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Marya D. Zilberberg, MD, MPH, FCCP; Andrew F. Shorr, MD, MPH, FCCP
Author and Funding Information

From EviMed Research Group, LLC (Dr Zilberberg); the University of Massachusetts (Dr Zilberberg); and the Washington Hospital Center (Dr Shorr).

Correspondence to: Marya Zilberberg, MD, MPH, FCCP, University of Massachusetts, School of Public Health and Health Sciences, PO Box 303, Goshen, MA 01032; e-mail: Marya@evimedgroup.org


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Zilberberg has participated in a speakers’ bureau supported by a grant from and has been a consultant to ViroPharma, the manufacturer of oral vancomycin. Dr Shorr has reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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):1001-1002. doi:10.1378/chest.09-2733
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To the Editor:

We appreciate Dr Porath’s attention to the connection between gastric acid suppressive medications and Clostridium difficile infection (CDI). Indeed, several observational studies have noted an elevated risk conferred by the use of H2 blockers as well as proton pump inhibitors (PPIs) for the development of such infectious complications as CDI and pneumonia.1-3 In this context, and as with every intervention undertaken in medicine, the risk-benefit ratio of stress ulcer prophylaxis (SUP) needs to be examined for each critically ill patient individually. In fact, despite the ubiquitous use of this process of care as a quality indicator within the ventilator bundle,4 a measured approach is recommended by the evidence-based practice guideline developed jointly by the Infectious Diseases Society of America and the American Thoracic Society.5 SUP decisions should engender two questions: (1) “Does the benefit of SUP outweigh its risk for my patient?” If the answer is “yes,” then (2) “What is the best choice of SUP agent for my patient, given his/her bleeding risk in conjunction with the risk of developing a nosocomial infection?” Although PPIs appear to be more effective than H2 blockers at reducing the incidence of gastrointestinal bleeding, they are also more frequently associated with nosocomial infections.1,3,6

Although in our study we were unable to quantify the impact of either antibiotic or SUP use on the rates of CDI in the population requiring prolonged acute mechanical ventilation,7 studies suggest that gastric suppressive agents are egregiously overused in US hospitals, and PPIs specifically, although started in the hospital as SUP, are frequently continued after discharge without any clinical indication for their use.8 Thus, far from being a part of an automatic electronic order set for any mechanically ventilated patient, the decisions to initiate and terminate SUP should be considered carefully and individually. We wholly agree with Dr Porath that both initiation of SUP and its continuation beyond the ICU and the hospital require meticulous attention in order to minimize individual and public burden from such costly nosocomial complications as CDI.

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]
 
Laheij RJ, Sturkenboom MC, Hassing RJ, Dieleman J, Stricker BH, Jansen JB. Risk of community-acquired pneumonia and use of gastric acid-suppressive drugs. JAMA. 2004;29216:1955-1960. [CrossRef] [PubMed]
 
Herzig SJ, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA. 2009;30120:2120-2128. [CrossRef] [PubMed]
 
Institute for Healthcare ImprovementInstitute for Healthcare Improvement http://www.ihi.org. Accessed November 3, 2009.
 
American Thoracic Society; Infectious Diseases Society of AmericaAmerican Thoracic Society; Infectious Diseases Society of America Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;1714:388-416. [CrossRef] [PubMed]
 
Pongprasobchai S, Kridkratoke S, Nopmaneejumruslers C. Proton pump inhibitors for the prevention of stress-related mucosal disease in critically-ill patients: a meta-analysis. J Med Assoc Thai. 2009;925:632-637. [PubMed]
 
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]
 
Heidelbaugh JJ, Goldberg KL, Inadomi JM. Overutilization of proton pump inhibitors: a review of cost-effectiveness and risk [corrected]. Am J Gastroenterol. 2009;104suppl 2:S27-S32. [CrossRef] [PubMed]
 

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References

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]
 
Laheij RJ, Sturkenboom MC, Hassing RJ, Dieleman J, Stricker BH, Jansen JB. Risk of community-acquired pneumonia and use of gastric acid-suppressive drugs. JAMA. 2004;29216:1955-1960. [CrossRef] [PubMed]
 
Herzig SJ, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA. 2009;30120:2120-2128. [CrossRef] [PubMed]
 
Institute for Healthcare ImprovementInstitute for Healthcare Improvement http://www.ihi.org. Accessed November 3, 2009.
 
American Thoracic Society; Infectious Diseases Society of AmericaAmerican Thoracic Society; Infectious Diseases Society of America Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;1714:388-416. [CrossRef] [PubMed]
 
Pongprasobchai S, Kridkratoke S, Nopmaneejumruslers C. Proton pump inhibitors for the prevention of stress-related mucosal disease in critically-ill patients: a meta-analysis. J Med Assoc Thai. 2009;925:632-637. [PubMed]
 
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]
 
Heidelbaugh JJ, Goldberg KL, Inadomi JM. Overutilization of proton pump inhibitors: a review of cost-effectiveness and risk [corrected]. Am J Gastroenterol. 2009;104suppl 2:S27-S32. [CrossRef] [PubMed]
 
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