Association between Proton Pump Inhibitor Use and Spontaneous Bacterial Peritonitis

Campbell, M.S.; Obstein, Keith L.; Reddy, K. Rajender; Yang, Yu‐Xiao

doi:10.1007/s10620-007-9899-9

Cited by 75 publications

(93 citation statements)

References 29 publications

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“…While our data for abscess was not statistically significant, there appeared to be a trend towards higher rate of infection. Of the cultures that were positive, there was a higher rate of Gram-negative (enteric) This data supports the conclusion of several studies on rodents and humans that found an association between acid suppression and bacterial overgrowth/infection [6][7][8][9]. In a landmark study by Franklin et al, it was found that the previously held notion of a ''sterile'' foregut was challenged by the finding of polymicrobial gastric flora.…”

Section: Discussionsupporting

confidence: 73%

“…More recently, the chronic use of PPI has been associated with community-acquired Clostridium difficile colitis [11] and a meta-analysis found an association with acid suppression and enteric infection [12]. Similarly, in two retrospective human studies, the crude odds ratio for development of spontaneous bacterial peritonitis among PPI users versus nonusers ranged from 1.22 to 7.0 [8,13]. A human study by Narula et al found that transgastric instrumentation contaminates the peritoneal cavity and those patients on PPIs have a higher bacterial load compared with nonusers [7].…”

Section: Discussionmentioning

confidence: 99%

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The impact of proton-pump inhibitors on intraperitoneal sepsis: a word of caution for transgastric NOTES procedures

et al. 2009

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Background During transgastric natural orifice transluminal endoscopic surgery (NOTES), there is an iatrogenic perforation of the gastric wall with leakage of gastric contents into the peritoneal cavity. The aim of this study is to determine the effect of proton-pump inhibitors (PPI) and alterations of gastric pH on infection during transgastric surgery. Methods Thirty 250-g male Sprague-Dawley rats were divided into a study group (SG, n = 15) and a control group (CG, n =15). SG were given 5 mg/kg pantoprazole for 3 days before procedure and another dose 1 h before. CG received saline at similar time points. A mini-laparotomy with gastrotomy was performed. Aspiration of 2.0 cc gastric contents was removed from the stomach and injected into the peritoneal cavity of both groups. Gastric pH and peritoneal pH levels were obtained. Gastric aspirate was sent for culture. White blood cell counts (WBC) were obtained on postoperative days 1, 7, and 14, and C-reactive protein (CRP) levels were obtained on postoperative day 1. At day 14, a necropsy was performed and aerobic and anaerobic cultures of the peritoneal cavity were obtained. Results There were no deaths in either group. The average gastric pH in the SG was 5.13 versus 3.26 (p = 0.03) in the CG. The average peritoneal pH was similar in both groups. The WBC in the SG was 4.5 vs. 3.5 (1,000 cells/ mm) in the CG. There was no elevation in CRP levels in either group. Bacterial cultures were positive in 3/15 (20%) rats in the CG and in 9/15 (60%) in the SG (p = 0.008). Intra-abdominal abscesses were found in 2/15 (13%) rats in the CG and in 5/15 (33%) in the SG (p = 0.08). Conclusions Pretreatment with a PPI resulted in a higher rate of peritoneal bacterial contamination and abscess formation. The acidic environment of the stomach appears to be protective against infection when intraperitoneal contamination occurs as a result of gastrotomy.

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Section: Discussionsupporting

confidence: 73%

Section: Discussionmentioning

confidence: 99%

The impact of proton-pump inhibitors on intraperitoneal sepsis: a word of caution for transgastric NOTES procedures

et al. 2009

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“…Several studies, including a meta-analysis [93] of four studies involving a total of 772 patients [94][95][96][97][98] , found significant association between PPI and the development of SBP in patients with cirrhosis (odds ratio 2.77, 95%CI: 1.82-4.23). However, a recent study suggests that even though PPIs may be a contributing factor, the predominant factor determining infection risk is the stage of the liver disease [99] .…”

