Ting Li, MD

Background: Acid suppressants inhibit gastric acid secretion and disrupt the intestinal microbiome, but whether that facilitates colonization and infection with MDROs is unclear.

Study design: Systematic review and meta-analysis.

Setting: Observational studies searched from database through July 2019.

Synopsis: A total of 26 observational studies published during 1996-2019 with 29,382 patients were included in this meta-analysis. Of those, 24 studies directly measured intestinal MDRO carriage and 2 used urinary tract infections (UTIs) as the outcome measure, since most UTIs are caused by bacteria that colonize the intestinal tract. Target MDROs included multidrug-resistant Enterobacteriaceae (MRD-E) and vancomycin-resistant enterococci (VRE). Meta-analysis demonstrated that acid suppression is associated with increased odds of intestinal MDRO colonization (MDR-E: odds ratio, 1.60; 95% confidence interval, 1.33-1.92; VRE: OR, 1.97; 95% CI, 1.49-2.60), in both community and health care settings. The risk was similar for colonization with MDR-E and VRE. Regarding the effect of acid suppression by drug class, results were mixed with some studies demonstrating increased risk of MDRO in PPI users only while others reported increased risk only with H₂-receptor antagonists.

Bottom line: Acid suppression therapy is associated with increased odds of MDRO colonization. While observational studies cannot prove causation, it is wise to avoid excessive use of acid suppressants.

Citation: Willems RPJ et al. Evaluation of the association between gastric acid suppression and risk of intestinal colonization with multidrug-resistant microorganisms: A systematic review and meta-­analysis. JAMA Intern Med. 2020 Feb 24;180(4):561-71.

Dr. Li is assistant professor of medicine, section of hospital medicine, at the University of Virginia School of Medicine, Charlottesville.

Background: Acid suppressants inhibit gastric acid secretion and disrupt the intestinal microbiome, but whether that facilitates colonization and infection with MDROs is unclear.

Study design: Systematic review and meta-analysis.

Setting: Observational studies searched from database through July 2019.

Synopsis: A total of 26 observational studies published during 1996-2019 with 29,382 patients were included in this meta-analysis. Of those, 24 studies directly measured intestinal MDRO carriage and 2 used urinary tract infections (UTIs) as the outcome measure, since most UTIs are caused by bacteria that colonize the intestinal tract. Target MDROs included multidrug-resistant Enterobacteriaceae (MRD-E) and vancomycin-resistant enterococci (VRE). Meta-analysis demonstrated that acid suppression is associated with increased odds of intestinal MDRO colonization (MDR-E: odds ratio, 1.60; 95% confidence interval, 1.33-1.92; VRE: OR, 1.97; 95% CI, 1.49-2.60), in both community and health care settings. The risk was similar for colonization with MDR-E and VRE. Regarding the effect of acid suppression by drug class, results were mixed with some studies demonstrating increased risk of MDRO in PPI users only while others reported increased risk only with H₂-receptor antagonists.

Bottom line: Acid suppression therapy is associated with increased odds of MDRO colonization. While observational studies cannot prove causation, it is wise to avoid excessive use of acid suppressants.

Citation: Willems RPJ et al. Evaluation of the association between gastric acid suppression and risk of intestinal colonization with multidrug-resistant microorganisms: A systematic review and meta-­analysis. JAMA Intern Med. 2020 Feb 24;180(4):561-71.

Dr. Li is assistant professor of medicine, section of hospital medicine, at the University of Virginia School of Medicine, Charlottesville.

Background: Acid suppressants inhibit gastric acid secretion and disrupt the intestinal microbiome, but whether that facilitates colonization and infection with MDROs is unclear.

Study design: Systematic review and meta-analysis.

Setting: Observational studies searched from database through July 2019.

