0
Correspondence |

Does Stress Ulcer Prophylaxis Explain the Association Between Clostridium difficile-Associated Disease and Mechanical Ventilation? FREE TO VIEW

Adam D. Porath, PharmD, BCPS
Author and Funding Information

From the Department of Pharmacy, Renown Regional Medical Center.

Correspondence to: Adam D. Porath, PharmD, BCPS, Renown Regional Medical Center, 1155 Mill St, Reno, NV 89502; e-mail: aporath@renown.org


Financial/nonfinancial disclosures: The author has reported to CHEST the following conflict of interest: Dr Porath has received a research grant from Merck on behalf of the Department of Pharmacy at Renown Regional Medical Center.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(4):1001. doi:10.1378/chest.09-2329
Text Size: A A A
Published online

To the Editor:

In the September 2009 issue of CHEST, Zilberberg and colleagues1 reported on the association between patients receiving prolonged acute mechanical ventilation (PAMV) and Clostridium difficile-associated disease (CDAD). The reported infection rate (5.3%) in the current study was significantly higher than previously reported by the same authors in the general hospital population (0.112%).2 The authors point out that the causality of the association between PAMV and CDAD cannot be established based on the results of the current study. Zilberberg and colleagues1 do, however, discuss several concomitant risk factors for CDAD that are likely in the mechanically ventilated patient, including increased exposure to antibiotics and C difficile spores. Perhaps one overlooked additional risk factor in the study population was exposure to acid-suppressive therapy (ie, proton-pump inhibitors and histamine-receptor blockers) for stress ulcer prophylaxis. These medications have previously been associated with CDAD,3 and exposure to these agents may be an important potential confounder of the current study. Evidence-based guidelines emphasize that stress ulcer prophylaxis is appropriate in a select group of critical care patients, including those on prolonged mechanical ventilation.4 It is plausible that the majority of patients included in the current study would have had exposure to acid-suppressive therapy. Murphy and colleagues5 reported that stress ulcer prophylaxis is often inappropriately continued when patients transfer out of a critical care unit. The results of the current study clearly show increased costs and length of stay with concurrent PAMV and CDAD. The authors of the current study conclude that “aggressive measures aimed at preventing [CDAD] need to be examined ….” Diligent medication reconciliation when transferring patients from the critical care unit to a lower level of care, particularly focusing on acid-suppressive therapy, may be one simple measure clinicians can take to aid in the prevention of CDAD.

Zilberberg MD, Nathanson BH, Sadigov S, Higgins TL, Kollef MH, Shorr AF. Epidemiology and outcomes ofClostridium difficile-associated disease among patients on prolonged acute mechanical ventilation. Chest. 2009;1363:752-758. [CrossRef] [PubMed]
 
Zilberberg MD, Shorr AF, Kollef MH. Increase in adultClostridium difficile-related hospitalizations and case-fatality rate, United States, 2000-2005. Emerg Infect Dis. 2008;146:929-931. [CrossRef] [PubMed]
 
Dial S, Delaney JA, Barkun AN, Suissa S. Use of gastric acid-suppressive agents and the risk of community-acquiredClostridium difficile-associated disease. JAMA. 2005;29423:2989-2995. [CrossRef] [PubMed]
 
American Society of Health-System PharmacistsAmerican Society of Health-System Pharmacists ASHP therapeutic guidelines on stress ulcer prophylaxis. ASHP Commission on Therapeutics and approved by the ASHP Board of Directors on November 14, 1998. Am J Health Syst Pharm. 1999;564:347-379. [PubMed]
 
Murphy CE, Stevens AM, Ferrentino N, et al. Frequency of inappropriate continuation of acid suppressive therapy after discharge in patients who began therapy in the surgical intensive care unit. Pharmacotherapy. 2008;288:968-976. [CrossRef] [PubMed]
 

Figures

Tables

References

Zilberberg MD, Nathanson BH, Sadigov S, Higgins TL, Kollef MH, Shorr AF. Epidemiology and outcomes ofClostridium difficile-associated disease among patients on prolonged acute mechanical ventilation. Chest. 2009;1363:752-758. [CrossRef] [PubMed]
 
Zilberberg MD, Shorr AF, Kollef MH. Increase in adultClostridium difficile-related hospitalizations and case-fatality rate, United States, 2000-2005. Emerg Infect Dis. 2008;146:929-931. [CrossRef] [PubMed]
 
Dial S, Delaney JA, Barkun AN, Suissa S. Use of gastric acid-suppressive agents and the risk of community-acquiredClostridium difficile-associated disease. JAMA. 2005;29423:2989-2995. [CrossRef] [PubMed]
 
American Society of Health-System PharmacistsAmerican Society of Health-System Pharmacists ASHP therapeutic guidelines on stress ulcer prophylaxis. ASHP Commission on Therapeutics and approved by the ASHP Board of Directors on November 14, 1998. Am J Health Syst Pharm. 1999;564:347-379. [PubMed]
 
Murphy CE, Stevens AM, Ferrentino N, et al. Frequency of inappropriate continuation of acid suppressive therapy after discharge in patients who began therapy in the surgical intensive care unit. Pharmacotherapy. 2008;288:968-976. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543