Continuous Proton Pump Inhibitor Therapy and the Associated Risk of Recurrent Clostridium difficile Infection
Continuous Proton Pump Inhibitor Therapy and the Associated Risk of Recurrent Clostridium difficile Infection
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DOI：
10.1001/jamainternmed.2015.42
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发表时间：
2015-05-01
影响因子：
39
通讯作者：
Lee, Todd C.
中科院分区：
文献类型：
--
作者：
McDonald, Emily G.;Milligan, Jonathon;Lee, Todd C.
艰难梭菌感染（CDI）与显著的发病率、死亡率和高复发风险相关。质子泵抑制剂（PPI）的使用与CDI的初始发作有关，PPI经常被过量使用。对于许多人来说，在CDI复发之前可能会停止使用PPIs。目的：确定使用PPI是否与初始CDI复发风险相关，评估发生CDI的患者因非循证指征而服用PPI的比例，并评估医生是否在CDI的情况下停止使用不必要的PPI。设计、环境和参与者：我们对医疗相关CDI病例进行了回顾性队列研究，以确定持续使用PPI与90天内CDI复发之间的关系。实验环境是两所大学附属医院，417个床位的蒙特利尔总医院（加拿大魁北克省蒙特利尔）和517个床位的皇家维多利亚医院（加拿大魁北克省蒙特利尔）。该队列包括754名在2010年1月1日至2013年1月30日期间发生医疗保健相关CDI的患者，这些患者在首次院内CDI发作后至少存活了15天。持续使用PPI。主要结局和测量方法CDI在首发后15 - 90天内复发。结果：使用多变量Cox比例风险模型，75岁以上患者复发的原因特异性风险比为1.5 (95% CI, 1.1-2.0)，持续使用PPI的患者复发的原因特异性风险比为1.5 (95% CI, 1.1-2.0)，住院时间的复发风险比为1.003 (95% CI, 1.002-1.004) /天，抗生素再暴露的复发风险比为1.3 （95% CI, 0.9-1.7）。PPIs的使用很常见（60.7%），只有47.1%的患者有循证指征。只有3例CDI患者停用质子泵抑制剂。在校正了其他独立的复发预测因素后，持续使用PPI的患者CDI复发的风险仍然升高。我们建议在CDI诊断时应考虑停止不必要的PPI使用。
IMPORTANCE Clostridium difficile infection (CDI) is associated with significant morbidity, mortality, and a high risk of recurrence. Proton pump inhibitor (PPI) use is associated with an initial episode of CDI, and PPIs are frequently overprescribed. For many, the use of PPIs could likely be discontinued before CDI recurrence.OBJECTIVES To determine whether PPI use was associated with a risk of initial CDI recurrence, to assess what proportion of patients who developed CDI were taking a PPI for a non-evidence-based indication, and to evaluate whether physicians discontinued unnecessary PPIs in the context of CDI.DESIGN, SETTING, AND PARTICIPANTS We conducted a retrospective cohort study of incident health care-associated CDI cases to determine the association between continuous PPI use and CDI recurrence within 90 days. The setting was 2 university-affiliated hospitals, the 417-bed Montreal General Hospital (Montreal, Quebec, Canada) and the 517-bed Royal Victoria Hospital (Montreal, Quebec, Canada). The cohort consisted of 754 patients who developed health care-associated CDI between January 1, 2010, and January 30, 2013, and who survived for a minimum of 15 days after their initial episode of nosocomial CDI.EXPOSURE Continuous PPI use.MAIN OUTCOMES AND MEASURES Recurrence of CDI within 15 to 90 days of the initial episode.RESULTS Using a multivariable Cox proportional hazards model, the cause-specific hazard ratios for recurrence were 1.5 (95% CI, 1.1-2.0) for age older than 75 years, 1.5 (95% CI, 1.1-2.0) for continuous PPI use, 1.003 (95% CI, 1.002-1.004) per day for length of stay, and 1.3 (95% CI, 0.9-1.7) for antibiotic reexposure. The use of PPIs was common (60.7%), with only 47.1% of patients having an evidence-based indication. Proton pump inhibitors were discontinued in only 3 patients with CDI.CONCLUSIONS AND RELEVANCE After adjustment for other independent predictors of recurrence, patients with continuous PPI use remained at elevated risk of CDI recurrence. We suggest that the cessation of unnecessary PPI use should be considered at the time of CDI diagnosis.