Synopsis: A total of 26 observational studies published during 1996-2019 with 29,382 patients were included in this meta-analysis. Of those, 24 studies directly measured intestinal MDRO carriage and 2 used urinary tract infections (UTIs) as the outcome measure, since most UTIs are caused by bacteria that colonize the intestinal tract. Target MDROs included multidrug-resistant Enterobacteriaceae (MRD-E) and vancomycin-resistant enterococci (VRE). Meta-analysis demonstrated that acid suppression is associated with increased odds of intestinal MDRO colonization (MDR-E: odds ratio, 1.60; 95% confidence interval, 1.33-1.92; VRE: OR, 1.97; 95% CI, 1.49-2.60), in both community and health care settings. The risk was similar for colonization with MDR-E and VRE. Regarding the effect of acid suppression by drug class, results were mixed with some studies demonstrating increased risk of MDRO in PPI users only while others reported increased risk only with H₂-receptor antagonists.

Bottom line: Acid suppression therapy is associated with increased odds of MDRO colonization. While observational studies cannot prove causation, it is wise to avoid excessive use of acid suppressants.

Citation: Willems RPJ et al. Evaluation of the association between gastric acid suppression and risk of intestinal colonization with multidrug-resistant microorganisms: A systematic review and meta-­analysis. JAMA Intern Med. 2020 Feb 24;180(4):561-71.

Dr. Li is assistant professor of medicine, section of hospital medicine, at the University of Virginia School of Medicine, Charlottesville.

Background: Empirical broad-spectrum antibiotics including anti-MRSA therapy are often selected because of concerns for resistant organisms. However, the outcomes of empirical anti-MRSA therapy among patients with pneumonia are unknown.

Study design: A national retrospective multicenter cohort study of hospitalizations for pneumonia.

Setting: This cohort study included 88,605 hospitalizations for pneumonia in the Veterans Health Administration health care system during 2008-2013, in which patients received either anti-MRSA or standard therapy for community-onset pneumonia.

Synopsis: Among 88,605 hospitalizations for pneumonia, 38% of the patients received empirical anti-MRSA therapy within the first day of hospitalization and vancomycin accounted for 98% of the therapy. The primary outcome was 30-day all-cause mortality after adjustment for patient comorbidities, vital signs, and laboratory results. Three treatment groups were studied: patients receiving anti-MRSA therapy (vancomycin hydrochloride or linezolid) plus guideline-recommended standard antibiotics (beta-lactam and macrolide or tetracycline hydrochloride, or fluoroquinolone); patients receiving anti-MRSA therapy without standard antibiotics; and patients receiving standard therapy alone. There was no mortality benefit of empirical anti-MRSA therapy versus standard antibiotics, even in those with risk factors for MRSA or in those whose clinical severity warranted admission to the ICU. Empirical anti-MRSA treatment was associated with greater 30-day mortality compared with standard therapy alone, with an adjusted risk ratio of 1.4 (95% confidence interval, 1.3-1.5) versus empirical anti-MRSA treatment plus standard therapy and 1.5 (1.4-1.6) versus empirical anti-MRSA treatment without standard therapy.

Bottom line: Empirical anti-MRSA therapy does not improve mortality and should not be routinely used in patients hospitalized for community-onset pneumonia, even in those with MRSA risk factors.

Citation: Jones BE et al. Empirical anti-MRSA vs. standard antibiotic therapy and risk of 30-day mortality in patients hospitalized for pneumonia. JAMA Intern Med. 2020 Feb 17;180(4):552-60.

Dr. Li is assistant professor of medicine, section of hospital medicine, at the University of Virginia School of Medicine, Charlottesville.

Background: Empirical broad-spectrum antibiotics including anti-MRSA therapy are often selected because of concerns for resistant organisms. However, the outcomes of empirical anti-MRSA therapy among patients with pneumonia are unknown.

Study design: A national retrospective multicenter cohort study of hospitalizations for pneumonia.

Setting: This cohort study included 88,605 hospitalizations for pneumonia in the Veterans Health Administration health care system during 2008-2013, in which patients received either anti-MRSA or standard therapy for community-onset pneumonia.

