Statins do not improve short-term survival in an oriental population with sepsis

A retrospective study on the effect of statins on mortality and antimicrobial resistance among patients with Staphylococcus aureus bloodstream infection

Introduction

There is insufficient evidence in statin on the treatment of Staphylococcus aureus (SA) infection, we observe and analyze the clinical outcomes and antibiotic resistance of SA bloodstream infections in patients who received statins.

Methods

A retrospective study was carried out in SA bloodstream infection of hospitalized patients from January 2018 to August 2023. The 30-day attributable mortality, 30-day all-cause mortality and clinical data of patients who received statins and non-statins were compared.

Results

A total of 74 patients with SA bloodstream infection were included, 32 (43.2%) patients received treatment with statins and 42 (56.8%) with non-statins. The incidence of methicillin-resistant SA (MRSA) was significantly lower in the statins group (15.6% vs. 38.1%, p = 0.034), however, no significant differences were observed in the mortality rate (p = 0.410).

Conclusions

This study revealed the superiority of statins in reducing incidence of MRSA among SA bloodstream infection patients, but statins do not improve the 30-day mortality rate.

Nephroprotective effect of apilarnil in lipopolysaccharide-induced sepsis through TLR4/NF-κB signaling pathway

AIMS

In this study, we aimed to investigate the protective effect of apilarnil on kidney damage in the sepsis model induced by LPS.

MAIN METHODS

64 Sprague Dawley adult male rats were randomly divided into eight groups; control group, groups in which 0.2, 0.4 and 0.8 g/kg/bw apilarnil (API) was applied by oral gavage method for 10 days, LPS group in which 30 mg/kg/bw lipopolysaccharide (LPS) administered as intraperitoneally, groups in which LPS + 0.2, LPS+ 0.4 and LPS +0,8 API was applied. Six hour after the last administration the rats were anesthetized for euthanasia and kidney tissues were removed for RT-PCR analysis, immunohistochemical analysis and histopathologic analysis.

KEY FINDING

According to the results of RT-PCR expression levels of IL-6, IL-1β, NF-κB, TNF-α and TLR4 were significantly reduced in the LPS + 0,8 API group. Immunoreactivity of TLR4, pNF-κB and TNF-α levels in the LPS + 0.8 apilarnil group were significantly lower than in the LPS and LPS + 0.2 apilarnil groups. Histologically, compared to the LPS group the glomerular damage score tended to decrease in the LPS + 0,4 API and LPS+ 0,8 API groups, while the tubulointerstitial injury score decreased especially in the LPS + 0,8 API group.

SIGNIFICANCE

In the present study, 0,8 g/kg dose of apilarnil promoted potential renoprotective effects which were achieved, at least in part, by the modulation of important markers of the local immune response in the model of LPS-induced sepsis.

Improved survival with continuation of statins in bacteremic patients

Objectives:

Varying statin exposures in bacteremic patients have different impacts on mortality. Among patients with adherent statin use, we sought to evaluate the impact of statin continuation on inpatient mortality in bacteremic patients.

Methods:

A retrospective cohort study was conducted using Optum Clinformatics^TM with matched Premier Hospital data (October 2009–March 2013). Patients with a primary diagnosis of bacteremia and 6 months of continuous enrollment prior to the admission, receiving antibiotics at least 2 days of antibiotics during the first 3 days of admission, were selected for inclusion. Furthermore, patients demonstrating adherent statin use based on 90 days of continuous therapy prior to admission were included. We then compared those continuing statin therapy for at least the first 5 days after admission and those not continuing during the admission.

Results:

Simvastatin (53.2%) and atorvastatin (33.8%) were the most commonly used statins among the 633 patients who met our inclusion and exclusion criteria. Propensity score adjusted Cox proportional hazards regression models demonstrated significantly lower inpatient mortality among those continuing statin therapy compared with those not continuing (n = 232 vs 401, adjusted hazard ratio 0.25, 95% confidence interval 0.08–0.79).

Conclusion:

Among patients adherent to their statin therapy prior to a bacteremia hospitalization, continued statin use after admission increased survival by 75% compared with those not continuing.

