Prevention of Intensive Care Unit-acquired Pneumonia

Michael Klompas, MD, MPH


Semin Respir Crit Care Med. 2019;40(4):548-557. 

In This Article

Stress Ulcer Prophylaxis

Stress ulcer prophylaxis has long been an integral component of ventilator bundles on the rationale that mechanically ventilated patients are at increased risk for gastrointestinal bleeding (which in turn could lead to aspiration pneumonitis and pneumonia).[92] The net risk versus benefit of stress ulcer prophylaxis has lately been called into question. Modern series report much lower rates of gastrointestinal bleeding compared with historical patterns and there is increasing appreciation that gastric acid suppression may be a risk factor for hospital-acquired pneumonia and Clostridioides difficile infections.[93–95] Huang and colleagues conducted a meta-analysis of seven randomized trials of stress ulcer prophylaxis versus placebo in 889 patients and reported significantly higher rates of hospital-acquired pneumonia in patients receiving stress ulcer prophylaxis and no difference in gastrointestinal bleeding rates (or C. difficile rates).[96]

Renewed interest in determining the necessity and safety of stress ulcer prophylaxis has catalyzed several randomized controlled trials comparing different stress ulcer prophylaxis regimens to one another or to placebo.[97–100] Many of these are still recruiting but one large randomized trial has been published. Krag and colleagues randomized 3,298 patients in 33 European intensive care units to daily intravenous pantoprazole versus placebo.[101] Patients randomized to pantoprazole had a lower rate of clinically notable gastrointestinal bleeding (2.5 vs. 4.2%) but no difference in the rates of red blood cell transfusions, pneumonia, C. difficile infections, or 90-day mortality. While this trial somewhat tempers the concern that stress ulcer prophylaxis may increase the risk of pneumonia in critically ill patients, it simultaneously failed to provide clear evidence that stress ulcer prophylaxis improves objective patient outcomes. The results of the additional large trials currently underway are eagerly awaited to shed further light upon risk–benefit balance of stress ulcer prophylaxis.