Section: Secondary Prophylaxis In Patients With Prior Sbpmentioning

confidence: 99%

Diagnosis and management of bacterial infections in decompensated cirrhosis

Pleguezuelo

Benítez²,

Jurado³

et al. 2013

WJH

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Bacterial infections are one of the most frequent complications in cirrhosis and result in high mortality rates. Patients with cirrhosis have altered and impaired immunity, which favours bacterial translocation. Episodes of infections are more frequent in patients with decompensated cirrhosis than those with compensated liver disease. The most common and life-threatening infection in cirrhosis is spontaneous bacterial peritonitis followed by urinary tract infections, pneumonia, endocarditis and skin and soft-tissue infections. Patients with decompensated cirrhosis have increased risk of developing sepsis, multiple organ failure and death. Risk factors associated with the development of infections are severe liver failure, variceal bleeding, low ascitic protein level and prior episodes of spontaneous bacterial peritonitis (SBP). The prognosis of these patients is closely related to a prompt and accurate diagnosis. An appropriate treatment decreases the mortality rates. Preventive strategies are the mainstay of the management of these patients. Empirical antibiotics should be started immediately following the diagnosis of SBP and the first-line antibiotic treatment is third-generation cephalosporins. However, the efficacy of currently recommended empirical antibiotic therapy is very low in nosocomial infections including SBP, compared to community-acquired episodes. This may be associated with the emergence of infections caused by Enterococcus faecium and extended-spectrum β-lactamaseproducing Enterobacteriaceae, which are resistant to the first line antimicrobial agents used for treatment. The emergence of resistant bacteria, underlines the need to restrict the use of prophylactic antibiotics to patients with the greatest risk of infections. Nosocomial infections should be treated with wide spectrum antibiotics. Further studies of early diagnosis, prevention and treatment are needed to improve the outcomes in patients with decompensated cirrhosis.

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“…Numerous studies have suggested that PPI use by cirrhotic patients may increase the risk of SBP (Bajaj et al, 2009;de Vos et al, 2013;Min et al, 2014;Ratelle et al, 2014). However, some studies have drawn opposite conclusions (Campbell et al, 2008;Aditi et al, 2012;Terg et al, 2012;van Vlerken et al, 2012).…”

Section: Introductionmentioning

confidence: 99%

Proton pump inhibitor use and risk of spontaneous bacterial peritonitis in cirrhotic patients: a systematic review and meta-analysis

et al. 2015

Genet. Mol. Res.

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ABSTRACT. We used a meta-analysis approach to investigate the association between proton pump inhibitor (PPI) use and risk of spontaneous bacterial peritonitis (SBP) in cirrhotic patients. We searched Ovid Medline, Embase, and the Cochrane Library to identify eligible studies. We included studies that compared cirrhotic patients who did or did not use PPIs. The primary outcome was SBP, and the secondary outcome was overall bacterial infection. Results were pooled using random-effect models. This process led to identification of 12 journal articles and 5 conference abstracts. The pooled data showed that PPI use in patients with cirrhosis and ascites was significantly associated with an increased risk of SBP [odds ratio (OR) = 2.17; 95% confidence interval (CI) = 1.46-3.23; P < 0.05; I 2 = 85.6%] and overall risk of bacterial infection (OR = 1.98; 95%CI = 1.36-2.87; P < 0.05; I 2 = 0). Subgroup analysis revealed that journal articles and studies reporting adjusted effect estimates demonstrated that PPI users had a significantly increased risk of SBP (OR = 2.13; 95%CI = 1.61-2.82; P < 0.05; I 2 = 29.4%; and OR = 1.98; 95%CI = 1.42-2.77; P < 0.05; I 2 = 67%, respectively). In conclusion, PPI use increased the risk of SBP and overall bacterial infection in patients with cirrhosis and ascites. PPIs should be administered after careful assessment of the indications in cirrhotic patients. Future well-designed prospective studies are warranted to clarify the dose relationships and to compare infection risks associated with different classes of PPIs.

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Association between Proton Pump Inhibitor Use and Spontaneous Bacterial Peritonitis

Cited by 75 publications

References 29 publications

The impact of proton-pump inhibitors on intraperitoneal sepsis: a word of caution for transgastric NOTES procedures

The impact of proton-pump inhibitors on intraperitoneal sepsis: a word of caution for transgastric NOTES procedures

Diagnosis and management of bacterial infections in decompensated cirrhosis

Proton pump inhibitor use and risk of spontaneous bacterial peritonitis in cirrhotic patients: a systematic review and meta-analysis

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