Effects of statins on the development of sepsis and organ dysfunction in hospitalized older patients in China

This study aimed to evaluate the protective role of statins on the development of sepsis and infection-related organ dysfunction and mortality in a hospitalized older Chinese population with bacterial infections. In this retrospective cohort study, 257 older patients with bacterial infection were divided into two groups: a statin group, those who had received statin therapy for ≥1 month before admission and continued receiving statin during hospitalization; and a non-statin group, those who had never received statin or used statin for <1 month prior to admission. A multivariate logistic regression analysis was performed to identify risk and protective factors for severe sepsis. A significantly lower incidence of organ dysfunction was found in the statin group, as compared with the non-statin group (13.3% vs 31.1%, respectively; p = 0.002), corresponding to adjusted rates ratio of 0.32 (95% confidence interval [CI], 0.13–0.75; p = 0.009). No significant difference was found between statin and non-statin groups in 30-day sepsis-related mortality (4.4% vs 10.2%, respectively; p = 0.109), incidence of intensive care unit admission (13.3% vs 16.8%, respectively; p = 0.469), or length of hospital stay (20.5 vs 25.9 days, respectively; p = 0.61). Statins significantly reduced the development of sepsis and infection-related organ dysfunction in hospitalized older Chinese patients but did not reduce 30-day mortality, ICU admission incidence, or length of hospital stay.

Statin Adverse Events in Primary Prevention: Between Randomized Trials and Observational Studies

Considerable debate exists regarding who might benefit from statins for primary prevention. Statins have wide pleotropic effects, which contribute to their efficacy in lowering cardiovascular disease but may also result in adverse events (AEs). Caveats in identifying AEs in randomized controlled trials (RCTs) include the lack of a standardized definition of statin-associated AEs, the differences in properties of different statins, the selectivity of RCTs in choosing their participants, the presence of high rate of nonadherence/withdrawal from trials and other concerns related to study design and conflict of interest. Caveats in identifying or overestimating AEs in observational studies include failure to identify baseline confounders, ascertainment bias, confounding by indication and healthy user bias. Statin use in observational studies may be a surrogate marker for higher socioeconomic standards, access to health care or use of other preventive services. Integrating evidence from both RCTs and observational studies is of paramount importance for appropriate patient-centered decision.

Impact of statins in outcomes of septic patients: a systematic review

BACKGROUND

The pleiotropic effects of statins have prompted considerable research in fields other than cardiovascular disease. We reviewed the literature aiming to summarize and critically evaluate the current evidence about the potential use of statins in sepsis.

MATERIALS AND METHODS

We searched the Pubmed, SciELO, and Cochrane electronic databases from inception through November 1, 2013, for randomized controlled trials (RCTs) and cohort studies that examined the association between statin use (upon hospital admission or previous users) and the risk or outcome of sepsis. Data on study characteristics, measurement of statin use, and outcomes (adjusted for potential confounders) were extracted. We structured our review according to the Principles of Reporting in Systematic Reviews and Meta-Analysis criteria. Quality assessment of cohort studies was performed using the Ottawa-Newcastle Scale.

RESULTS

Twenty-three cohort studies and 5 RCTs were eligible, comprising 42 549 statin users and 54 201 non-statin users, from 1995 to 2013. The populations included varied from patients admitted to general wards or intensive care units with bacterial infections, community-acquired pneumonia, ventilator-associated pneumonia, bacteremia, or sepsis, to outpatients with chronic kidney disease or established cardiovascular disease. Overall, 16 studies reported a benefit from statin use in morbidity or mortality outcomes (range of adjusted odds ratio, 0.06-0.62; α = 0.05). The remaining 12 studies found no protective effect associated with statin use upon hospital admission or previous users. Among the 5 RCTs, none demonstrated a reduction in mortality.

CONCLUSION

There is insufficient evidence to support the use of statins in patients with sepsis, as the existing studies failed to prove a consistent mortality benefit. More clinical trials are warranted to provide more conclusive knowledge and ultimately change clinical practice.

Prior statin use and 90-day mortality in Gram-negative and Gram-positive bloodstream infection: a prospective observational study

In several studies on patients with bloodstream infection (BSI), prior use of statins has been associated with improved survival. Gram-positive and Gram-negative bacteria alert the innate immune system in different ways. We, therefore, studied whether the relation between prior statin use and 90-day total mortality differed between Gram-positive and Gram-negative BSI. We conducted a prospective observational cohort study of 1,408 adults with BSI admitted to Levanger Hospital between January 1, 2002, and December 31, 2011. Data on the use of statins and other medications at admission, comorbidities, functional status, treatment, and outcome were obtained from the patients’ hospital records. The relation of statin use with 90-day mortality differed between Gram-negative and Gram-positive BSI (p-value for interaction 0.01). Among patients with Gram-negative BSI, statin users had significantly lower 90-day total mortality [odds ratio (OR) 0.42, 95 % confidence interval (CI) 0.23–0.75, p = 0.003]. The association remained essentially unchanged after adjusting for the effect of sex, age, functional status before the infection, and underlying diseases that were considered confounders (adjusted OR 0.38, 95 % CI 0.20–0.72, p = 0.003). A similar analysis of patients with Gram-positive BSI showed no association of statin use with mortality (adjusted OR 1.22, 95 % CI 0.69–2.17, p = 0.49). The present study suggests that prior statin use is associated with a lower 90-day total mortality in Gram-negative BSI, but not in Gram-positive BSI.

