title: Changes in gastric and lung microflora with acid suppression: acid suppression and bacterial growth.
abstract: OBJECTIVE
  The use of acid suppression has been associated with an increased risk of upper and lower respiratory tract infections in the outpatient setting but the mechanism behind this increased risk is unknown. We hypothesize that this infection risk results from gastric bacterial overgrowth with subsequent seeding of the lungs.
  
  
  OBJECTIVE
  To determine if acid-suppression use results in gastric bacterial overgrowth, if there are changes in lung microflora associated with the use of acid suppression, and if changes in lung microflora are related to full-column nonacid gastroesophageal reflux.
  
  
  METHODS
  A 5-year prospective cohort study at a tertiary care center where children ages 1 to 18 years were undergoing bronchoscopy and endoscopy for the evaluation of chronic cough. Acid-suppression use was assessed through questionnaires with confirmation using an electronic medical record review.
  
  
  METHODS
  Our primary outcome was to compare differences in concentration and prevalence of gastric and lung bacteria between patients who were and were not receiving acid-suppression therapy. We compared medians using the Wilcoxon signed rank test and determined prevalence ratios using asymptotic standard errors and 95% confidence intervals. We determined correlations between continuous variables using Pearson correlation coefficients and compared categorical variables using the Fisher exact test.
  
  
  RESULTS
  Forty-six percent of patients taking acid-suppression medication had gastric bacterial growth compared with 18% of untreated patients (P = .003). Staphylococcus (prevalence ratio, 12.75 [95% CI, 1.72-94.36]), Streptococcus (prevalence ratio, 6.91 [95% CI, 1.64-29.02]), Veillonella (prevalence ratio, 9.56 [95% CI, 1.26-72.67]), Dermabacter (prevalence ratio, 4.78 [95% CI, 1.09-21.02]), and Rothia (prevalence ratio, 6.38 [95% CI, 1.50-27.02]) were found more commonly in the gastric fluid of treated patients. The median bacterial concentration was higher in treated patients than in untreated patients (P = .001). There was no difference in the prevalence (P > .23) of different bacterial genera or the median concentration of total bacteria (P = .85) in the lungs between treated and untreated patients. There were significant positive correlations between proximal nonacid reflux burden and lung concentrations of Bacillus (r = 0.47, P = .005), Dermabacter (r = 0.37, P = .008), Lactobacillus (r = 0.45, P = .001), Peptostreptococcus (r = 0.37, P = .008), and Capnocytophagia (r = 0.37, P = .008).
  
  
  CONCLUSIONS
  Acid-suppression use results in gastric bacterial overgrowth of genera including Staphylococcus and Streptococcus. Full-column nonacid reflux is associated with greater concentrations of bacteria in the lung. Additional studies are needed to determine if acid suppression-related microflora changes predict clinical infection risk; these results suggest that acid suppression use may need to be limited in patients at risk for infections.
authors.affiliation: Aerodigestive Center, Department of Gastroenterology, Boston Children's Hospital, Boston, Massachusetts.
authors.forename: Rachel
authors.initials: R
authors.lastname: Rosen
authors.affiliation: Aerodigestive Center, Department of Gastroenterology, Boston Children's Hospital, Boston, Massachusetts.
authors.forename: Janine
authors.initials: J
authors.lastname: Amirault
authors.affiliation: Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts.
authors.forename: Hongye
authors.initials: H
authors.lastname: Liu
authors.affiliation: Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts.
authors.forename: Paul
authors.initials: P
authors.lastname: Mitchell
authors.affiliation: Center for Computational Cancer Biology, Dana Farber Cancer Institute, Boston, Massachusetts.
authors.forename: Lan
authors.initials: L
authors.lastname: Hu
authors.affiliation: Aerodigestive Center, Department of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts.
authors.forename: Umakanth
authors.initials: U
authors.lastname: Khatwa
authors.affiliation: Department of Microbiology, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Andrew
authors.initials: A
authors.lastname: Onderdonk
mesh_terms: D000293:Adolescent; D000863:Antacids / Q000009:adverse effects*; D001424:Bacterial Infections / Q000139:chemically induced*; D002648:Child; D002675:Child, Preschool; D005260:Female; D005764:Gastroesophageal Reflux / Q000188:drug therapy*; D006801:Humans; D006863:Hydrogen-Ion Concentration; D007223:Infant; D008168:Lung / Q000382:microbiology; D008171:Lung Diseases / Q000139:chemically induced* / Q000382:microbiology; D008297:Male; D011446:Prospective Studies; D013270:Stomach / Q000382:microbiology; D013272:Stomach Diseases / Q000139:chemically induced* / Q000382:microbiology
chemical_list: D000863:Antacids