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Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection.
Arch Intern Med 2010; 170(9):784-90AI

Abstract

BACKGROUND

The incidence and severity of Clostridium difficile infections are increasing. Acid-suppressive therapy has been suggested as a risk factor for C difficile, but this remains controversial.

METHODS

We conducted a pharmacoepidemiologic cohort study, performing a secondary analysis of data collected prospectively on 101 796 discharges from a tertiary care medical center during a 5-year period. The primary exposure of interest was acid suppression therapy, classified by the most intense acid suppression therapy received (no acid suppression, histamine(2)-receptor antagonist [H(2)RA] therapy, daily proton pump inhibitor [PPI], and PPI more frequently than daily).

RESULTS

As the level of acid suppression increased, the risk of nosocomial C difficile infection increased, from 0.3% (95% confidence interval [CI], 0.21%-0.31%) in patients not receiving acid suppressive therapy to 0.6% (95% CI, 0.49%-0.79%) in those receiving H(2)RA therapy, to 0.9% (95% CI, 0.80%-0.98%) in those receiving daily PPI treatment, and to 1.4% (1.15%-1.71%) in those receiving more frequent PPI therapy. After adjustment for comorbid conditions, age, antibiotics, and propensity score-based likelihood of receipt of acid-suppression therapy, the association persisted, increasing from an odds ratio of 1 (no acid suppression [reference]) to 1.53 (95% CI, 1.12-2.10) (H(2)RA), to 1.74 (95% CI, 1.39-2.18) (daily PPI), and to 2.36 (95% CI, 1.79-3.11) (more frequent PPI). Similar estimates were found with a matched cohort analysis and with nested case-control techniques.

CONCLUSIONS

Increasing levels of pharmacologic acid suppression are associated with increased risks of nosocomial C difficile infection. This evidence of a dose-response effect provides further support for the potentially causal nature of iatrogenic acid suppression in the development of nosocomial C difficile infection.

Authors+Show Affiliations

Silverman Institute for Healthcare Quality and Safety, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, USA. mhowell@bidmc.harvard.eduNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article

Language

eng

PubMed ID

20458086

Citation

Howell, Michael D., et al. "Iatrogenic Gastric Acid Suppression and the Risk of Nosocomial Clostridium Difficile Infection." Archives of Internal Medicine, vol. 170, no. 9, 2010, pp. 784-90.
Howell MD, Novack V, Grgurich P, et al. Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection. Arch Intern Med. 2010;170(9):784-90.
Howell, M. D., Novack, V., Grgurich, P., Soulliard, D., Novack, L., Pencina, M., & Talmor, D. (2010). Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection. Archives of Internal Medicine, 170(9), pp. 784-90. doi:10.1001/archinternmed.2010.89.
Howell MD, et al. Iatrogenic Gastric Acid Suppression and the Risk of Nosocomial Clostridium Difficile Infection. Arch Intern Med. 2010 May 10;170(9):784-90. PubMed PMID: 20458086.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection. AU - Howell,Michael D, AU - Novack,Victor, AU - Grgurich,Philip, AU - Soulliard,Diane, AU - Novack,Lena, AU - Pencina,Michael, AU - Talmor,Daniel, PY - 2010/5/12/entrez PY - 2010/5/12/pubmed PY - 2010/6/3/medline SP - 784 EP - 90 JF - Archives of internal medicine JO - Arch. Intern. Med. VL - 170 IS - 9 N2 - BACKGROUND: The incidence and severity of Clostridium difficile infections are increasing. Acid-suppressive therapy has been suggested as a risk factor for C difficile, but this remains controversial. METHODS: We conducted a pharmacoepidemiologic cohort study, performing a secondary analysis of data collected prospectively on 101 796 discharges from a tertiary care medical center during a 5-year period. The primary exposure of interest was acid suppression therapy, classified by the most intense acid suppression therapy received (no acid suppression, histamine(2)-receptor antagonist [H(2)RA] therapy, daily proton pump inhibitor [PPI], and PPI more frequently than daily). RESULTS: As the level of acid suppression increased, the risk of nosocomial C difficile infection increased, from 0.3% (95% confidence interval [CI], 0.21%-0.31%) in patients not receiving acid suppressive therapy to 0.6% (95% CI, 0.49%-0.79%) in those receiving H(2)RA therapy, to 0.9% (95% CI, 0.80%-0.98%) in those receiving daily PPI treatment, and to 1.4% (1.15%-1.71%) in those receiving more frequent PPI therapy. After adjustment for comorbid conditions, age, antibiotics, and propensity score-based likelihood of receipt of acid-suppression therapy, the association persisted, increasing from an odds ratio of 1 (no acid suppression [reference]) to 1.53 (95% CI, 1.12-2.10) (H(2)RA), to 1.74 (95% CI, 1.39-2.18) (daily PPI), and to 2.36 (95% CI, 1.79-3.11) (more frequent PPI). Similar estimates were found with a matched cohort analysis and with nested case-control techniques. CONCLUSIONS: Increasing levels of pharmacologic acid suppression are associated with increased risks of nosocomial C difficile infection. This evidence of a dose-response effect provides further support for the potentially causal nature of iatrogenic acid suppression in the development of nosocomial C difficile infection. SN - 1538-3679 UR - http://www.unboundmedicine.com/medline/citation/20458086/full_citation L2 - https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/10.1001/archinternmed.2010.89 DB - PRIME DP - Unbound Medicine ER -