Effect of the use of low and high potency statins and sepsis outcomes

INTRODUCTION

Although statins have been shown to have cholesterol-lowering effects, their pleiotropic benefits on sepsis remain a matter of debate. In addition, the influence of statin potency on sepsis-related mortality has never been explored. The aim of our study was to determine the sepsis outcomes of low- and high-potency statin users and non-users.

METHODS

This nationwide, population-based, propensity score-matched analysis used data from the linked administrative databases of Taiwan's National Health Insurance program. Patients were hospitalized for sepsis between 2000 and 2010. All-cause mortality and major adverse consequences of sepsis, such as in-hospital death, intensive care unit admission, shock events, and the use of mechanical ventilation, were assessed. Patients were divided into high-potency statin users (at least 10 mg rosuvastatin, at least 20 mg atorvastatin, or at least 40 mg simvastatin), low-potency statin users (all other statin treatments), and non-users.

RESULTS

A propensity score-matched cohort of 27,792 statin users and 27,792 non-users was included. Of 27,792 statin users, 9,785 (35.2 %) were treated with high-potency statins and 18,007 (64.8 %) were treated with low-potency statins. The 1-year mortality risk was significantly lower among both low-potency [adjusted hazard ratio (aHR) 0.89, 95 % confidence interval (CI) 0.85-0.93] and high-potency (aHR 0.80, 95 % CI 0.75-0.86) statin users compared with non-users. The risks of mortality and adverse consequences of sepsis were lower among high-potency than among low-potency statin users.

CONCLUSIONS

High-potency statin use is associated with a lower risk of sepsis-related mortality compared with low-potency statin use.

Statins role in the prevention and treatment of sepsis

Sepsis is a complex disease with typically poor outcomes. While the onset of sepsis is typically infectious, the detrimental consequences follow pathogen toxin release that produces activation of numerous cytokines and a pro-inflammatory response. These same cytokines also stimulate activation of coagulation and inhibit natural fibrinolysis. Despite decades of research targeted against these pathways the development of sepsis and mortality in patients with sepsis remains high. While statins were developed for reducing cholesterol in patients with atherosclerotic disease, we now know they have a number of other properties which may be helpful in the prevention and treatment of sepsis. Statins have demonstrated the ability to reduce a number of pro-inflammatory cytokines known to be detrimental in the development and progression of sepsis. Statins have also demonstrated the ability to limit the coagulation response and promote fibrinolysis in the setting of sepsis. Based on these encouraging pharmacologic properties of statins a number of trials have been conducted evaluating the impact of statins on the prevention and treatment of sepsis. Most of the trials to date have been retrospective cohort trials, with very few prospective randomized trials. While some trials fail to demonstrate a benefit of statins, most trials suggest a reduction in the development of sepsis and/or other important sepsis related outcomes. While the laboratory and early clinical experience with statins are encouraging, randomized controlled trials will be need to fully define the role of statins in the prevention and treatment of sepsis.

The effect of statin therapy on the incidence of infections: a retrospective cohort analysis

BACKGROUND

Statins have been postulated to prevent infection through immunomodulatory effects.

OBJECTIVES

To compare the incidence of infections in statin users to that in nonusers within the same health care system.

METHODS

This was a retrospective cohort study of patients enrolled as Tricare Prime or Plus in the San Antonio military multimarket. Statin users were patients who received a statin for at least 3 months between October 1, 2004 and September 30, 2005. Nonusers were patients who did not receive a statin within the study period (October 1, 2003-September 30, 2009). Inpatient and outpatient International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes were used to determine the incidence of infections during the follow-up period (October 1, 2005-September 30, 2009) via multivariable regression analysis and time to infection via Cox regression analysis.

RESULTS

Of 45,247 patients who met the study criteria, 12,981 (29%) were statin users and 32,266 were nonusers. After adjustments for age, gender, Charlson Comorbidity Score, tobacco use, alcohol abuse/dependence, health care utilization and use of specific medication classes, statin use was associated with an increased incidence of common infections (odds ratio [OR]: 1.13; 95% confidence interval [CI]: 1.06-1.19) but not influenza or fungal infections (OR: 1.06, 95% CI: 0.80-1.39; OR: 0.97; 95% CI: 0.91-1.04, respectively). Time-to-first infection was similar in statin users and nonusers in all infection categories examined.

CONCLUSIONS

Statin use was associated with an increased incidence of common infections but not influenza or fungal infections. This study does not support a protective role of statins in infection prevention; however, the influence of potential confounders cannot be excluded.

