111: PPIs increase the risk and severity of hospital-acquired CDiff, will IV lipids work for liposomal bupivacaine toxicity, and a resource to polish up your CV

In this episode I’ll:

1. Discuss an article about the risk and severity of Clostridium difficile Infection with PPIs.
2. Answer the drug information question “Will IV fat emulsion work for cardiac toxicity caused by liposomal bupivacaine?”
3. Share a resource for polishing up your CV.
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Shout out to Pharmacy Jen for leaving a review on my book A Pharmacist’s Guide to Inpatient Medical Emergencies at Amazon.  Jen wrote: I wish I had this book when I started to respond to code blues in my hospital! Even though I have been going to codes for a while, this book has been super helpful. Each chapter gets right to the point and contains practical information about what a pharmacist can do to help at a code or rapid response.

Article

Risk and Severity of Hospital-Acquired Clostridium difficile Infection in Patients Taking Pump Inhibitors

Lead author: Paul O. Lewis

Published in Pharmacotherapy Early Access July 2016

Methods

The authors sought to compare the rates and severity of hospital-acquired Clostridium difficile infection (CDI) among patients taking proton pump inhibitors (PPIs) with those not taking PPIs. The study was a retrospective, single-center, cohort study in a tertiary community hospital.

17,471 patients who had received a PPI during hospitalization were compared to 24,192 patients who had not received a PPI.

Results

A total of 65 patients (0.38%) in the PPI group had hospital-acquired CDI. Only 14 patients (0.058%) in the control group had hospital-acquired CDI. Severe CDI occurred in 36 patients (0.21%) in the PPI group. Only 8 patients (0.03%) developed severe CDI in the control group.

The unadjusted relative risk of developing CDI in the PPI group was 6.46. The unadjusted relative risk of developing severe CDI in the PPI group was 6.27. The authors also reported the unadjusted relative risk of developing severe-complicated CDI in the PPI group; it was 15.3!

Conclusion

The authors concluded:

PPI use was associated with an increase in both the rate and severity of hospital-acquired CDI.

Discussion

The relative risk increases for hospital-acquired CDI with PPI use from this study are alarming. It is true that the absolute risk of hospital-acquired CDI in patients in this study was very low. But when PPIs are only being used for symptom relief, I think this risk is unacceptable.

The study was single center, retrospective, and only reported unadjusted relative risks. It should be confirmed across multiple sites or by meta-analysis before routine practice is changed. Even so, I think we should plan for what should be done if and when this study is confirmed.

Do you think we will begin to automatically discontinue PPIs in patients when they are admitted to the hospital? Let me know in the comment section below.

Drug information question

Q: Will IV lipid emulsion work for cardiac toxicity caused by liposomal bupivacaine?

A: I have no idea, but I would try it anyway.

This question came in the Pharmacy Nation Slack group. I was unable to find any literature in Pubmed to support using IV lipid emulsion for cardiac toxicity caused by liposomal bupivacaine. The trouble with bupivacaine toxicity is that the alternatives to using lipid emulsion are either ECMO or death. For this reason, I would try using IV lipid emulsion in a patient with cardiac toxicity from liposomal bupivacaine.

Resource

The resource I’d like to share on this episode are the CV review services provided by ASHP and ACCP. Both of these organizations allow student and new practitioner members to submit their CV for review by one or more experienced practitioners.

ASHP’s CV review service is open from August 17 to September 7, 2016. Feedback is provided by October 19. ACCP has made their CV review service available year-round. Feedback is provided within 14 business days. I encourage all of my students that are thinking of applying to residency programs to utilize these review services.

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If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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