Guidelines for proton pump inhibitor prescriptions in paediatric intensive care unit

Proton Pump Inhibitor Use and Associated Infectious Complications in the PICU: Propensity Score Matching Analysis

OBJECTIVES

We aimed to evaluate the association between proton pump inhibitor (PPI) exposure and nosocomial infection (NI) during PICU stay.

DESIGN

Propensity score matched analysis of a single-center retrospective cohort from January 1, 2017, to December 31, 2018.

SETTING

Tertiary medical and surgical PICU in France.

PATIENTS

Patients younger than 18 years old, admitted to the PICU with a stay greater than 48 hours.

INTERVENTION

Patients were retrospectively allocated into two groups and compared depending on whether they received a PPI or not.

MEASUREMENTS AND MAIN RESULTS

Seven-hundred fifty-four patients were included of which 231 received a PPI (31%). PPIs were mostly used for stress ulcer prophylaxis (174/231; 75%), but upper gastrointestinal bleed risk factors were rarely present (18%). In the unadjusted analyses, the rate of NI was 8% in the PPI exposed group versus 2% in the nonexposed group. After propensity score matching ( n = 184 per group), we failed to identify an association between PPI exposure and greater odds of NI (adjusted odds ratio 2.9 [95% CI, 0.9-9.3]; p = 0.082). However, these data have not excluded the possibility that there is up to nine-fold greater odds of NI.

CONCLUSIONS

This study highlights the prevalent use of PPIs in the PICU, and the potential association between PPIs and nine-fold greater odds of NI is not excluded.

Stress ulcer prophylaxis for critically ill children: routine use needs to be re-examined

INTRODUCTION

Stress ulcer prophylaxis (SUP) is commonly used in Paediatric Intensive Care Units (PICUs). However, strong evidence for this practice is lacking and there is a dire need for paediatric randomized controlled trials (RCTs). Our aim was to assess the usefulness of SUP with omeprazole in critically ill children.

PATIENTS AND METHODS

We conducted a randomized, controlled open-label trial, including 144 children admitted into a PICU with a paediatric Sequential Organ Failure Assessment (pSOFA) score of less than 16. We randomly allocated patients to SUP with omeprazole or no SUP. The primary outcome was development of upper gastrointestinal bleeding or nosocomial infection.

RESULTS

The incidence of gastrointestinal bleeding was 27.1%, but clinically significant bleeding developed in only 5.6% of patients. We did not find a significant difference in the incidence of bleeding between the prophylaxis and control groups (27.8% vs 26.4%; P = .85). We also did not find a significant difference between the groups in the incidence of ventilator-associated pneumonia (VAP) (9.6% vs 8.3%; P = .77). The incidence of central line-associated bloodstream infection (CLABSI) was higher in the prophylaxis group compared to the control group (30.6% vs 12.5%; P = .014). None of the patients developed Clostridium difficile-associated diarrhoea. We did not find significant differences in mortality, length of PICU stay or duration of mechanical ventilation. Mechanical ventilation was an independent predictor of bleeding (OR, 6.4; 95%CI, 2.73-14.9).

CONCLUSION

In PICU patients with mild to moderate organ dysfunction, omeprazole does not seem to be useful for prevention of gastrointestinal bleeding while at the same time increasing the risk of CLABSI. Thus, we recommend restricting SUP to mechanically ventilated children.

A Narrative Review on Efficacy and Safety of Proton Pump Inhibitors in Children

Proton pump inhibitors (PPIs) are among the most prescribed drugs worldwide and include omeprazole, esomeprazole, lansoprazole, pantoprazole, and rabeprazole. Their use in pediatrics is approved for children older than 1 year, for the short-term treatment of symptomatic gastroesophageal reflux disease (GERD), healing of erosive esophagitis, treatment of peptic ulcer disease, and eradication of Helicobacter pylori. PPIs are also considered the standard of care for pediatric eosinophilic esophagitis. Despite the strict range of indications, the use of this class of molecules has increased in all pediatric age ranges. The long-term gastric acid suppression in children has been linked to increased risks of gastrointestinal and lower respiratory tract infections, bone fractures, and allergy. This study aims to provide a comprehensive overview of the mechanism of actions, use (and misuse) in infants and children, and safety of PPIs.

