الفهرس 
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Abstract
Stress ulcers are a significant cause of morbidity and mortality in patients admitted to the ICU induced by abnormally elevated physiological demands such as sepsis, trauma, burns and neurologic damage. Therefore, acid suppression is often utilized to prevent ulcer formation, a practice known as stress ulcer prophylaxis (SUP). SUP is a widely utilized practice in hospitalized patients, particularly in the ICU. The primary pharmacological agents used to prevent stress ulcers include Proton Pump Inhibitors and Histamine 2 receptor blockers.
Established guidelines on who should receive SUP in critically ill patients are not followed consistently. The American Society of Health-System Pharmacists (ASHP) has published widely accepted guidelines for SUP. Lately, there has been a trend toward overutilization of SUP in patients in the ICU as well as those admitted to general medical wards increasing health care costs, adverse effects, and medication interactions. The objective of this study is to assess the extent to which SUP guidelines are being implemented and to determine physicians’ rationale for prescribing SUP.
The study design is a cross sectional study, done in the ICU and wards of a public hospital ‘Ras El Tin General Hospital’ and a private hospital ‘Andalusia hospitals’ in Alexandria, Egypt. Patients files were revised to collect data regarding SUP indication to check appropriateness of prescription and treating physicians were interviewed anonymously through pretested questionnaires to identify factors that influence their prescription of SUP.
For assessing appropriateness of SUP indication, the target population were patients admitted to the ICU and wards of both hospitals and prescribed any de novo SUP medication.
Inclusion Criteria; Adults aged ≥ 18 years
Exclusion Criteria;
- Patients on AST for treatment of GI diseases.
- Patients with active GI bleeding.
- Patients using NSAIDs treatment at home or within hospital.
- Patients receiving concurrent antiplatelet and anticoagulation therapy or dual antiplatelet therapy.
- Patients taking AST prior to hospital admission.
For identifying factors influencing SUP prescribing, the target population was treating physicians identified from patient’s files.
Ethical consideration
- Ethical approval was obtained from Medical Research Institute before the beginning of the research data collection.
- Approval was obtained from hospitals where the study was conducted prior to study initiation.
- Confidentiality was ensured for participating physicians and patients.
Summary
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The study incorporated 313 patients, of which 51.4% were found taking SUP for no valid indication. There was no difference in inappropriateness of SUP prescription between hospitals, but the extent of misuse was significantly higher in general medical wards than in the ICU. Patients admitted to wards are 3.5 more likely to be prescribed SUP inappropriately than those admitted to the ICU due to lack of definitive factors to initiate SUP medications. There was also an inverse relationship between age and inappropriate SUP prescription, younger age was reported as a clear variable for SUP misuse.
Proton pump inhibitors and H2-blockers were the agents of choice for SUP in this study with a significantly higher frequency for PPIs. Intravenous route was the most commonly used route of administration although many patients tolerated oral medications. The public hospital in contrast to the private hospital preferred low cost alternatives for managing SUP as they used H2-blockers and oral route significantly higher than the private hospital.
More than half of the physicians surveyed were classified as high prescribers. High prescribing behavior was associated with poor knowledge for SUP indications and unconcern for SUP side effects. Physicians with poor knowledge were 8.5 times more likely to be high prescribers and those who were unconcerned about side effects were 6.2 times more likely to be high prescribers.
Good knowledge for SUP indications was significantly higher in physicians with more than 10 years of practice, while concern for side effects was significantly higher in consultants. There was no difference in prescribing behavior when the variable tested was physician’s professional level, years of practice, and speciality.
The results of this study highlight the need for the implementation of correction measures and practice guidelines in critical care as well as non-critical care settings. More awareness and education should be considered in health care centers in Alexandria, Egypt.