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To the Editor: The study by Dr Herzig and colleagues¹ concluded that there was a 30% increased risk in the odds of HAP in patients treated with proton-pump inhibitors. However, we believe that inadequate control for confounders calls this conclusion into question.

The authors noted the absence of information on activity order, presence of a nasogastric tube, or socioeconomic status. As they stated, all of these could have an association with both acid-suppressive medication use and HAP. Aspiration is common in hospitalized patients, especially in those who have difficulty swallowing and protecting their airway, which is characteristic of patients with nasogastric or gastric tubes. There is evidence that tube feedings put patients at high risk for aspiration if the head of the bed is not maintained in a semirecumbent position during feeding.² It is not clear whether this was accomplished for all of the patients included in this study who . . . [Full Text of this Article]

Patrick McCullough, MD
patrick.mccullough@healthall.com

Donald Benson, MD
Drake Center for Rehabilitative and Restorative Medicine
Cincinnati, Ohio

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