Effect of statin therapy on mortality from infection and sepsis: a meta-analysis of randomized and observational studies

INTRODUCTION

Observational data have suggested that statin therapy may reduce mortality in patients with infection and sepsis; however, results from randomized studies are contradictory and do not support the use of statins in this context. Here, we performed a meta-analysis to investigate the effects of statin therapy on mortality from infection and sepsis.

METHODS

We searched electronic databases (PubMed and Embase) for articles published before November 2013. Randomized or observational studies reporting the effects of statin therapy on mortality in patients with infection or sepsis were eligible. Randomized and observational studies were separately pooled with relative risks (RRs) and random-effects models.

RESULTS

We examined 5 randomized controlled trials with 867 patients and 27 observational studies with 337,648 patients. Among the randomized controlled trials, statins did not significantly decrease in-hospital mortality (RR, 0.98; 95% confidence interval (CI), 0.73 to 1.33) or 28-day mortality (RR, 0.93; 95% CI, 0.46 to 1.89). However, observational studies indicated that statins were associated with a significant decrease in mortality with adjusted data (RR, 0.65; 95% CI, 0.57 to 0.75) or unadjusted data (RR, 0.74; 95% CI, 0.59 to 0.94).

CONCLUSIONS

Limited evidence suggests that statins may not be associated with a significant reduction in mortality from infection and sepsis. Although meta-analysis from observational studies showed that the use of statins was associated with a survival advantage, these outcomes were limited by high heterogeneity and possible bias in the data. Therefore, we should be cautious about the use of statins in infection and sepsis.

Statin use and clinical outcomes among pneumonia patients

It was suggested that statin may improve the outcomes of pneumonia patients. However, there are sparse data regarding this topic in ethnic Chinese populations. In the present study, we investigated associations between previous statin use and pneumonia outcomes in Taiwan with a large-scale matched cohort study. A total of 11,576 patients with pneumonia were selected, comprising 2894 patients with previous statin use and 8682 matched patients. We used a separate conditional logistic regression to explore relationships between statin use and each clinical outcome, including 'intensive care unit admission,' 'use of mechanical ventilation,' 'acute respiratory failure' and 'in-hospital death'. We found that patients who were statin users were 0.81 (95% CI 0.74-0.89), 0.80 (95% CI 0.71-0.89), 0.84 (95% CI 0.75-0.94) and 0.69 times (95% CI 0.57-0.85) less likely to be admitted to the intensive care unit, to have acute respiratory failure, to need mechanical ventilation, and to die in the hospital, respectively, than patients who were not statin users. In addition, it consistently revealed that compared with patients who were not statin users, regular statin users had lower ORs of intensive care unit admission, acute respiratory failure, the use of mechanical ventilation and in-hospital death. However, there were no significant differences in the above adverse outcomes between irregular users of statin and non-statin users. We concluded that patients with regular previous statin use were significantly associated with favourable outcomes during admission for pneumonia in Taiwan.

Effect of statin therapy in the outcome of bloodstream infections due to Staphylococcus aureus: a prospective cohort study

INTRODUCTION

Statins have pleiotropic effects that could influence the prevention and outcome of some infectious diseases. There is no information about their specific effect on Staphylococcus aureus bacteremia (SAB).

METHODS

A prospective cohort study including all SAB diagnosed in patients aged ≥18 years admitted to a 950-bed tertiary hospital from March 2008 to January 2011 was performed. The main outcome variable was 14-day mortality, and the secondary outcome variables were 30-day mortality, persistent bacteremia (PB) and presence of severe sepsis or septic shock at diagnosis of SAB. The effect of statin therapy at the onset of SAB was studied by multivariate logistic regression and Cox regression analysis, including a propensity score for statin therapy.

RESULTS

We included 160 episodes. Thirty-three patients (21.3%) were receiving statins at the onset of SAB. 14-day mortality was 21.3%. After adjustment for age, Charlson index, Pitt score, adequate management, and high risk source, statin therapy had a protective effect on 14-day mortality (adjusted OR = 0.08; 95% CI: 0.01-0.66; p = 0.02), and PB (OR = 0.89; 95% CI: 0.27-1.00; p = 0.05) although the effect was not significant on 30-day mortality (OR = 0.35; 95% CI: 0.10-1.23; p = 0.10) or presentation with severe sepsis or septic shock (adjusted OR = 0.89; CI 95%: 0.27-2.94; p = 0.8). An effect on 30-day mortality could neither be demonstrated on Cox analysis (adjusted HR = 0.5; 95% CI: 0.19-1.29; p = 0.15).

