Association of Proton Pump Inhibitor Therapy With Spontaneous Bacterial Peritonitis in Cirrhotic Patients With Ascites

• Published in: The American journal of gastroenterology Vol. 104; no. 5; pp. 1130 - 1134
• Main Authors: BAJAJ, Jasmohan S, ZADVORNOVA, Yelena, HEUMAN, Douglas M, HAFEEZULLAH, Muhammad, HOFFMANN, Raymond G, SANYAL, Arun J, SAEIAN, Kia
• Format: Journal Article
• Language: English
• Published: Basingstoke Nature Publishing Group 01-05-2009; Wolters Kluwer Health Medical Research, Lippincott Williams & Wilkins
• Subjects: Abdomen; Adult; Age Distribution; Aged; Ascites - epidemiology; Ascites - microbiology; Bacteremia - epidemiology; Bacteremia - microbiology; Biological and medical sciences; Case-Control Studies; Comorbidity; Confidence Intervals; Female; Gastroenterology; Gastroenterology. Liver. Pancreas. Abdomen; Gram-Negative Bacterial Infections - diagnosis; Gram-Negative Bacterial Infections - epidemiology; Gram-Positive Bacterial Infections - diagnosis; Gram-Positive Bacterial Infections - epidemiology; Humans; Incidence; Liver Cirrhosis - diagnosis; Liver Cirrhosis - drug therapy; Liver Cirrhosis - epidemiology; Liver. Biliary tract. Portal circulation. Exocrine pancreas; Logistic Models; Male; Medical sciences; Middle Aged; Odds Ratio; Other diseases. Semiology; Peritonitis - epidemiology; Peritonitis - microbiology; Peritonitis - therapy; Probability; Prognosis; Proton Pump Inhibitors - adverse effects; Proton Pump Inhibitors - therapeutic use; Retrospective Studies; Risk Assessment; Severity of Illness Index; Sex Distribution; Survival Analysis; Human; Effusion; Spontaneous; Hepatic disease; Proton pump inhibitor; Infection; Cirrhosis; Treatment; Abdominal disease; Gastroenterology; Bacteriosis; Digestive diseases; Ascites; Peritonitis
• ISSN: 0002-9270; 1572-0241
• DOI: 10.1038/ajg.2009.80

Spontaneous bacterial peritonitis (SBP) is a frequent complication of cirrhosis. Bacterial contamination of ascites fluid leading to SBP is caused by bacterial translocation with subsequent bacteremia. Proton pump inhibitors (PPIs) suppress gastric acid secretion, allowing bacterial colonization of the upper gastrointestinal tract, and may predispose to bacterial overgrowth and translocation. The aim of this study was to determine whether PPI use in cirrhotics with ascites is associated with SBP.
A retrospective case-control study was performed. Seventy cirrhotics admitted with paracentesis-proven SBP between 2002 and 2007 were matched 1:1 (for age and Child's class) with comparable cirrhotics with ascites who were admitted for conditions other than SBP. We excluded patients on chronic antibiotic prophylaxis or with antecedent gastrointestinal bleeding. Outpatient PPI use at the time of admission was compared between groups, and the effect of covariates was analyzed.
Patients with SBP had a significantly higher rate of prehospital PPI use (69%) compared with ascitic cirrhotics hospitalized without SBP (31%, P = 0.0001). There was no significant difference in demographics, diabetes, etiology, or survival between groups. On multivariate analysis, PPI use was independently associated with SBP (odds ratio (OR) 4.31, confidence interval (CI) 1.34-11.7), and ascitic fluid protein was protective (OR 0.1, CI 0.03-0.25). In total, 47% of cirrhotic patients receiving PPI in this study had no documented indication for PPI treatment.
PPI therapy is associated with SBP in patients with advanced cirrhosis. Prospective studies are needed to determine whether PPI avoidance can reduce the incidence of SBP and improve outcomes.