Bleeding or Breathing? Rethinking Hospital Admission Orders
Bleeding or Breathing? Rethinking Hospital Admission Orders
Abstract & Commentary
By Barbara A. Phillips, MD, MSPH, Professor of Medicine, University of Kentucky; Director, Sleep Disorders Center, Samaritan Hospital, Lexington. Dr. Phillips reports no financial relationship to this field of study.
Synopsis: Patients who receive proton-pump inhibitors in the hospital are at increased risk for hospital-acquired pneumonia.
Source: Herzig SJ, et al. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA 2009;301:2120-2128.
This report is based on an analysis of a cohort of patients admitted to "a large, urban, academic medical center in Boston, Massachusetts" (probably Beth Israel Deaconess Medical Center) over a 4-year period. To be included in this study, patients had to be at least 18 years old and hospitalized for at least 3 days. ICU patients were excluded. Pharmacy records identified which, if any, acid suppression medication patients received. The primary outcome was hospital-acquired pneumonia, defined as any discharge code from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) for bacterial pneumonia listed as a secondary discharge diagnosis. Covariates included age, sex, race, season and day of the week of admission, admitting service, admission type (elective, urgent, emergent), length of hospitalization, any ICD-9-CM code for gastrointestinal hemorrhage, any ICD-9-CM code for nausea and/or vomiting, and use of specific classes of medications. Covariates were chosen on the basis that these factors are thought to predict use of acid-suppressive medications and/or to increase the risk of hospital-acquired pneumonia. Because there was no information on the date of development of hospital-acquired pneumonias, it could not be determined whether the acid-suppressive medication was started before or after the onset of pneumonia; to address this possible misclassification error, the percentage of orders for acid-suppressive medication that were written within the first 48 hours of admission was determined, and these cases were reclassified as not having received acid-suppressive medication. The percentage of orders for acid-suppressive medication that occurred within 48 hours of discharge was also ascertained.
A total of 63,878 admissions (from 42,093 unique patients) made up the cohort. Their mean age was 54 years, and 37% were men. Overall, about half (52%) of the patients received acid-suppressive medication; 27,236 (83%) received proton-pump inhibitors (PPIs) and 7548 (23%) received histamine-2 receptor antagonists. A small number of patients received both. Those who received acid-suppressing drugs were older and generally sicker than those who did not. The authors do not tell us which of the differences were statistically significant, but those who got acid suppression were more than twice as likely to have heart failure, COPD, connective tissue disease, liver disease, diabetes, renal disease, and cancer.
The primary outcome of hospital-acquired pneumonia occurred in 2219 admissions (3.5%). After adjusting for potential confounders as well as clustering of admissions, the odds ratio of hospital-acquired pneumonia in the group exposed to acid-suppressive medication was 1.3 (95% confidence interval [CI], 1.1-1.4) compared with those who were not exposed.
To better control for covariates (underlying conditions), the authors matched 16,396 patient admissions with acid-suppressive medication exposure to 16,396 patient admissions without exposure. In this analysis, the group exposed to acid-suppressive medication was much more similar in baseline characteristics to the unexposed group. A significant association between exposure to acid-suppressive medication and hospital-acquired pneumonia again existed, with an odds ratio of 1.3 (95% CI, 1.1-1.4), and increased risk for both aspiration and non-aspiration pneumonia. When analyzed by type of acid-suppressing medication, the odds ratio for risk of pneumonia for proton-pump inhibitors, but not histamine-2 receptor antagonists, remained elevated by about 30%.
Commentary
The prevalence of acid-suppression medication use in this study (52%) is fairly typical. Recent estimates place the use of these agents at 40%-70% of medical inpatients, approximately 50% of which are initiations.1,2 Most of this use is for indications that are off-label, such as stress ulcer prophylaxis in low-risk patients; such use has not been shown to be of benefit.3-5 Further, recent data in outpatients suggest an increased risk for community-acquired pneumonia in current users of acid-suppressive medication.6 The current study is the largest, prospective evaluation of the association between acid-suppressive medication and hospital-acquired pneumonia in nonventilated inpatients.
A couple of caveats are in order. First, the analysis remained statistically significant only for the PPIs after consideration of confounders. Second, this evaluation included only non-ICU patients. Current guidelines recommend the use of prophylactic acid-suppressing medications in ventilated patients because of the increased risk of stress-related gastric mucosal ulceration in such patients.7
But beyond those two disclaimers, this study strongly suggests that elimination of the routine use of PPIs in non-ICU patients would do more good than harm, and might even help address the pervasive problem of nosocomial pneumonia.
References
1. Nardino RJ, et al. Overuse of acid-suppressive therapy in hospitalized patients. Am J Gastroenterol 2000;95: 3118-3122.
2. Pham CQ, et al. Acid suppressive therapy use on an inpatient internal medicine service. Ann Pharmacother 2006;40:1261-1266.
3. Heidelbaugh JJ, Inadomi JM. Magnitude and economic impact of inappropriate use of stress ulcer prophylaxis in non-ICU hospitalized patients. Am J Gastroenterol 2006;101:2200-2205.
4. Parente F, et al. Hospital use of acid-suppressive medications and its fall-out on prescribing in general practice: A 1-month survey. Aliment Pharmacol Ther 2003;17:1503-1506.
5. Janicki T, Stewart S. Stress-ulcer prophylaxis for general medical patients: A review of the evidence. J Hosp Med 2007;2:86-92.
6. Sarkar M, et al. Proton-pump inhibitor use and the risk for community-acquired pneumonia. Ann Intern Med 2008;149:391-398.
7. 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; 56:347-379.
Patients who receive proton-pump inhibitors in the hospital are at increased risk for hospital-acquired pneumonia.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.