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PPI use independently associated with rectal carriage of ESBL-E
Use of proton pump inhibitors was independently associated with rectal carriage of extended-spectrum beta-lactamase–producing Enterobacteriaceae, or ESBL-E, among patients upon admission to a hospital in the Netherlands.
“The use of medication that neutralizes or reduces the production of gastric acid has been shown to increase the risk of gastrointestinal infections,” researchers wrote in Clinical Infectious Diseases. “Whether the use of such medication is associated with an increase in ESBL-E rectal carriage is less clear, and studies have reported conflicting results. The objective of this cross-sectional study was, therefore, to assess the association between [proton pump inhibitors (PPI)] use and ESBL-E rectal carriage at hospital admission.”
The researchers analyzed voluntary prevalence surveys performed in November 2014 and November 2015 as part of a routine infection control program at Amphia Hospital, an 850-bed teaching hospital in Breda, the Netherlands, including only adult patients who were hospitalized no longer than 2 days. Preadmission use of PPIs was determined using electronic medical records and verified on day of admission by an assistant pharmacist.
According to the researchers, univariable and multivariable logistic regression determined whether PPI use was independently associated with ESBL-E rectal carriage.
“Based on the available literature on ESBL-E carriage and PPI use, age, antibiotic use on the day of culture, and hospital admission within the 6 months prior to the current hospital admission were included as potential confounding variables in the logistic regression analysis,” they wrote.
Among the 570 patients with valid rectal cultures, 259 used PPIs on admission. Of those, 8.5% were rectal carriers of ESBL-E compared with 2.9% of non-PPI users. In the univariable model, PPI use was statistically significantly associated with rectal carriage of ESBL-E, the researchers noted (OR = 3.12; 95% CI, 1.41-6.89).
“In conclusion, we found that PPI use is associated with ESBL-E rectal carriage at hospital admission,” the researchers wrote. “Prospective studies are warranted to further elucidate the role of PPI use in the acquisition of ESBL-E rectal carriage and may provide insight into the effect of different PPIs or dosage schedules.” – by Gerard Gallagher
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Jason Burnham
In this interesting cross-sectional study from the Netherlands, Huizinga and colleagues elucidate another risk factor for acquisition of intestinal ESBL carriage — proton pump inhibitor (PPI) use. PPIs have previously been vilified for their association with infections, including Clostridium difficile, Listeria monocytogenes, bacterial gastroenteritis, Salmonella typhimurium, Salmonella enteritidis, Campylobacter jejuni, and Giardia lamblia, to name a few. With these studies as a precedent, it is not surprising that Huizinga and colleagues found that PPI use was associated with intestinal ESBL carriage.
Unfortunately, the study authors did not have recent antibiotic exposure data or travel histories available, which are potential confounders for ESBL carriage. Regardless, the findings are biologically plausible and important from an infection prevention perspective in an era of uncertainty about who to screen for intestinal ESBL carriage. In addition, intestinal carriage of multidrug-resistant bacteria is a known risk factor for future multidrug-resistant infections. Identifying PPI use in patients admitted with infections may alter empiric antibiotic choices.
Multidrug-resistant pathogens in any part of the globe should be of concern to all nations, as the globetrotters among us take resistant bacteria from one nation to another. These bacteria are likely to set up reservoirs wherever the weary traveler lands, as they can persist in the gut for up to 1 year, and have a 12% chance of being passed on to household contacts. In addition to practicing antimicrobial stewardship to prevent the emergence of multidrug resistance, it seems prudent that we practice PPI stewardship given the risks of prolonged therapy and the paucity of indications for prolonged PPI use.
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Disclosure: Burnham reports no relevant financial disclosures.