The use of PPI is associated with spontaneous bacterial peritonitis in cirrhotic patients of different ethnic groups: A meta-analysis

Background: Spontaneous bacterial peritonitis (SBP) is one of the most serious complications of cirrhotic patients. A few studies have shown that use of proton pump inhibitors (PPI) may increase the risk of occurrence of SBP in cirrhotic patients. However, controversial results have been obtained in the last decades. Therefore, the purpose of our analysis was to investigate the relationship between the risk of development of Spontaneous bacterial peritonitis (SBP) and the administration of proton pump inhibitors (PPI) in cirrhotic patients. Methods: Observational studies, about the relationship between PPI therapy and SBP in cirrhotic patients, were searched in PubMed, Medline, Embase, Web of Knowledge and other databases, and retrieval time ended in Jun 2015. Data from the identified studies were evaluated by odds ratios (ORs) and 95% confidence interval (CI) using traditional meta-analytic techniques. Results: Eleven studies (n = 4567 patients) met the inclusion criteria. The results showed that the risk of development of SBP significantly increased (OR = 2.04, 95% CI 1.56-2.69, P < 0.00001) in cirrhotic patients with PPI. The fixed effect model was used because of low heterogeneity, P < 0.1 and I² = 44%. Subgroup analysis was performed in different study regions. The risk of developing SBP in cirrhotic patients with PPI treatment was significantly increased (OR = 2.22, 95% CI 1.72-2.87, P < 0.0001; OR = 1.70, 95% CI 0.70-4.13, P = 0.24; OR = 1.99, 95% CI 1.19-3.32, P = 0.009) in Asian, European, and American patients. Moderate heterogeneity existed in Euro-American patients. Conclusion: There was a significant correlation between the development of SBP and the use of PPI in cirrhotic patients. Therefore, clinicians should be aware of the indications of PPI, and use PPI cautiously in these patients. Further research need to clarify the correlation between the type, dose and course of treatment of PPI and the development of SBP in cirrhotic patients.