Adequacy of stress ulcer prophylaxis prescription in the intensive care unit: an observational study
Stress ulcer prophylaxis prescriptions might not be sufficiently challenged throughout a patient's stay in an intensive care unit (ICU) and might be erroneously maintained after ICU discharge. This study aimed to determine (1) stress ulcer prophylaxis adequacy in ICU and (2) the proportion of patients receiving inappropriate stress ulcer prophylaxis after ICU discharge.
MATERIAL AND METHODS
This was an observational, single centre study (University Hospital Lausanne, Switzerland). All patients without a previous indication for acid-suppressive therapy and admitted to our ICU for >24 hrs during a two-month period were included. The adequacy of stress ulcer prophylaxis prescriptions according to our guidelines was assessed. We then assessed stress ulcer prophylaxis prescriptions and their adequacy on ICU and hospital discharge, as well as the costs associated with inadequate prescription.
Of the 372 patients admitted during the study period, 140 (855 patient-days) fulfilled the inclusion criteria. Of these, 130 (92.9%) received stress ulcer prophylaxis in the ICU (796 [93.1%] patient-days). Stress ulcer prophylaxis consisted of esomeprazole in 686 (86.2%) patient-days. Overall, stress ulcer prophylaxis was inadequate in 558 (65.3%) patient-days, mostly because it was prescribed while not indicated (543 patient-days [63.5%]). On ICU discharge, stress ulcer prophylaxis prescription was inadequately maintained in 55 patients (51.9% of survivors). Similarly, stress ulcer prophylaxis was inadequately maintained on hospital discharge in 30 (28% of survivors) patients. We estimated the in-hospital cost of inadequate stress ulcer prophylaxis prescription as approximately CHF 2870 per year. Outpatient therapy maintenance would be associated with additional costs ranging from CHF 33,912 to 92,692 (EUR 31,832 to 87,012) for each additional year they receive the therapy, depending on the medication used.
The adequacy of stress ulcer prophylaxis in the ICU is low. In addition, the prescription is frequently continued after ICU and many patients are even discharged home with inadequate acid-suppressive therapy.
- Cook DJ, Griffith LE, Walter SD, Guyatt GH, Meade MO, Heyland DK, et al.; Canadian Critical Care Trials Group. The attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients. Crit Care. 2001;5(6):368–75. doi:.https://doi.org/10.1186/cc1071
- Marik PE, Vasu T, Hirani A, Pachinburavan M. Stress ulcer prophylaxis in the new millennium: a systematic review and meta-analysis. Crit Care Med. 2010;38(11):2222–8. doi:.https://doi.org/10.1097/CCM.0b013e3181f17adf
- Krag M, Perner A, Wetterslev J, Wise MP, Borthwick M, Bendel S, et al.; SUP-ICU co-authors. Prevalence and outcome of gastrointestinal bleeding and use of acid suppressants in acutely ill adult intensive care patients. Intensive Care Med. 2015;41(5):833–45. doi:.https://doi.org/10.1007/s00134-015-3725-1
- Cook DJ, Witt LG, Cook RJ, Guyatt GH. Stress ulcer prophylaxis in the critically ill: a meta-analysis. Am J Med. 1991;91(5):519–27. doi:.https://doi.org/10.1016/0002-9343(91)90189-5
- Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43(3):304–77. doi:.https://doi.org/10.1007/s00134-017-4683-6
- Farley KJ, Barned KL, Crozier TM. Inappropriate continuation of stress ulcer prophylaxis beyond the intensive care setting. Crit Care Resusc. 2013;15(2):147–51.