Adverse reactions related to proton pump inhibitors in pediatric population: an analysis of spontaneous reporting data

BACKGROUND

The use of proton pump inhibitors (PPIs) has increased in the last 10 years in children. Data regarding their safety profile are limited. The aim of this study was to analyze data from the Italian spontaneous reporting system (SRS) database to evaluate the incidence and characteristics of PPI-related adverse drug reactions (ADRs) in children.

RESEARCH DESIGN AND METHODS

This was an observational, retrospective study analyzing PPI-related ADR reports in children in the Italian SRS database between January 1^st, 2001, and December 31^st, 2020. ADRs were coded according to the system organ class term level. Factors associated with ADR seriousness were investigated.

RESULTS

Seventy spontaneous reports of ADRs related to PPIs were analyzed. Esomeprazole and lansoprazole caused the highest number of ADRs equally (27% respectively), and the most frequently reported ADRs presented with gastrointestinal (24%) and/or skin manifestations (21.3%). More than a half of PPI prescriptions were off label for pediatric population. Serious ADRs were 19 (27.1%). Serious ADRs were more frequent in reports presenting PPIs combined with other drugs in comparison to reports with PPI single therapies (p = 0.03).

CONCLUSIONS

PPI-related ADRs in children are mostly not serious, and combination therapy seems to be associated with ADR seriousness.

Development of an evaluation indicator system for the rational use of proton pump inhibitors in pediatric intensive care units: An application of Delphi method

Proton pump inhibitors are frequently used to prevent gastrointestinal bleeding in critically ill patients. But there is little information in the instructions about the usages for children. It is important to monitor the appropriate use of proton pump inhibitors, especially in pediatrics. Therefore, we developed an evaluation indicator system for the rational use of proton pump inhibitors in pediatric intensive care units.First, a systematic review was conducted to developed the initial indicators. Then 2 rounds of Delphi surveys were conducted to collecting opinions from a panel of independent experts, and the indicator system was modified to form the final indicators according to the opinions. Finally, the analytic hierarchy procedure was used to determine the weight of each indicator.A total of 6 guidelines and 2 studies met the inclusion and exclusion criteria. Based on literature and discussion among experts, an initial indicator system including 4 first-rank indicators and 12 second-rank indicators was formed. After 2 rounds of Delphi surveys, 2 indicators were added, 5 indicators were deleted, and 1 indicator was revised, so the final indicator system contained a total of 13 indicators including 3 first-rank indicators (drug selection, drug usage and dosage, duration of drug therapy) and 10 second-rank indicators (the proportion of PPIs used in children, children under 1 year old, children who is using glucocorticoids, children with nonsteroidal anti-inflammatory drugs, children with gastroesophageal reflux disease, children with sepsis, children with ventilators in PICU; the strength of PPIs' use, the proportion of omeprazole in children using PPIs during the same period; the average days of PPIs used in children). By analyzing scores, all coefficients met the standard, indicating the indicators were scientific and credible.Through a two-round Delphi survey, 3 first-rank indicators and ten second-rank indicators were developed, which will help drug administrative departments to promote the rational use of PPIs for children in PICUs. What is more, our study can constitute a methodological reference for the development of other indicator systems.

[Stress ulcer prophylaxis for critically ill children: Routine use needs to be re-examined]

INTRODUCTION

Stress ulcer prophylaxis (SUP) is commonly used in Paediatric Intensive Care Units (PICUs). However, strong evidence for this practice is lacking and there is a dire need for paediatric randomized controlled trials (RCTs). Our aim was to assess the usefulness of SUP with omeprazole in critically ill children.

PATIENTS AND METHODS

We conducted a randomized, controlled open-label trial, including 144 children admitted into a PICU with a paediatric Sequential Organ Failure Assessment (pSOFA) score of less than 16. We randomly allocated patients to SUP with omeprazole or no SUP. The primary outcome was development of upper gastrointestinal bleeding or nosocomial infection.

RESULTS

The incidence of gastrointestinal bleeding was 27.1%, but clinically significant bleeding developed in only 5.6% of patients. We did not find a significant difference in the incidence of bleeding between the prophylaxis and control groups (27.8 vs. 26.4%; p = 0.85). We also did not find a significant difference between the group in the incidence of ventilator-associated pneumonia (VAP) (9.6 vs. 8.3%; p = 0.77). The incidence of central line-associated bloodstream infection (CLABSI) was higher in the prophylaxis group compared to the control group (30.6% vs. 12.5%; p = 0.014). None of the patients developed Clostridium difficile-associated diarrhoea. We did not find significant differences in mortality, length of PICU stay or duration of mechanical ventilation. Mechanical ventilation was an independent predictor of bleeding (OR 6.4; 95% CI, 2.73-14.9).

