加護病房胃酸抑制藥物使用與發生院內感染型肺炎危險之相關性探討

The Use of Acid-Suppressive Medications and the Risk for Hospital-Acquired Pneumonia in Intensive Care Units

林麗梅(Li-Mei Lin)

指導教授 ： 陳香吟

臺北醫學大學/藥學院/藥學研究所/碩士(2010年)

https://doi.org/10.6831/TMU.2010.00188

摘要

使用胃酸抑制藥品，如制酸劑、第二型組織胺受體拮抗劑與氫離子幫浦抑制劑等，均會藉由抑制胃酸分泌的作用使得胃內pH值增加，造成胃中革蘭氏陰性菌生長增加。許多研究已證實使用制酸劑及第二型組織胺受體拮抗劑，作為重症病人壓力性潰瘍預防之用途時，會增加病人發生院內感染型肺炎的危險性。自1989年第一個氫離子幫浦抑制劑上市後，目前氫離子幫浦抑制劑已成為全世界最常被處方的藥品，研究指出氫離子幫浦抑制劑與增加社區感染型肺炎的發生具有相關性。
本研究的目的在探討加護病房病人使用胃酸抑制藥品-氫離子幫浦抑制劑與院內感染型肺炎之關係。本研究為回溯性觀察世代研究，蒐集自2000年1月1日至2009年12月31日期間年齡大於或等於18歲住加護病房的病人；此段期間多次住加護病房者，僅取第一次住入加護病房期間的資料。主要結果為比較使用氫離子幫浦抑制劑或sucralfate，院內感染型肺炎的發生率。本研究共收入388位病人為研究對象，氫離子幫浦抑制劑組為302人，sucralfate組86人。
結果顯示PPI組有63位病人感染肺炎，發生率為20.9%；而sucralfate組發生肺部感染則為8人，發生率為9.3%。因此與sucralfate相較下，使用PPI發生院內感染型肺炎的危險較高 (adjusted odds ratio為2.83 ，95% CI 1.17-6.83，p= 0.021)。當病人使用PPI同時加護病房的住院天數＞8天時，其發生院內感染型肺炎的風險為最高 (adjusted odds ratio為9.04，95% CI 1.9-42.0，p值=0.005)。
內科加護病房病人使用PPI相較於sucralfate，發生院內感染型肺炎的風險較高。因此，當內科加護病房病人沒有引起壓力性潰瘍的高危險因子，如使用呼吸器>48小時或發生凝血病變時，則可考慮使用sucralfate作為預防壓力性潰瘍的藥物。當病人住加護病房的時間延長，考慮使用PPI時，應權衡可能發生肺炎的風險。

關鍵字

院內感染型肺炎 ； 氫離子幫浦抑制劑 ； sucralfate

並列摘要

Acid suppressive medications, such as antacids, histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs), have shown that agents which raise the gastric pH by inhibiting secretion of gastric acid may promote proliferation of gram-negative bacilli in the stomach. Studies have demonstrated that antacids and H2RAs may increase the risk of hospital-acquired pneumonia in critically ill patients for stress ulcer prophylaxis. The first PPI emerged on the market since 1989, proton pump inhibitors are among the most widely prescribed medications worldwide. Several studies have noted PPIs use has been linked to an increased risk of community-acquired pneumonia.
The purpose of this study is to determine the association between acid suppressive medications- proton pump inhibitors and hospital-acquired pneumonia in critically ill patients. This is a retrospective observational cohort analysis of patients admitted to the intensive care units from January 1, 2000 to December 31, 2009. Patients were eligible for inclusion in the study if they were ³ 18 years of age. For patients with multiple hospital admissions during the study period, only the first hospital admission was eligible for inclusion. The primary outcome is the incidence of hospital-acquired pneumonia. The final cohort comprised 388 patients (PPIs, 302 patients; sucralfate, 86 patients).
Hospital-acquired pneumonia developed in 63 of the 302 patients (20.9%) who received PPI, compared with 8 of the 86 patients ( 9.3%) who received sucralfate (adjusted odds ratio, 2.83；95% CI, 1.17-6.83, p= 0.021). The use of PPIs and the length of stay of ICU that was more than 8 days were associated with the highest risk of HAP (adjusted odds ratio,9.04；95% CI, 1.9-42.0, p= 0.005).
In a population of medical intensive care units patients, the use of PPIs was associated with a higher risk of hospital-acquired pneumonia compared with sucalfate. Therefore, when MICU patients don’t have high risk factors of stress ulcer, such as receiving mechanical ventilation more than 48 hours or coagulopathy. We can consider using sucralfate as stress ulcer prophylaxis. As patients must increase the length of stay of ICU, we have to weigh the risk and benefit before using PPI.

並列關鍵字

words：hospital-acquired pneumonia ； proton pump inhibitor ； sucralfate

參考文獻

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