连续质子泵抑制剂治疗与复发性艰难梭菌感染的相关风险。

Continuous Proton Pump Inhibitor Therapy and the Associated Risk of Recurrent Clostridium difficile Infection.

机构信息

Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada2McGill Centre for Quality Improvement, Montreal, Quebec, Canada.

Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

出版信息

JAMA Intern Med. 2015 May;175(5):784-91. doi: 10.1001/jamainternmed.2015.42.

DOI:10.1001/jamainternmed.2015.42

PMID:25730198

Abstract

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.

摘要

重要性

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，并且 PPI 经常被过度开处方。对于许多人来说，在 CDI 复发之前，可能可以停止使用 PPI。

目的

确定 PPI 的使用是否与初始 CDI 复发的风险相关，评估在发生 CDI 的患者中有多少人正在使用 PPI 进行无证据支持的治疗，以及评估医生在 CDI 发生时是否停止了不必要的 PPI 使用。

设计、地点和参与者：我们进行了一项回顾性队列研究，研究了与医疗保健相关的 CDI 病例，以确定连续使用 PPI 与 90 天内 CDI 复发之间的关联。该研究的地点是 2 家大学附属医院，即拥有 417 张床位的蒙特利尔总医院（加拿大魁北克省蒙特利尔市）和拥有 517 张床位的皇家维多利亚医院（加拿大魁北克省蒙特利尔市）。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，并且在首次发生医院获得性 CDI 后至少存活 15 天。

暴露

连续使用 PPI。

主要结局和测量指标

初始发作后 15 至 90 天内 CDI 的复发。

结果

使用多变量 Cox 比例风险模型，复发的特定病因风险比为：年龄大于 75 岁的患者为 1.5（95%CI，1.1-2.0），连续使用 PPI 的患者为 1.5（95%CI，1.1-2.0），住院时间每增加 1 天为 1.003（95%CI，1.002-1.004），抗生素再暴露的患者为 1.3（95%CI，0.9-1.7）。PPI 的使用很常见（60.7%），只有 47.1%的患者有基于证据的指征。在发生 CDI 的 3 名患者中停止了 PPI 的使用。