CONCLUSION

In PICU patients with mild to moderate organ dysfunction, omeprazole does not seem to be useful for prevention of gastrointestinal bleeding while at the same time increasing the risk of CLABSI. Thus, we recommend restricting SUP to mechanically ventilated children.

[Proton pump inhibitors in pediatrics: Review of the prescriptions' relevance for hospitalised children in a university hospital]

INTRODUCTION

Proton Pump Inhibitors (PPIs) are a pharmacological class designed to reduce the acidity of gastric secretions. They are prescribed for 11 % of the children in our institution.

AIMS

To assess the relevance of PPI prescriptions in pediatrics.

MATERIAL AND METHOD

A clinical audit according to the methodology proposed by the High Authority of Health was carried out between August 27 and August 31, 2018 in the pediatric departments of our institution. The main judgement criteria were the indication of the PPI. The main guidelines are the recommendations of the European society of pediatric gastroenterology, hepatology and nutrition.

RESULTS

Thirty patients were included. The average age was 8.6 years. The indication was compliant in 19 patients. The non-compliant indications were: two ulcer risk preventions related to the prescription of non-steroidal anti-inflammatory drugs (NSAIDs), one endoscopic biopsy, four ulcer risk preventions related to corticosteroid therapy, one hematopoietic stem cell transplantation and three mucositis.

DISCUSSION

The sample of patients included in the study was representative of the pediatric population with PPIs in our institution. The non-conformities identified could be justified in some cases. Only one study reported a compliance rate for PPI indications in pediatrics in the literature. This rate, in the order of 34 %, was much lower than that found in our institution (P<0.01).

CONCLUSION

The respect of the latest recommendations for the prescription of PPIs is quite good. A usage sheet will be diffused to improve the practices.

A retrospective study on prescribing pattern and cost analysis of proton-pump inhibitors used among adults of Saudi Arabia

Objective

To evaluate the use of proton-pump inhibitors (PPIs) for treatment of different gastric disease in Saudi population and their related administration cost.

Materials and methods

It was a cross-sectional retrospective drug utilization study. The utilization rates and cost analysis of each PPIs class of drugs were compared. Study data were obtained from pharmacy database. Data between 1 January 2019 and 31 December 2019 were investigated, including incidence, prevalence and duration of use of proton-pump inhibitors among adults of Saudi Arabia.

Key findings

We observed 26 798 (4.27%) prescription of PPIs were dispensed in the in-patient and out-patient pharmacy department of Al-Mana Group of Hospital (AGH) Al khobar. Among all the PPIs user, more than the half ((53.01%, n = 14 208), 95% CI (52.42–53.62)) were male. 30–40 years age patients (24.57%, 95% CI (24.06–25.09) (n = 6585)) were highest number of PPI users. Nearly, equal number of PPI users belongs between 51–60 years ((20.88%, n = 5596), 95% CI (20.40–21.37)) and &gt;60 years ((20.36%, n = 5456), 95% CI (19.8–20.85)). Among all the dispensed PPIs drugs, Pantoprazole is dispensed to the highest number of patients (79.09% (95% CI, 78.61–79.58) (n = 21 197)) while their average duration of therapy was 18.86 days. Among all PPIs, pantoprazole average unit wise cost was highest SR 8.83 (USD 2.35) in comparison to other PPIs.

Conclusion

In our study, among all the PPIs Pantoprazole was prescribed to the highest number of patients also it was costliest; hence, their safe and effective use must be warranted. Current study will also help in to develop nation database regarding utilization of proton-pump inhibitors.

Natural history of gastroesophageal reflux in infancy: new data from a prospective cohort

Background

Gastroesophageal reflux (GER) is common in infants. Gastroesophageal reflux disease (GERD) is defined as GER leading to troublesome symptoms that affect daily functioning and/or complications. This study is aimed at determining the prevalence and progression of GER and GERD in a cohort of healthy term infants from birth to 12 months old.

Methods

We conducted a prospective cohort study including all full-term living neonates born at Besançon Teaching Hospital, France. Parents completed a clinical report form and the Infant Gastroesophageal Reflux Questionnaire-Revised (I-GERQ-R) at 1, 3, 6, 10, and 12 months of age. GER was defined as score ≥ 1 to the first question with I-GERQ-R score < 16, and GERD as score ≥ 1 to the first question with I-GERQ-R score ≥ 16. Regurgitation was based on the answer to the first question of the I-GERQ-R as anything coming out of the mouth daily.

