Annals of Long Term Care

This article is part II of a two-part series update on pharmacotherapy, and it focuses on infectious disease, positive Beers criteria, and pharmacist interventions. Part I appeared in the December issue of the Journal and focused on cardiology, neurology, and psychiatry.

Introduction

This article is intended to provide a review of recently published literature of relevance to the care of older adults. It focuses on studies that involve pharmacotherapeutic interventions, including both risks and benefits. It is important for clinicians to decide independently how the results of these investigations should be applied to individual patients; clinicians are encouraged to refer to the original articles to assist with making decisions and applying the results to patient care.

Infectious Disease

Acid-Suppressive Medications and Nosocomial Pneumonia

Previous trials have linked acid-suppressive medication use and the risk of pneumonia, both in the ambulatory care setting as well as the inpatient setting. Two recent articles have again looked at acid-suppressive medication and risk of pneumonia, with focus on the association with nosocomial pneumonia. The first of two articles was published in May 2009.1 This prospective pharmacoepidemiologic cohort study at a single institution focused on general, nonintubated hospitalized patients admitted for 3 or more days. The primary outcome was hospital-acquired pneumonia (HAP) as defined by a secondary discharge diagnosis of bacterial pneumonia, which was identified by ICD-9 codes. A total of 64,878 admissions consisting of 43,093 unique patients with a mean age of 54 years were included in the final analysis. Of those admissions, 32,922 admissions (52%) were categorized as being exposed to acid-suppressive medication, which was defined as an order for a proton pump inhibitor (PPI) or histamine2-receptor antagonist during admission. Of those admissions exposed, 83% received a PPI. HAP, the primary outcome, occurred in 3.5% (2219) of admissions. The unadjusted and confounder adjusted incidence of HAP was higher in those admissions exposed to acid-suppression medication as compared to those admissions not exposed to acid-suppressive medication (odds ratio [OR], 2.6 [2.3-2.8]; OR, 1.3 [1.1-1.4], respectively). When the groups were propensity-matched, a total of 16,396 patient admissions in each group were compared again, with a higher incidence of HAP in the patient admissions exposed to acid-suppressive medications (OR, 1.3 [1.1-1.4]). Overall, in this cohort study, the use of acid-suppressive medications was associated with a 0.9% attributable risk of developing HAP or a number needed to harm of 111.

The second of the two articles was published in August 2009.2 This retrospective cohort analysis at a large, single institution teaching hospital included a total of 834 patients age 18 years or older (mean age, 65 yr) admitted to the cardiothoracic surgery service over a 4-year period. The patients were identified and data collected from the Society of Thoracic Surgeons database. The primary outcome of the study was the incidence of nosocomial pneumonia, including both HAP and ventilator-associated pneumonia (VAP). Of the 834 patients included, 377 patients received pantoprazole and 457 received ranitidine, with no crossover between the agents throughout the study period. The primary outcome of nosocomial pneumonia occurred in a total of 42 admissions, with 35 in the pantoprazole group (9.3%) and 7 in the ranitidine group (1.5%; OR, 6.6 [2.9-14.9]). When the groups were propensity-adjusted, pantoprazole remained an independent risk factor for nosocomial pneumonia (OR, 2.7 [1.1-6.7]).