Wednesday, September 19, 2012

Proton pump inhibitors increased infection rate in decompensated cirrhosis patients

Proton pump inhibitors increased infection rate in decompensated cirrhosis patients

Bajaj JS. Aliment Pharmacol Ther. 2012;doi:10.1111/apt.12045.

Veterans with decompensated cirrhosis who started proton pump inhibitor therapy after decompensation were more likely than nonusers to develop serious infections in a recent study.

Researchers evaluated data from 1,268 US veterans who began proton pump inhibitor (PPI) use for decompensated cirrhosis between 2001 and 2009, along with 1,268 matched controls who did not use PPI. A parallel analysis was conducted of patients using H2 receptor antagonists (H2RA) (n=199) and matched controls (n=199). Incidence of serious infections requiring hospitalization, including skin, lower respiratory, urinary and kidney infections, along with Clostridium difficile, infectious gastroenteritis, sepsis and bactremia, was recorded.

Serious infections occurred in 25.3% of PPI users, with an incidence rate of 675 per 1,000 person-years. No association was found between PPI use and serious infection incidence rate (crude propensity-matched HR=1.08; 95% CI, 0.90-1.31), but infections related to acid suppression tended to occur more frequently in this group than among nonusers (crude HR=1.22; 95% CI, 0.97-1.52). Potential confounders, including age, race/ethnicity and concomitant medication, were similarly distributed between the two groups, but PPI users were more likely to have five or more comorbidities (41.2% of patients vs. 32.1% of nonusers).

Accounting for time-varying PPI use, serious infections were found to develop more quickly among PPI users than nonusers (adjusted HR=1.66; 95% CI, 1.31-2.12). Serious infections related to acid suppression also developed more quickly among PPI users (adjusted HR=1.75; 95% CI, 1.32-2.34), and comprised a larger number of all infections (75%) than among nonusers (64%).

Among H2RA users, 25.9% experienced serious infections, with 17.7% of patients developing infections related to acid suppression. Adjusted HRs were 1.59 for serious infection (95% CI, 0.80-3.18) and 0.92 for infections related to acid suppression (95% CI, 0.31-2.73) compared with nonusers. Neither result was statistically significant.

“Veterans with decompensated cirrhosis who were started on PPI therapy after decompensation had a significantly higher risk of developing serious infections compared with those who were not initiated on gastric acid suppression,” the researchers concluded. “As patients with decompensated cirrhosis remain at a high risk of serious infections, clinicians should reevaluate the reason for prescribing PPI and, wherever possible, replace their acid suppressive needs with H2RAs.”

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