Impact of Stress Ulcer Prophylaxis Discontinuation Guidance in Mechanically Ventilated, Critically Ill Patients: A Pre-Post Cohort Study

Purpose: Recent data highlight unclear efficacy and potential negative sequelae of stress ulcer prophylaxis (SUP) in the intensive care unit (ICU). Minimizing SUP exposure has pertinent clinical and other implications. This study assessed medication use and clinical outcomes before and after implementation of a practice guideline promoting early discontinuation of SUP in mechanically ventilated ICU patients. Methods: Retrospective, single-center, pre-post cohort study within a medical ICU at a large, academic medical center. Adult patients requiring mechanical ventilation and receiving SUP via a histamine-2 receptor antagonist (H2RA) or proton pump inhibitor (PPI) were eligible for inclusion. The clinical practice guideline was implemented on January 1, 2020. The impact of implementation was assessed via percent of patient-days with inappropriate SUP. Incidence of clinically important GI bleed was the primary safety outcome. Results: A total of 137 pre-guideline and 112 post-guideline patients were included. Comorbidity burden was similar between groups. A higher prevalence of baseline vasopressor receipt (39% vs 67%, P < .01) and acute kidney injury (56% vs 69%, P = .04) was observed in post-guideline patients. Post-guideline patients experienced a significantly lower percentage of patient-days of inappropriate SUP (25% vs 50%, P < .01) as well as higher rates of SUP discontinuation before extubation (71% vs 12%, P < .01) and during ICU stay (93% vs 50%, P < .01). Post-guideline patients observed a significantly lower incidence of SUP at hospital discharge (4% vs 35%, P < .01). No differences in bleeding outcomes were observed, though post-guideline patients experienced longer durations of mechanical ventilation, ICU stay, and hospital stay. Conclusions: Implementation of an early SUP discontinuation guideline was associated with significant improvements in SUP prescribing practices. Baseline differences between groups likely explain observed differences in clinical outcomes.

Current Practice of Stress Ulcer Prophylaxis in Surgical Departments in Mecklenburg Western Pomerania, Germany

Background: Despite the growing concern over its potentially severe side effects and considerable economic burden, stress ulcer prophylaxis (SUP) is still frequently prescribed to patients in medical non-intensive care units. Recent data indicate that the situation is similar in surgical departments. Currently, data on the concepts within and regulation of routine SUP practice in surgical departments are sparse. The present study was designed to examine the current practice of SUP in Mecklenburg West Pomerania, Germany, and to identify possible reasons for the dissociation of medical literature and clinical practice. Methods: A questionnaire-based survey was conducted to elucidate current SUP practices in surgical departments of acute care hospitals in Mecklenburg Western Pomerania, Germany. Results: In most surgical departments (68%), a standard operating procedure (SOP) for SUP had not been developed. In departments with an existing SOP, 47.6% of responding medical staff members (MSM) with prescribing authority did not know of its existence. Of the MSMs aware of the existence of an SUP-SOP, only 42.9% indicated that they were familiar with its content. Critical re-evaluation of SUP indications upon transfer from the intensive care unit (ICU) to the general hospital ward (GHW) and before hospital discharge was performed frequently or systematically by only about half of the responding MSMs. Discussion: In the face of continued massive over-prescription of SUP in the perioperative routine, the development of easy-to-use local guidelines and their strict implementation in the clinical routine, as well as intensified medial education on this subject, may be effective tools to reduce acid-suppressive medication (ASM) associated side effects and economic burden.

Stress ulcer prophylaxis in the critically ill patients

Background Sfress Ulceration was an important cause of morbidity and mortality in critically ill patients. Early active treatment reduces the risk of clinically significant bleeding, ulcer prophylaxis therefore became a standard of care in all critically ill patients. Objective The overall aims of the Stress ulcer prophylaxis in the critically ill patients is to determine the benefits and risks of stress ulcer prophylaxis stress ulcer prophylaxis (SUP) in intensive care unit Materials and Methods We performed this systematic review and meta-analysis according to the recommendations of the Meta-analysis of Observational Studies in Epidemiology (MOOSE) statement and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. In the our systematic review and meta-analysis, we searched Medline via PubMed, CENTRAL, Web of Science, SCOPUS, and Google Scholar from March 1977 till August 2019. The search retrieved 2289 unique records. We then obtained 237 final results for full-text screening. At last, 28 recorded studies were involved in our in the present study. Results 23 included studies reported the rates of clinically important GI bleeding. The overall effect estimates favored SUP over control for decreasing the hazards of clinically significant GI hemorrhage (P value &lt;0.001, OR— 0.55, CI of 95%[0.35 0.86]). The overall effect estimates did not favor SUP over control for reducing the rate of death (P value =0.24, OR 1.21, 95% CI [0.87 — 1.69]). 23 studies reported the rates of pneumonia. The overall effect estimates showed that the SUP was not related to elevated hazards of nosocomial pneumonia over control (P value —0.15, OR —1.5, CI of 95% [0.83 3.02]). The analysis showed that only Cimetidine 900 mg was effective in reducing the incidence of clinically important GI bleeding (OR 0.45 [0.24, 0.82], p *0.009). In contrary, none of the included PPIs (pantoprazole, lansoprazole, omeprazole), ranitidine, or sucralfate were effective in reducing the incidence of clinically important GI bleeding. Conclusion SUP is associated with lower risk of GI bleeding in critically ill patients; however, the current published literature shows significant inconsistency. Our analysis showed that, no significant difference between H2RA and PPI in term of incidence of clinically important GI bleeding, H2RAs (mainly cimetidine) more effective than other classes of SUP which significantly reduced the risk of overt GI hemorrhage, and none of the drug classes was effective in reducing the mortality rates.

Comparison of proton pump inhibitors and histamine 2 receptor antagonists for stress ulcer prophylaxis in the intensive care unit

Proton pump inhibitors (PPIs), followed by histamine 2 receptor antagonists (H2RAs), are the most commonly used drugs to prevent gastrointestinal bleeding in critically ill patients through stress ulcer prophylaxis. The relative efficacy and drug-related adverse events of PPIs and H2RAs remain unclear. In this retrospective, observational, comparative cohort study, PPIs and H2RAs for stress ulcer prophylaxis in critically ill patients were compared using a common data model. After propensity matching, 935 patients from each treatment group (PPI or H2RA) were selected. The PPI group had a significantly higher 90-day mortality than the H2RA group (relative risk: 1.28; P = 0.01). However, no significant inter-group differences in the risk of clinically important gastrointestinal bleeding were observed. Moreover, there were no significant differences between the groups concerning the risk of pneumonia or Clostridioides difficile infection, which are known potential adverse events related to these drugs. Subgroup analysis of patients with high disease severity were consistent with those of the total propensity score-matched population. These findings do not support the current recommendations, which prefer PPIs for gastrointestinal bleeding prophylaxis in the intensive care unit.