Proton Pump Inhibitors Increase the Overall Risk of Developing Bacterial Infections in Patients With Cirrhosis

Abstract

-Background -Acid suppression has been associated with adverse events; such as, enteric infections. Proton pump inhibitors (PPI) are frequently prescribed in patients with cirrhosis, but is unclear if PPI are associated with the development of bacterial infections in these patients. Objective -To assess the impact of PPI intake on the development of bacterial, viral and fungal infections in patients with cirrhosis. Methods -An observational, retrospective, historic cohort study. The exposed cohort included patients with cirrhosis with chronic use of PPI. The non-exposed cohort had not been using PPI. The follow-up period was 3 years, searching in the medical records for any events of bacterial infection confirmed by bacteriological culture. Results -One hundred and thirteen patients met the selection criteria, 44 (39%) had chronic use of PPI; of them, 28 (63.6%) patients had not a clear clinical indication to justify the prescription of PPI. Twenty four (21.2%) patients developed bacterial infections during the follow-up period. In the univariate analysis, decompensated cirrhosis (Child B/C), presence of ascites, history of variceal bleeding, and chronic consumption of PPI were risk factors related to the development of infections. But, in the adjusted multivariate analysis only the chronic use of PPI was associated with development of infections (RR=3.6; 95% CI=1.1-12.3; P=0.04). Conclusion -There is an over-prescription of PPI without a justified clinical indication. The long-term consumption of PPI in patients with cirrhosis is associated with the development of bacterial infections; therefore these drugs must be carefully prescribed in this specific population. HEADINGS -Proton pump inhibitors, adverse effects. Inappropriate prescribing. Liver cirrhosis. Risk assessment.Declared conflict of interest of all authors: Fátima Higuera-de la Tijera has received fees for serving as a speaker for Laboratorios Liomont. The other authors have not conflict of interest to declare. None of the other researchers involved in this study have received fees for serving as a speaker, consultant or as advisory board member for any organization. Disclosure of funding: no funding received

Proton Pump Inhibitors and the Risk of Community-Acquired Pneumonia: An Updated Meta-analysis

“…Because patients with hepatitis and cirrhosis often have high stress ulcers of the digestive tract, such as coagulation dysfunction, PPIs are routinely used for gastric protection; however, there are no reports on the rational evaluation of their use in China. Some studies indicate that patients with liver cirrhosis are prone to bacterial infections 24,25 because of their impaired immune status, the increased use of invasive procedures, and alterations in the enteric flora. 26,27 For example, Hermos et al 10 showed that use of PPI would increase the risk of CAP by 1.80-fold when compared with non–PPI use in liver disease patients.…”

Correlation Between Proton Pump Inhibitors and the Complications of Liver Cirrhosis: A Systematic Review and Meta-Analysis

“…After full-text reviews, 29 studies were selected for the final analysis. Thirteen articles reported the results of case-control studies [19][20][21][22][23][24][25][26][27][28][29][30][31] and 16 the results of cohort study [12,13,[32][33][34][35][36][37][38][39][40][41][42][43][44][45] Figure 1 summarizes the study selection process and Table 1 shows the characteristics of the studies involved. A total of 20,484 participants across the 29 studies were included in the meta-analysis.…”

Use of proton pump inhibitors is associated with a higher risk of pneumonia in cirrhotic patients: a systematic review and meta-analysis

“…Therefore, 35 full-length articles were thoroughly reviewed, and 27 articles were further excluded as they did not report the outcome of interest. Finally, 3 cohort and 5 cross-sectional studies with a total of 40,295 participants met the eligibility criteria and were included in the metaanalysis [10][11][12][13][14][15][16][17]. Two of the 3 included cohort studies were published as conference abstracts [10,14].…”

“…The use of PPI may also lead to an increased risk of other types of organspecific bacterial infection. In fact, studies have suggested an increased risk of bacterial pneumonia among cirrhotic patients who use PPIs, although the results are inconsistent [10][11][12][13][14][15][16][17]. The current study aimed to further investigate this risk by identifying all available studies and summarizing their results together.…”