Acid-suppressive therapy is associated with spontaneous bacterial peritonitis in cirrhotic patients: a meta-analysis.

BACKGROUND AND AIM: Proton pump inhibitors (PPI) and H(2) -receptor antagonists (H2RA) are frequently prescribed in hospitalized patients with cirrhosis. There are conflicting reports regarding the role of acid-suppressive therapy in predisposing hospitalized patients with cirrhosis to spontaneous bacterial peritonitis (SBP). The aim of this meta-analysis was to evaluate the association between acid-suppressive therapy and the risk of SBP in hospitalized patients with cirrhosis. METHODS: We searched MEDLINE and four other databases for subject headings and text words related to SBP and acid-suppressive therapy. All observational studies that investigated the risk of SBP associated with PPI/H2RA therapy and utilized SBP as an endpoint were considered eligible. Data from the identified studies were combined by means of a random-effects model and odds ratios (ORs) were calculated. RESULTS: Eight studies (n = 3815 patients) met inclusion criteria. The risk of hospitalized cirrhotic patients developing SBP increased when using acid-suppressive therapy. The risk was greater with PPI therapy (n = 3815; OR 3.15, 95% confidence interval 2.09-4.74) as compared to those on H2RA therapy (n = 562; OR 1.71, 95% confidence interval 0.97-3.01). CONCLUSIONS: Pharmacologic acid suppression was associated with a greater risk of SBP in hospitalized patients with cirrhosis. Cirrhotic patients receiving a PPI have approximately three times the risk of developing SBP compared with those not receiving this medication. Prospective studies may help clarify this relationship and shed light on the mechanism(s) by which acid-suppressive therapy increases the risk of SBP in hospitalized patients with cirrhosis.

The association between pneumococcal pneumonia and acute cardiac events.

BACKGROUND: Increased cardiac stress, hypoxemia, and inflammation may contribute to acute cardiac events, such as myocardial infarction (MI), arrhythmia, and/or congestive heart failure (CHF). We sought to determine the incidence of such events in patients who were hospitalized for community-acquired pneumococcal pneumonia. METHODS: We studied the medical records of all patients who were admitted for pneumococcal pneumonia during a 5-year period (2001-2005) to identify those who had MI, atrial fibrillation or ventricular tachycardia, or new-onset or worsening CHF at the time of hospital admission. RESULTS: Of 170 patients, 33 (19.4%) had > or =1 of these major cardiac events. Twelve had MI, of whom 2 also had arrhythmia and 5 had new-onset or worsening CHF. Eight had new-onset atrial fibrillation or ventricular tachycardia; 6 of these also had new CHF. Thirteen had newly diagnosed or worsening CHF, without MI or new arrhythmias. Hypoxemia and anemia were prominent. Importantly, patients with concurrent pneumococcal pneumonia and cardiac events had a significantly higher mortality than those with pneumococcal pneumonia alone (P<.008). The coexistence of pulmonary and cardiac disease was often overlooked by admitting physicians who, seeking a unifying diagnosis, emphasized one diagnosis to the exclusion of the other. CONCLUSIONS: Patients with pneumococcal pneumonia are at substantial risk for a concurrent acute cardiac event, such as MI, serious arrhythmia, or new or worsening CHF. This concurrence significantly increases mortality due to pneumonia. Admitting physicians tend to seek a unifying diagnosis, but the frequent coexistence of pneumonia and cardiac events indicates the importance of considering multiple diagnoses.