CONCLUSIONS

Statin treatment in patients with SAB was associated with lower early mortality and PB. Randomized studies are necessary to identify the role of statins in the treatment of patients with SAB.

Statins decrease mortality in Lebanese patients with sepsis: A multicenter study

BACKGROUND

Sepsis is a significant public health concern. The clinical response to statins is variable among sepsis patients.

OBJECTIVE

The aim of the study was to determinate the effect of statin-treatment on mortality in Lebanese patients with sepsis.

METHODS

A retrospective multicenter study on Lebanese patients with sepsis between January 2008 and March 2012 was conducted. Patients with a primary diagnosis of sepsis admitted to the intensive care unit of two tertiary care hospitals in Beirut were included. Patients who continued to receive statin therapy for dyslipidemia during the hospital course were included in the statin treatment group. The control group consisted of patients not taking statin. Demographic characteristics, clinical signs, standard laboratory test and treatment received were compared between these two groups using univariate analysis. Logistic regression and survival analysis were performed by SPSS.

RESULTS

THREE HUNDRED FIFTY ONE LEBANESE PATIENTS WERE INCLUDED (AGE: 71.33 SD=14.97 years; Male: 56%). Among them, 30% took a statin at the doses recommended for dyslipidemia. The comparison of the two groups showed that in the statin treatment group: The mean serum level of C-reactive protein at the time of sepsis was significantly decreased (P=0.050), the length-stay at ICU significantly increased (P=0.047) and mortality significantly reduced (P<0.001). Results were confirmed by logistic regression, particularly for mortality. In the Cox regression analysis, hypothermia and shock were significantly associated with high mortality while statin treatment decreased mortality (hazard ratio = 0.540; 95% CI: 0.302-0.964; P=0.037).

CONCLUSIONS

At usual doses for dyslipidemia, statin treatment decreased incidence of mortality related to sepsis and improved the survival in this Lebanese septic population. Large randomized controlled clinical trials must be realized to give conclusive results about the potential beneficial effect of statins in sepsis.

The controversy of a wider statin utilization: why?

INTRODUCTION

Several medical journals published viewpoints and counter-viewpoints supporting or opposing a wider utilization of statins for primary prevention. The objective of this article is not to weigh in the benefits versus risks of statin use, but to discuss various aspects of this controversy.

AREAS COVERED

This review discusses the challenges in examining the pleotropic effects/adverse events of statins. It also discusses the pitfalls in assessment of adverse events in randomized controlled trials and observational studies.

EXPERT OPINION

The challenges in solving this controversy include that the pleotropic effect of statins results in an extremely wide spectrum of reported benefits or adverse events, the reported harms/benefits are contradictory, there is basic research ground supporting both sides of the controversy, it is difficult to separate if adverse events are due to statins or due to lower cholesterol, and that there is a lack of standardized definition of statin-associated adverse events and their methods of ascertainment. Both randomized controlled trials and observational studies have pitfalls and caveats in assessment of adverse events. Understanding the points of debate is of paramount significance to enable clinicians to individualize patient care.

Systematic review and meta-analysis on the association between outpatient statins use and infectious disease-related mortality

BACKGROUND

To update and refine systematic literature review on the association between outpatient statins use and mortality in patients with infectious disease.

MATERIALS AND METHODS

We searched articles published before September 31, 2012, on the association between statins and infectious disease-related mortality through electronic databases. Eligible articles were analyzed in Review Manager 5.1. We conducted stratification analysis by study design, infection types, clinical outcomes and study locations.

RESULTS

The pooled odds ratio (OR) for death (statins use vs. no use) across the 41 included studies was 0.71 (95% confidence interval: 0.64, 0.78). The corresponding pooled ORs were 0.58 (0.38, 0.90), 0.66 (0.57, 0.75), 0.71 (0.57, 0.89) and 0.83 (0.67, 1.04) for the case-control study, retrospective cohort studies, prospective cohort studies and RCTs; 0.40 (0.20, 0.78), 0.61 (0.41, 0.90), 0.69 (0.62, 0.78) and 0.86 (0.68, 1.09) for bacteremia, sepsis, pneumonia and other infections; 0.62 (0.534, 0.72), 0.68 (0.53, 0.89), 0.71 (0.61, 0.83) and 0.86 (0.70, 1.07) for 30-day, 90-day, in-hospital and long-term (>1 year) mortality, respectively.

CONCLUSIONS

Outpatient statins use is associated with a lower risk of death in patients with infectious disease in observational studies, but in a less extent in clinical trials. This association also varies considerably by infection types and clinical outcomes.

