs and H2RAs are treatment options for stress ulcer prophylaxis in patients undergoing ECMO.

Evaluation of the prescribing of proton pump inhibitors as stress ulcer prophylaxis for non-ICU patients in a Malaysian tertiary hospital

Proton pump inhibitors (PPIs) are widely prescribed in hospital settings. Several reports have highlighted concerns about the inappropriate use of PPIs as stress ulcer prophylaxis (SUP) in patients outside the intensive care unit (ICU) setting. Little is known about this phenomenon in Malaysian hospitals. This study aimed to evaluate the appropriateness of PPI prescribing as SUP for patients admitted to the general medical wards of a Malaysian tertiary hospital and to determine the rate of unnecessary prescription of PPI for discharged patients. This was a retrospective cross-sectional study conducted in a tertiary hospital in Pahang, Malaysia. We reviewed the information held on electronic databases for patients admitted to the general medical wards from January to September 2019. Appropriateness of PPI prescribing was assessed using the criteria for SUP from predefined clinical guidelines. Of 660 screened patients admitted to the general medical wards, 200 were prescribed PPIs as SUP. Oral pantoprazole was the most frequently prescribed PPI (51.5%). Only 61 (30.5%) PPIs were prescribed according to current recommendations for the use of PPI for SUP. Sex, age, number of medications, length of hospital stay, and receiving PPI at discharge were not significantly associated with appropriateness of PPI prescribing. Half of the patients continued receiving PPIs at discharge without a documented indication. Our findings indicated a high prevalence of inappropriate prescribing of PPIs as SUP for non-ICU patients. Interventions to reduce the unnecessary use of PPIs in Malaysian hospital settings are desperately required. The need for national criteria that address the proper indications and dosing regimens for PPIs as SUP in ICU and non-ICU patients is high.

Adequacy of stress ulcer prophylaxis prescription in the intensive care unit: an observational study.

Stress ulcer prophylaxis prescriptions might not be sufficiently challenged throughout a patient&#39;s stay in an intensive care unit (ICU) and might be erroneously maintained after ICU discharge. This study aimed to determine (1) stress ulcer prophylaxis adequacy in ICU and (2) the proportion of patients receiving inappropriate stress ulcer prophylaxis after ICU discharge. This was an observational, single centre study (University Hospital Lausanne, Switzerland). All patients without a previous indication for acid-suppressive therapy and admitted to our ICU for &gt;24 hrs during a two-month period were included. The adequacy of stress ulcer prophylaxis prescriptions according to our guidelines was assessed. We then assessed stress ulcer prophylaxis prescriptions and their adequacy on ICU and hospital discharge, as well as the costs associated with inadequate prescription. Of the 372 patients admitted during the study period, 140 (855 patient-days) fulfilled the inclusion criteria. Of these, 130 (92.9%) received stress ulcer prophylaxis in the ICU (796 [93.1%] patient-days). Stress ulcer prophylaxis consisted of esomeprazole in 686 (86.2%) patient-days. Overall, stress ulcer prophylaxis was inadequate in 558 (65.3%) patient-days, mostly because it was prescribed while not indicated (543 patient-days [63.5%]). On ICU discharge, stress ulcer prophylaxis prescription was inadequately maintained in 55 patients (51.9% of survivors). Similarly, stress ulcer prophylaxis was inadequately maintained on hospital discharge in 30 (28% of survivors) patients. We estimated the in-hospital cost of inadequate stress ulcer prophylaxis prescription as approximately CHF 2870 per year. Outpatient therapy maintenance would be associated with additional costs ranging from CHF 33,912 to 92,692 (EUR 31,832 to 87,012) for each additional year they receive the therapy, depending on the medication used. The adequacy of stress ulcer prophylaxis in the ICU is low. In addition, the prescription is frequently continued after ICU and many patients are even discharged home with inadequate acid-suppressive therapy. &nbsp; &nbsp.