title: Bacterial infections in cirrhosis: role of proton pump inhibitors and intestinal permeability.
abstract: BACKGROUND
  Cirrhotic patients are at considerable risk for bacterial infections, possibly through increased intestinal permeability and bacterial overgrowth. Proton pump inhibitors (PPIs) may increase infection risk. We aimed to explore the potential association between PPI use and bacterial infection risk in cirrhotic patients and potential underlying mechanisms in complementary patient and animal models.
  
  
  METHODS
  Bacterial overgrowth was determined in jejunum of 30 rats randomly allocated to 6-week PPI treatment, gastrectomy or no treatment. In 84 consecutive cirrhotic patients, bacterial infection risk was prospectively assessed and related to PPI use. Intestinal permeability was determined by polyethylene glycol (PEG) test in nine healthy individuals and 12 cirrhotic patients.
  
  
  RESULTS
  Bacterial overgrowth was much more common in jejunum of rats treated with PPI or gastrectomy compared with nontreated rats. Twenty-four patients (29%) developed a bacterial infection during a median follow-up of 28 months. Although PPI users tended to experience infection more often than patients without PPI therapy, PPI use was not an independent predictor of bacterial infection (HR 1·2, 95% CI 0·5-3·0, P = 0·72), after correction for Child-Pugh class (HR 3·6, 95% CI 1·5-8·7, P = 0·004) and age (HR 1·05, 95%CI 1·01-1·09, P = 0·02). In cirrhotic patients, 24-h urinary recovery of PEGs 1500 and 3350 was significantly higher compared with healthy controls.
  
  
  CONCLUSIONS
  Although in our animal model PPIs induced intestinal overgrowth, stage of liver disease rather than PPI use was the predominant factor determining infection risk in cirrhotic patients. Increased intestinal permeability may be a factor contributing to infection risk.
authors.affiliation: Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Lotte G
authors.initials: LG
authors.lastname: van Vlerken
authors.forename: Ellen J
authors.initials: EJ
authors.lastname: Huisman
authors.forename: Bart
authors.initials: B
authors.lastname: van Hoek
authors.forename: Willem
authors.initials: W
authors.lastname: Renooij
authors.forename: Felix W M
authors.initials: FW
authors.lastname: de Rooij
authors.forename: Peter D
authors.initials: PD
authors.lastname: Siersema
authors.forename: Karel J
authors.initials: KJ
authors.lastname: van Erpecum
mesh_terms: D053799:2-Pyridinylmethylsulfinylbenzimidazoles / Q000009:adverse effects; D000328:Adult; D000368:Aged; D000818:Animals; D001419:Bacteria / Q000302:isolation & purification; D001424:Bacterial Infections / Q000209:etiology*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007583:Jejunum / Q000378:metabolism / Q000382:microbiology*; D008103:Liver Cirrhosis / Q000382:microbiology*; D008297:Male; D008875:Middle Aged; D023421:Models, Animal; D009426:Netherlands; D009853:Omeprazole / Q000009:adverse effects; D000077402:Pantoprazole; D010538:Peritonitis / Q000382:microbiology*; D010539:Permeability / Q000187:drug effects; D011092:Polyethylene Glycols / Q000378:metabolism; D054328:Proton Pump Inhibitors / Q000009:adverse effects*; D011899:Ranitidine / Q000009:adverse effects; D051381:Rats; D017208:Rats, Wistar; D012307:Risk Factors
chemical_list: D053799:2-Pyridinylmethylsulfinylbenzimidazoles; D054328:Proton Pump Inhibitors; D011092:Polyethylene Glycols; D011899:Ranitidine; D000077402:Pantoprazole; D009853:Omeprazole