Stress ulcer prophylaxis versus placebo or no prophylaxis in critically ill patients. A systematic review of randomised clinical trials with meta-analysis and trial sequential analysis

Intensive Care Med. 2014 Jan;40(1):11-22. doi: 10.1007/s00134-013-3125-3. Epub 2013 Oct 19.


Purpose: To assess the effects of stress ulcer prophylaxis (SUP) versus placebo or no prophylaxis on all-cause mortality, gastrointestinal (GI) bleeding and hospital-acquired pneumonia in adult critically ill patients in the intensive care unit (ICU).

Methods: We performed a systematic review using meta-analysis and trial sequential analysis (TSA). Eligible trials were randomised clinical trials comparing proton pump inhibitors or histamine 2 receptor antagonists with either placebo or no prophylaxis. Two reviewers independently assessed studies for inclusion and extracted data. The Cochrane Collaboration methodology was used. Risk ratios/relative risks (RR) with 95% confidence intervals (CI) were estimated. The predefined outcome measures were all-cause mortality, GI bleeding, and hospital-acquired pneumonia.

Results: Twenty trials (n = 1,971) were included; all were judged as having a high risk of bias. There was no statistically significant difference in mortality (fixed effect: RR 1.00, 95% CI 0.84-1.20; P = 0.87; I(2) = 0%) or hospital-acquired pneumonia (random effects: RR 1.23, 95% CI 0.86-1.78; P = 0.28; I(2) = 19%) between SUP patients and the no prophylaxis/placebo patients. These findings were confirmed in the TSA. With respect to GI bleeding, a statistically significant difference was found in the conventional meta-analysis (random effects: RR 0.44, 95% CI 0.28-0.68; P = 0.01; I(2) = 48%); however, TSA (TSA adjusted 95% CI 0.18-1.11) and subgroup analyses could not confirm this finding.

Conclusions: This systematic review using meta-analysis and TSA demonstrated that both the quality and the quantity of evidence supporting the use of SUP in adult ICU patients is low. Consequently, large randomised clinical trials are warranted.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Adult
  • Anti-Ulcer Agents / therapeutic use*
  • Cause of Death
  • Chemoprevention / methods
  • Critical Illness / mortality
  • Cross Infection / complications*
  • Cross Infection / etiology
  • Gastrointestinal Hemorrhage / etiology*
  • Gastrointestinal Hemorrhage / mortality
  • Gastrointestinal Hemorrhage / prevention & control
  • Histamine H2 Antagonists / therapeutic use
  • Humans
  • Length of Stay
  • Peptic Ulcer / complications
  • Peptic Ulcer / prevention & control*
  • Pneumonia / complications*
  • Pneumonia / etiology
  • Proton Pump Inhibitors / therapeutic use
  • Randomized Controlled Trials as Topic
  • Risk
  • Stress, Psychological


  • Anti-Ulcer Agents
  • Histamine H2 Antagonists
  • Proton Pump Inhibitors