Results

157/347 births were included (83 boys). The prevalence of regurgitation at least once a day was 45.7% overall. In total: 72, 69, 56, 18, and 13% of infants regurgitated at least once a day at 1, 3, 6, 10, and 12 months of age, respectively. Physiological GER affected 53, 59, 51, 16, and 12% of infants; GERD, 19, 9, 5, 2, and 2%, respectively. Two risk factors were identified: family history of GER and exposure to passive smoking. Treatment included dietary modification (14%) and pharmacotherapy (5%).

Conclusion

Physiological GER peaked at 3 months, GERD at 1 month. Most cases resolved on their own. GER and GERD are very common in the infant’s population and parents should be reassured/educated regarding symptoms, warning signs, and generally favorable prognosis. I-GERQ-R is useful to the clinical screening and follow up for GER and GERD.

Non-indicated acid-suppression prescribing in a tertiary paediatric hospital: An audit and costing study

AIM

To quantify (i) indicated versus non-indicated prescribing of acid-suppression therapies (AST) in a tertiary paediatric hospital; (ii) patient, provider and hospital factors associated with non-indicated prescribing; and (iii) medication costs.

METHODS

This was a prospective, electronic medical audit conducted at The Royal Children's Hospital (RCH) Melbourne in August-September 2016. Proton pump inhibitor (PPI) and histamine-2 receptor antagonist (H₂ RA) prescriptions were extracted, with relevant patient, provider and hospital data. Logistic regression analysis of variables associated with indicated and non-indicated prescribing was undertaken. Costs of indicated and non-indicated prescriptions were estimated, with annual costs projected.

RESULTS

There was more non-indicated than indicated prescribing across inpatient, outpatient and emergency department settings. Of the total 303 prescriptions analysed, 238 (78.5%) were non-indicated. Gastrostomy presence (odds ratio (OR) 5.51 (1.96-15.46), P = 0.001), consultant providers (OR 2.69 (1.23-5.87), P = 0.01) and inpatient setting (OR 2.35 (1.16-4.77), P = 0.02) were all associated with a higher likelihood of non-indicated prescribing. The child having a predisposing diagnosis was significantly associated with indicated prescribing (OR 0.41 (0.21-0.80), P = 0.009). A total of 75% of hospital and patient spending was for non-indicated prescriptions. Annual costs of non-indicated AST for Melbourne's RCH were projected to be $15 493.

CONCLUSIONS

Non-indicated acid-suppression prescribing is common in a tertiary paediatric hospital and associated with gastrostomy presence, consultant providers and inpatient status. Future research should use qualitative methods to understand clinician and patient drivers of prescribing and use this information to develop and test targeted solutions to reduce non-indicated AST prescribing.

Stress ulcer prophylaxis in children with status asthmaticus receiving systemic corticosteroids: a descriptive study assessing frequency of clinically important bleeding

Objective: To determine the frequency of clinically important bleeding (CIB) among children hospitalized for status asthmaticus with and without exposure to stress ulcer prophylaxis (SUP).Methods: We performed a single-center, retrospective cohort in 217 children admitted for asthma exacerbation aged 5-18 years from May 2015 to May 2017. We assessed cohorts with and without exposure to SUP to determine if differences in frequency of CIB exist. Study outcomes included frequency of CIB, gastrointestinal complications (occult bleeding, macroscopic bleeding, gastric perforation, and acquired gastritis), and SUP-related adverse events (ventilator associated pneumonia, C. difficile colitis, necrotizing enterocolitis, and acute thrombocytopenia).Results: Ninety-two (42%) children received SUP of which 82 were admitted to the pediatric intensive care unit (PICU). There were no differences in asthma severity or known risk factors for CIB in children with and without SUP in the PICU subcohort. We observed no CIB or SUP-related adverse events. Two subjects acquired gastritis in the no-SUP cohort and one additional subject experienced occult gastrointestinal bleeding with spontaneous symptom resolution.Conclusion: Children admitted for status asthmaticus with and without SUP had no observed incidence of CIB. In this specific population, we propose a prerequisite assessment for the presence of known stress ulcer related gastrointestinal bleeding risk factors prior to the blanket administration of SUP.