Proton Pump Inhibitor Use in Patients With Cirrhosis and Its Association With Spontaneous Bacterial Peritonitis

Background: Cirrhosis is a major cause of morbidity and mortality in the United States, with spontaneous bacterial peritonitis (SBP) being a serious complication. Established SBP risk factors include gastrointestinal bleeding and low ascitic protein, but the role of proton pump inhibitors (PPIs) remains unclear. Objective: This study evaluated the impact of PPI use on primary SBP development in hospitalized patients with cirrhosis. Additional objectives included reviewing PPI prescribing patterns and associated clinical outcomes. Methods: An institutional review board-approved, retrospective chart review was conducted on adults (≥18 years) with cirrhosis admitted for presumed SBP between June 1, 2022, and June 30, 2024. Exclusion criteria included pregnancy, incarceration, and recent or current upper gastrointestinal bleeding. Patients were grouped by PPI exposure, defined as PPI use prior to admission. The primary outcome was SBP incidence; secondary outcomes included mortality and hepatic decompensation events. Results: Eighty-one patients were included: 42 reported home PPI therapy, and 39 did not. SBP incidence was 33.3% in the PPI group versus 20.5% in the no PPI group (χ² = 0.249, P = 0.618). Worsening ascites occurred in 99%, encephalopathy in 42%, varices in 11%, and suspected hepatorenal syndrome in 21%. In-hospital mortality was 9.9%. PPI indications were often undocumented. Conclusion and Relevance: Although no significant association was found between home PPI use and SBP, frequent undocumented use and potential overuse of PPIs underscore the need for targeted intervention. Pharmacists are well-positioned to lead stewardship efforts by reviewing indications and minimizing unnecessary therapy to enhance safety and outcomes.