Proton pump inhibitors therapy and risk of Clostridium difficile infection: Systematic review and meta-analysis.

AIM: To perform a systematic review and meta-analysis on proton pump inhibitors (PPIs) therapy and the risk of Clostridium difficile infection (CDI). METHODS We conducted a systematic search of MEDLINE/PubMed and seven other databases through January 1990 to March 2017 for published studies that evaluated the association between PPIs and CDI. Adult case-control and cohort studies providing information on the association between PPI therapy and the development of CDI were included. Pooled odds ratios (ORs) estimates with 95% confidence intervals (CIs) were calculated using the random effect. Heterogeneity was assessed by I2 test and Cochran's Q statistic. Potential publication bias was evaluated via funnel plot, and quality of studies by the Newcastle-Otawa Quality Assessment Scale (NOS). RESULTS: Fifty-six studies (40 case-control and 16 cohort) involving 356683 patients met the inclusion criteria and were analyzed. Both the overall pooled estimates and subgroup analyses showed increased risk for CDI despite substantial statistical heterogeneity among studies. Meta-analysis of all studies combined showed a significant association between PPI users and the risk of CDI (pooled OR = 1.99, CI: 1.73-2.30, P < 0.001) as compared with non-users. The association remained significant in subgroup analyses: by design-case-control (OR = 2.00, CI: 1.68-2.38, P < 0.0001), and cohort (OR = 1.98, CI: 1.51-2.59, P < 0.0001); adjusted (OR = 1.95, CI: 1.67-2.27, P < 0.0001) and unadjusted (OR = 2.02, CI: 1.41-2.91, P < 0.0001); unicenter (OR = 2.18, CI: 1.72-2.75, P < 0.0001) and multicenter (OR = 1.82, CI: 1.51-2.19, P < 0.0001); age ≥ 65 years (OR = 1.93, CI: 1.40-2.68, P < 0.0001) and < 65 years (OR = 2.06, CI: 1.11-3.81, P < 0.01). No significant differences were found in subgroup analyses (test for heterogeneity): P = 0.93 for case-control vs cohort, P = 0.85 for adjusted vs unadjusted, P = 0.24 for unicenter vs multicenter, P = 0.86 for age ≥ 65 years and < 65 years. There was significant heterogeneity across studies (I2 = 85.4%, P < 0.001) as well as evidence of publication bias (funnel plot asymmetry test, P = 0.002). CONCLUSION: This meta-analysis provides further evidence that PPI use is associated with an increased risk for development of CDI. Further high-quality, prospective studies are needed to assess whether this association is causal.

PLATELET INDICES AND LIVER FIBROSIS EVALUATION IN CHRONIC HEPATITIS C.

UNLABELLED: Recently, several studies have reported that the mean platelet volume and platelet distribution width may give information about liver fibrosis severity in chronic hepatitis C. The aim of the present study was to evaluate whether platelet indices correlate with hepatic fibrosis measured by transient elastography in patients with chronic hepatitis C. MATERIALS AND METHODS: Patients with chronic hepatitis C were prospectively enrolled. Samples for complete blood count and routine biochemical parameters were collected and analyzed in the same day with liver fibrosis assessment by transient elastography. Mean platelet volume, platelet large cell ratio and platelet distribution width were compared with stages of liver fibrosis. Statistical analysis was carried out using SPSS 17.0 software. A P-value of less than 0.05 was considered statistically significant. RESULTS: There were 139 patients with chronic hepatitis C (70.5% males, mean age 54.8 +/- 16.7 years). Compared with mild/moderate liver fibrosis patients, those with advanced liver fibrosis had an increased mean platelet volume (10.4 +/- 0.7 vs. 10.9 +/- 0.9, p < 0.002), platelet large cell ratio (28.5 +/- 5.3 vs. 32.5 +/- 7.2, P < 0.0001), and platelet distribution width (12.8 +/- 1.5 vs. 14.1 +/- 2.7, P = 0.003). CONCLUSIONS: Increased platelet indices were associated with advanced liver fibrosis stages evaluated by transient elastography in patients with chronic hepatitis C.

Clostridium difficile Infection in Hospitalized Cirrhotic Patients with Hepatic Encephalopathy.

BACKGROUND AND AIMS: Patients with liver cirrhosis are at-risk population for Clostridium difficile infection (CDI). There is a paucity of data on the incidence of CDI in cirrhotics with hepatic encephalopathy (HE). The aim of the study was to evaluate the incidence and risk factors for CDI in cirrhotics hospitalized with HE. METHODS: A retrospective analysis of all cirrhotics with HE admitted at a tertiary referral center from January 2012 to December 2014 was made. Patients' medical charts were reviewed, and demographics, laboratory parameters, antibiotics use, etiology of cirrhosis, and therapy of HE, as well as the results of stool samples for toxins A and B (enzyme immunoassay) were carefully searched. The presence of toxin A or B (or both) in stool samples was defined as CDI. Data on cirrhotics with HE and CDI (study group) were compared with those from patients without CDI (control group). RESULTS: A total of 231 cirrhotic patients were hospitalized with HE mostly stage 2 and 3, and 17 (7.3%) of them were diagnosed with CDI. The overall CDI incidence rate was 57.2 cases per 10,000 patient-days. As compared with control patients, those with HE and CDI were more likely to have older age, increased serum creatinine level, hepatorenal syndrome (HRS), and more prior hospitalizations. On multivariate analysis, antibiotic therapy, age over 65 years, and HRS remained significantly related with the development of CDI. CONCLUSION: Hospitalized cirrhotics with HE are at risk for developing CDI, and clinicians treating such patients should be aware of this infection as rapid detection and prompt treatment may improve outcomes.