Synopsis: Among 88,605 hospitalizations for pneumonia, 38% of the patients received empirical anti-MRSA therapy within the first day of hospitalization and vancomycin accounted for 98% of the therapy. The primary outcome was 30-day all-cause mortality after adjustment for patient comorbidities, vital signs, and laboratory results. Three treatment groups were studied: patients receiving anti-MRSA therapy (vancomycin hydrochloride or linezolid) plus guideline-recommended standard antibiotics (beta-lactam and macrolide or tetracycline hydrochloride, or fluoroquinolone); patients receiving anti-MRSA therapy without standard antibiotics; and patients receiving standard therapy alone. There was no mortality benefit of empirical anti-MRSA therapy versus standard antibiotics, even in those with risk factors for MRSA or in those whose clinical severity warranted admission to the ICU. Empirical anti-MRSA treatment was associated with greater 30-day mortality compared with standard therapy alone, with an adjusted risk ratio of 1.4 (95% confidence interval, 1.3-1.5) versus empirical anti-MRSA treatment plus standard therapy and 1.5 (1.4-1.6) versus empirical anti-MRSA treatment without standard therapy.

Bottom line: Empirical anti-MRSA therapy does not improve mortality and should not be routinely used in patients hospitalized for community-onset pneumonia, even in those with MRSA risk factors.

Citation: Jones BE et al. Empirical anti-MRSA vs. standard antibiotic therapy and risk of 30-day mortality in patients hospitalized for pneumonia. JAMA Intern Med. 2020 Feb 17;180(4):552-60.

Dr. Li is assistant professor of medicine, section of hospital medicine, at the University of Virginia School of Medicine, Charlottesville.

Background: Empirical broad-spectrum antibiotics including anti-MRSA therapy are often selected because of concerns for resistant organisms. However, the outcomes of empirical anti-MRSA therapy among patients with pneumonia are unknown.

Study design: A national retrospective multicenter cohort study of hospitalizations for pneumonia.

Setting: This cohort study included 88,605 hospitalizations for pneumonia in the Veterans Health Administration health care system during 2008-2013, in which patients received either anti-MRSA or standard therapy for community-onset pneumonia.

Synopsis: Among 88,605 hospitalizations for pneumonia, 38% of the patients received empirical anti-MRSA therapy within the first day of hospitalization and vancomycin accounted for 98% of the therapy. The primary outcome was 30-day all-cause mortality after adjustment for patient comorbidities, vital signs, and laboratory results. Three treatment groups were studied: patients receiving anti-MRSA therapy (vancomycin hydrochloride or linezolid) plus guideline-recommended standard antibiotics (beta-lactam and macrolide or tetracycline hydrochloride, or fluoroquinolone); patients receiving anti-MRSA therapy without standard antibiotics; and patients receiving standard therapy alone. There was no mortality benefit of empirical anti-MRSA therapy versus standard antibiotics, even in those with risk factors for MRSA or in those whose clinical severity warranted admission to the ICU. Empirical anti-MRSA treatment was associated with greater 30-day mortality compared with standard therapy alone, with an adjusted risk ratio of 1.4 (95% confidence interval, 1.3-1.5) versus empirical anti-MRSA treatment plus standard therapy and 1.5 (1.4-1.6) versus empirical anti-MRSA treatment without standard therapy.

Bottom line: Empirical anti-MRSA therapy does not improve mortality and should not be routinely used in patients hospitalized for community-onset pneumonia, even in those with MRSA risk factors.

Citation: Jones BE et al. Empirical anti-MRSA vs. standard antibiotic therapy and risk of 30-day mortality in patients hospitalized for pneumonia. JAMA Intern Med. 2020 Feb 17;180(4):552-60.

Dr. Li is assistant professor of medicine, section of hospital medicine, at the University of Virginia School of Medicine, Charlottesville.