Statins in the critically ill

The use or misuse of statins in critically ill patients recently attracted the attention of intensive care clinicians. Indeed, statins are probably the most common chronic treatment before critical illness and some recent experimental and clinical data demonstrated their beneficial effects during sepsis, acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), or after aneurismal subarachnoidal hemorrhage (aSAH). Due to the heterogeneity of current studies and the lack of well-designed prospective studies, definitive conclusions for systematic and large-scale utilization in intensive care units cannot be drawn from the published evidence. Furthermore, the extent of statins side effects in critically ill patients is still unknown. For the intensive care clinician, it is a matter of individually identifying the patient who can benefit from this therapy according to the current literature. The purpose of this review is to describe the mechanisms of actions of statins and to synthesize the clinical data that underline the relevant effects of statins in the particular setting of critical care, in an attempt to guide the clinician through his daily practice.

Statins in sepsis

Sepsis is a common intensive care unit event occurring in approximately 750 000 patients annually, with a case mortality rate approaching 50%. Sepsis is characterized by a chaotic and excessive release of inflammatory cytokines and procoagulants including tumor necrosis factor, interleukin (IL)-1, IL-6, IL-8, platelet-activating factor, and tissue factor. Efforts to inhibit individual cytokines in order to modify poor outcomes have been generally disappointing, suggesting the need to target multiple inflammatory mediators to obtain clinical benefit. Statins lower lipids by inhibiting 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase, which in turn inhibits the rate-limiting step in cholesterol biosynthesis. In addition to lowering total cholesterol, statins have pleiotropic effects on inflammation and immunity. Instead of impacting a single entity in the sepsis syndrome, statins may have positive effects on multiple inflammatory, immunomodulating, and coagulation targets involved in the development of infection and sepsis. There have been a number of institutional- and population-based studies that have evaluated the impact of statins in patients with infection and sepsis. Most of these studies, but not all, have demonstrated a number of positive outcomes in patients with statins, including reduction in mortality. Based on these data, statins are a promising therapy in the management of patients with sepsis and warrant larger and more rigorous clinical trials.

Effect of statins on the clinical outcomes of patients with sepsis

Despite numerous attempts at novel intervention and tests to aid in earlier diagnosis and improved treatment, there has been an increased incidence of overall mortality related to sepsis, despite improvements in in-hospital mortality. Statins have emerged as potential immunomodulatory and antioxidant agents that might impact on sepsis outcomes. Definitive evidence to support the routine use of statins in patients with sepsis has not yet been elicited. We retrospectively analysed data from patients who presented with sepsis, severe sepsis or septic shock, stratifiying them according to statin use into two groups (statin and no statin). Sequential Organ Failure Assessment was used to evaluate severity of illness. The primary outcome was hospital mortality. Secondary outcomes included intensive care unit (ICU) mortality, hospital and ICU length of stay, and mechanical ventilation and vasopressor therapy duration. Five hundred and sixty-eight patients were included. Patients with prior statin use (statin group) were older; more obese and had higher prevalence of smoking, diabetes and ischaemic heart disease. There was no difference in Sequential Organ Failure Assessment scores and mortality did not vary between the two groups (19.6 vs. 16.9%). Furthermore, secondary outcomes including ICU mortality, hospital and ICU length of stay, mechanical ventilation and vasopressor duration did not differ Multivariate analysis revealed age and Sequential Organ Failure Assessment score were independent predictors of survival, while history of statin use was not (p = 0.403). This current retrospective study did not find any benefit of statin use on primary and secondary outcomes of the patients admitted to an academic hospital with sepsis.

Effect of statin treatment on three-month outcomes in patients with stroke-associated infection: a prospective cohort study

BACKGROUND AND PURPOSE

Infection is a major medical problem in patients with acute stroke. Recent evidences suggest that statins reduce infection-associated complications. The purpose of this study was to examine the influence of statin treatment on mortality and functional outcomes in patients with stroke-associated infection.

METHODS

In this prospective observational cohort study, 514 patients with acute ischaemic stroke or transient ischaemic attack (mean age, 74 ± 11 years; men, 48%) with infection occurring in the first 7 days after admission were included. We examined the effect of in-hospital statin treatment on mortality and favorable functional outcome (modified Rankin Scale score ≤2) at 3 months follow-up.

RESULTS

  Infection occurred at 0.93 ± 1.49 days after admission. All patients had not received statin treatment prior to admission, and 121 patients (24%) received statin at 1.71 ± 1.28 days after admission. Follow-up at 3 months was completed for 511 patients (99%). National Institutes of Health Stroke Scale score and Charlson index were the most important independent predictors of mortality and functional outcome. Univariate [hazard ratio (HR), 0.82; 95% confidence intervals (CI), 0.47-1.42] and multivariate (HR, 1.68; 95% CI, 0.79-3.56) Cox regression analysis showed that statin did not significantly decrease the morality. In propensity analysis, statin treatment still had no significant association with mortality (HR, 1.54; 95% CI, 0.68-3.47) in the multivariate analyses after adjusting for age, sex, and propensity score.

