Iatrogenic Gastric Acid Suppression and the Risk of Nosocomial Clostridium difficile Infection
Iatrogenic Gastric Acid Suppression and the Risk of Nosocomial Clostridium difficile Infection
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DOI：
10.1001/archinternmed.2010.89
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发表时间：
2010-05-10
影响因子：
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通讯作者：
Talmor, Daniel
中科院分区：
文献类型：
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作者：
Howell, Michael D.;Novack, Victor;Talmor, Daniel
背景：艰难梭菌感染的发生率和严重程度都在增加。抑酸治疗被认为是难辨梭菌的危险因素，但这仍然存在争议。方法：我们进行了一项药物流行病学队列研究，对一家三级医疗中心5年期间101796例出院患者的前瞻性数据进行了二次分析。主要暴露于抑酸治疗，根据所接受的最强抑酸治疗进行分类(无酸抑制，组胺（2)受体拮抗剂[H(2)RA]治疗，每日质子泵抑制剂[PPI]， PPI频率高于每日）。结果：随着抑酸水平的提高，院内难辨梭菌感染的风险增加，从未接受抑酸治疗的患者的0.3%(95%可信区间[CI]， 0.21%-0.31%)，到接受H(2)RA治疗的患者的0.6% (95% CI, 0.49%-0.79%)，到每天接受PPI治疗的患者的0.9% (95% Cl, 0.80%-0.98%)，以及接受更频繁PPI治疗的患者的1.4%（1.15%-1.71%）。在对合并症、年龄、抗生素和基于接受抑酸治疗可能性的倾向评分进行调整后，这种关联仍然存在，比值比从1（无抑酸[文献]）增加到1.53 (95% Cl, 1.12-2.10) (H(2)RA)，增加到1.74 (95% Cl, 1.39-2.18)（每日PPI），增加到2.36(95% Cl, 1.79-3.11)（更频繁的PPI）。匹配的队列分析和嵌套病例对照技术也发现了类似的估计。结论：药理学抑酸水平的增加与院内难辨梭菌感染的风险增加有关。这一剂量反应效应的证据进一步支持了医源性酸抑制在院内难辨梭菌感染发展中的潜在因果性质。高级实习医师，2010；170 (9): 784 - 790
Background: The incidence and severity of Clostridium difficile infections are increasing. Acid-suppressive therapy has been suggested as a risk factor for C difficile, but this remains controversial.Methods: We conducted a pharmacoepidemiologic cohort study, performing a secondary analysis of data collected prospectively on 101 796 discharges from a tertiary care medical center during a 5-year period. The primary exposure of interest was acid suppression therapy, classified by the most intense acid suppression therapy received (no acid suppression, histamine(2)-receptor antagonist [H(2)RA] therapy, daily proton pump inhibitor [PPI], and PPI more frequently than daily).Results: As the level of acid suppression increased, the risk of nosocomial C difficile infection increased, from 0.3% (95% confidence interval [CI], 0.21%-0.31%) in patients not receiving acid suppressive therapy to 0.6% (95% CI, 0.49%-0.79%) in those receiving H(2)RA therapy, to 0.9% (95% Cl, 0.80%-0.98%) in those receiving daily PPI treatment, and to 1.4% (1.15%-1.71%) in those receiving more frequent PPI therapy. After adjustment for comorbid conditions, age, antibiotics, and propensity score based likelihood of receipt of acid-suppression therapy, the association persisted, increasing from an odds ratio of 1 (no acid suppression [reference]) to 1.53 (95% Cl, 1.12-2.10) (H(2)RA), to 1.74 (95% Cl, 1.39-2.18) (daily PPI), and to 2.36(95% Cl, 1.79-3.11) (more frequent PPI). Similar estimates were found with a matched cohort analysis and with nested case-control techniques.Conclusions: Increasing levels of pharmacologic acid suppression are associated with increased risks of nosocomial C difficile infection. This evidence of a dose-response effect provides further support for the potentially causal nature of iatrogenic acid suppression in the development of nosocomial C difficile infection. Arch Intern Med. 2010;170(9):784-790