Archief Roodbont

Lately, proton-pump inhibitor (PPI) use has attracted considerable attention for some possible untoward consequences, including excess risk for several conditions (pneumonia, Clostridium difficile-associated disease, and fractures) and lowered efficacy of concurrent clopidogrel. Now, a retrospective case-control study suggests an association with spontaneous bacterial peritonitis (SBP) in hospitalized patients with cirrhosis and ascites.

Seventy patients with SBP were matched by age and Child’s class to 70 patients without SBP. The prevalence of prehospital use of PPIs was much higher in the SBP group than in the control group (69% vs. 31%). Significantly heightened risk with PPI use persisted in multivariate analysis (odds ratio for association between PPI use and SBP, 4.3). Chart reviews suggested that half the patients who received PPIs (in either group) had no indication for these drugs.

Comment: The difference in PPI use between patients with and without SBP was striking in this study. A proposed mechanism is that, by weakening the acid barrier to gastrointestinal colonization by orally ingested bacteria, PPIs abet bacterial overgrowth, translocation of bacteria across the intestinal wall, bacteremia, and seeding of ascitic fluid. Although case-control studies don’t establish cause and effect, limiting use of PPIs to valid indications makes sense in all patients, including those with cirrhosis and ascites.

— Allan S. Brett, MD

Published in Journal Watch General Medicine May 19, 2009