- MacLaren R, Reynolds PM, Allen RR. Histamine-2 receptor antagonists vs proton pump inhibitors on gastrointestinal tract hemorrhage and infectious complications in the intensive care unit. JAMA Intern Med. 2014;174(4):564–74. doi:.https://doi.org/10.1001/jamainternmed.2013.14673
- Charlot M, Grove EL, Hansen PR, Olesen JB, Ahlehoff O, Selmer C, et al. Proton pump inhibitor use and risk of adverse cardiovascular events in aspirin treated patients with first time myocardial infarction: nationwide propensity score matched study. BMJ. 2011;342(may11 1):d2690. doi:.https://doi.org/10.1136/bmj.d2690
- Sehested TSG, Gerds TA, Fosbøl EL, Hansen PW, Charlot MG, Carlson N, et al. Long-term use of proton pump inhibitors, dose-response relationship and associated risk of ischemic stroke and myocardial infarction. J Intern Med. 2018;283(3):268–81. doi:.https://doi.org/10.1111/joim.12698
- Tan B, Norman R, Litton E, Heath C, Hawkins DJ, Krishnamurthy R, et al. Incidence and cost of stress ulcer prophylaxis after discharge from the intensive care unit: a retrospective study. Crit Care Resusc. 2016;18(4):270–4.
- Pavlov A, Muravyev R, Amoateng-Adjepong Y, Manthous CA. Inappropriate discharge on bronchodilators and acid-blocking medications after ICU admission: importance of medication reconciliation. Respir Care. 2014;59(10):1524–9. doi:.https://doi.org/10.4187/respcare.02913
- Fumeaux T, Luca L. Top-9-liste de la SSMI: faire plus avec moins. Bull Med Suisses. 2017;40:1293–4.
- Farrell CP, Mercogliano G, Kuntz CL. Overuse of stress ulcer prophylaxis in the critical care setting and beyond. J Crit Care. 2010;25(2):214–20. doi:.https://doi.org/10.1016/j.jcrc.2009.05.014
- Thomas L, Culley EJ, Gladowski P, Goff V, Fong J, Marche SM. Longitudinal analysis of the costs associated with inpatient initiation and subsequent outpatient continuation of proton pump inhibitor therapy for stress ulcer prophylaxis in a large managed care organization. J Manag Care Pharm. 2010;16(2):122–9. doi:.https://doi.org/10.18553/jmcp.2010.16.2.122
- Alhazzani W, Alshamsi F, Belley-Cote E, Heels-Ansdell D, Brignardello-Petersen R, Alquraini M, et al. Efficacy and safety of stress ulcer prophylaxis in critically ill patients: a network meta-analysis of randomized trials. Intensive Care Med. 2018;44(1):1–11. doi:.https://doi.org/10.1007/s00134-017-5005-8
- Barletta JF, Bruno JJ, Buckley MS, Cook DJ. Stress Ulcer Prophylaxis. Crit Care Med. 2016;44(7):1395–405. doi:.https://doi.org/10.1097/CCM.0000000000001872
- Marker S, Krag M, Møller MH. What’s new with stress ulcer prophylaxis in the ICU? Intensive Care Med. 2017;43(8):1132–4. doi:.https://doi.org/10.1007/s00134-017-4733-0
- Bez C, Perrottet N, Zingg T, Leung Ki EL, Demartines N, Pannatier A. Stress ulcer prophylaxis in non-critically ill patients: a prospective evaluation of current practice in a general surgery department. J Eval Clin Pract. 2013;19(2):374–8. doi:.https://doi.org/10.1111/j.1365-2753.2012.01838.x
- Huang HB, Jiang W, Wang CY, Qin HY, Du B. Stress ulcer prophylaxis in intensive care unit patients receiving enteral nutrition: a systematic review and meta-analysis. Crit Care. 2018;22(1):20. doi:.https://doi.org/10.1186/s13054-017-1937-1
- Sridharan K, Sivaramakrishnan G, Gnanaraj J. Pharmacological interventions for stress ulcer prophylaxis in critically ill patients: a mixed treatment comparison network meta-analysis and a recursive cumulative meta-analysis. Expert Opin Pharmacother. 2018;19(2):151–8. doi:.https://doi.org/10.1080/14656566.2017.1419187
- Krag M, Marker S, Perner A, Wetterslev J, Wise MP, Schefold JC, et al.; SUP-ICU trial group. Pantoprazole in Patients at Risk for Gastrointestinal Bleeding in the ICU. N Engl J Med. 2018;379(23):2199–208. doi:.https://doi.org/10.1056/NEJMoa1714919
- Esteves M, Rollason V, Grosgurin O. [Proton pump inhibitors overprescription]. Rev Med Suisse. 2017;13(579):1782–6.