CONCLUSIONS

  Statin use was not associated with a better functional outcome or survival in patients with stroke-associated infection.

The impact of prior long-term versus short-term statin use on the mortality of bacteraemic patients

BACKGROUND

The aim of this investigation was to assess the effect of prior statin use on the 30-day in-hospital mortality among bacteraemic patients and to determine the impact of long-term versus short-term statin use on the mortality of bacteraemic patients.

PATIENTS AND METHODS

A retrospective study of 342 bacteraemic patients who presented to the emergency department (ED) within a period of 7 years was undertaken. Twenty-three patients did not meet the inclusion criteria. The remaining 319 patients were divided into three groups according to statin use and duration of therapy prior to the bacteraemic episode: group 1 (n = 123) had long-term statin use ≥ 12 weeks, group 2 (n = 35) had short-term statin use < 12 weeks, and group 3 (n = 161) had no statin use.

RESULTS

The overall 30-day in-hospital all-cause mortality of patients with statins was lower than patients without statin therapy (13 vs. 24%, p = 0.001). The mortality rate in group 1 was lower than in group 2 (11 vs. 17%, p = 0.04). After adjusting for confounding variables, the results of a multiple Cox regression analysis revealed that the absence of statin use (hazard ratio [HR] = 2.98; 95% confidence interval [CI] 1.59-5.56, p = 0.001) was associated with increased 30-day in-hospital all-cause mortality in bacteraemic patients.

CONCLUSIONS

Statins reduce the 30-day in-hospital all-cause mortality of bacteraemic patients. Long-term statin use prior to the bacteraemia improves the survival of bacteraemic patients more than short-term statin use.

Association between statin therapy and outcomes in critically ill patients: a nested cohort study

Background

The effect of statin therapy on mortality in critically ill patients is controversial, with some studies suggesting a benefit and others suggesting no benefit or even potential harm. The objective of this study was to evaluate the association between statin therapy during intensive care unit (ICU) admission and all-cause mortality in critically ill patients.

Methods

This was a nested cohort study within two randomised controlled trials conducted in a tertiary care ICU. All 763 patients who participated in the two trials were included in this study. Of these, 107 patients (14%) received statins during their ICU stay. The primary endpoint was all-cause ICU and hospital mortality. Secondary endpoints included the development of sepsis and severe sepsis during the ICU stay, the ICU length of stay, the hospital length of stay, and the duration of mechanical ventilation. Multivariate logistic regression was used to adjust for clinically and statistically relevant variables.

Results

Statin therapy was associated with a reduction in hospital mortality (adjusted odds ratio [aOR] = 0.60, 95% confidence interval [CI] 0.36-0.99). Statin therapy was associated with lower hospital mortality in the following groups: patients >58 years of age (aOR = 0.58, 95% CI 0.35-0.97), those with an acute physiology and chronic health evaluation (APACHE II) score >22 (aOR = 0.54, 95% CI 0.31-0.96), diabetic patients (aOR = 0.52, 95% CI 0.30-0.90), patients on vasopressor therapy (aOR = 0.53, 95% CI 0.29-0.97), those admitted with severe sepsis (aOR = 0.22, 95% CI 0.07-0.66), patients with creatinine ≤100 μmol/L (aOR = 0.14, 95% CI 0.04-0.51), and patients with GCS ≤9 (aOR = 0.34, 95% CI 0.17-0.71). When stratified by statin dose, the mortality reduction was mainly observed with statin equipotent doses ≥40 mg of simvastatin (aOR = 0.53, 95% CI 0.28-1.00). Mortality reduction was observed with simvastatin (aOR = 0.37, 95% CI 0.17-0.81) but not with atorvastatin (aOR = 0.80, 95% CI 0.84-1.46). Statin therapy was not associated with a difference in any of the secondary outcomes.

Conclusion

Statin therapy during ICU stay was associated with a reduction in all-cause hospital mortality. This association was especially noted in high-risk subgroups. This potential benefit needs to be validated in a randomised, controlled trial.

