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Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection.

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.

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  • 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.edu

    , , , , ,

    Source

    Archives of internal medicine 170:9 2010 May 10 pg 784-90

    MeSH

    Aged
    Anti-Ulcer Agents
    Boston
    Case-Control Studies
    Clostridium Infections
    Clostridium difficile
    Cross Infection
    Dose-Response Relationship, Drug
    Female
    Histamine H2 Antagonists
    Humans
    Kaplan-Meier Estimate
    Male
    Matched-Pair Analysis
    Multivariate Analysis
    Propensity Score
    Prospective Studies
    Proton Pump Inhibitors
    Risk Factors

    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 - https://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 -