Statins in prevention and treatment of severe sepsis and septic shock

Severe sepsis is an infection-induced inflammatory syndrome that can lead to multi-organ dysfunction and continues to be a major cause of morbidity and mortality worldwide. Because numerous cascades are triggered during sepsis, selective blocking of inflammatory mediators may be insufficient to arrest this process, and recent therapeutic approaches have proven controversial. Statins are the most commonly prescribed agents for hypercholesterolaemia and dominate the area of cardiovascular risk reduction. Moreover, these drugs have a variety of actions that are independent of their lipid lowering effect. Such anti-inflammatory, antioxidant, immunomodulatory, and antiapoptotic features have been collectively referred to as pleiotropic effects. By virtue of their pleiotropic effects, statins have also emerged as potentially useful in various critical care areas such as bacteraemia, the early phases of sepsis and septic shock, as well as the management of serious infections. This review outlines current evidence on the use of statins for preventing and treating sepsis.

Prior statin use is not associated with improved outcome in emergency patients admitted with infection: a prospective observational study

OBJECTIVES

The objective was to determine whether prior statin use is associated with lower mortality in emergency patients admitted with infection.

METHODS

A prospective observational study was conducted at the emergency department (ED) of a tertiary adult hospital with an annual census of over 73,000 patients. Patients presenting to the ED who were subsequently hospitalized with a primary diagnosis of infection were identified within 24 hours of presentation. Data were abstracted from patients' charts and from hospital electronic databases. Patients were stratified according to reported regular statin use on presentation. The outcome measure was in-hospital mortality truncated at 30 days. An association between statin use and mortality was sought using logistic regression analysis.

RESULTS

Data were collected over a 60-week period from 2,642 admissions. Patients taking a statin on admission had a higher unadjusted mortality risk (odds ratio [OR] = 2.14, 95% confidence interval [CI] = 1.32 to 3.46) compared to those not on a statin. However, this result became nonsignificant (OR = 0.96, 95% CI = 0.55 to 1.69) after adjusting for age, severity of disease, comorbid status, and propensity score.

CONCLUSIONS

These data do not support an independent association between current preadmission statin use and lower 30-day in-hospital mortality in emergency patients admitted with infection. This result is contrary to most previously published studies.

Statin treatment and mortality in bacterial infections--a systematic review and meta-analysis

BACKGROUND

Several studies have reported improved survival in severe bacterial infections among statin treated patients. In addition, statins have been ascribed beneficial anti-inflammatory effects. The aim of this study was to evaluate the effect of statin-treatment on mortality in patients with bacterial infections, by means of a systematic review and a meta-analysis.

METHODOLOGY AND PRINCIPAL FINDINGS

Studies investigating the association between statin use and mortality in patients with bacterial disease were identified in a systematic literature review and a meta-analysis was performed to calculate the overall odds ratio of mortality in statin users. The literature search identified 947 citations from which 40 relevant studies were extracted. In all, 15 studies comprising 113,910 patients were included in the final analysis. Statin use was associated with a significantly (p<0.0001) reduced mortality in patients suffering from bacterial infections (OR 0.52, 95% CI 0.42-0.66). However, all studies included were of observational design and funnel plot analyses indicated influence by a possible publication bias (Egger's bias test p<0.05). When a precision estimate test was used to adjust for publication bias the effect of statin treatment was no longer significant, with an OR of 0.79 (95% CI 0.58-1.07).

CONCLUSION/SIGNIFICANCE

According to the meta-analysis of observational studies presented here, patients on statin therapy seem to have a better outcome in bacterial infections. However, the association did not reach statistical significance after adjustment for apparent publication bias. Thus, there is a great need for randomised controlled trials investigating the possible beneficial effect of statins in bacterial infections.

The effect of statins on mortality from severe infections and sepsis: a systematic review and meta-analysis

PURPOSE

The aim of this study was to systematically review the literature on the effect of statins on mortality in patients with infection and/or sepsis.

MATERIALS AND METHODS

MEDLINE, EMBASE, PapersFirst, and the Cochrane collaboration and the Cochrane Register of controlled trials were searched and were current as of December 2009. Randomized, double-blind or single-blind, placebo-controlled studies; observational cohort studies (retrospective and prospective); and case-controlled studies were included. Types of participants included adult and pediatric subjects with sepsis or various other types of infection. Exposure was defined as the use of a statin for any indication. The primary outcome chosen was mortality from any cause, and secondary outcomes included 30-day mortality, in-hospital mortality, mortality from pneumonia, mortality from bacteremia, mortality from sepsis, and mortality from mixed infection.

RESULTS

A total of 20 studies were included in the analysis, 18 being cohort studies (12 retrospective, 6 prospective), 1 matched cohort study with 2 case-control studies, and 1 randomized control trial. Meta-analysis for various infection-related outcomes revealed the following pooled odds ratios all in favor of statin use vs non: 0.61 (95% confidence interval [CI], 0.48-0.73) for 30-day mortality (n = 7), 0.38 (95% CI, 0.13-0.64) for in-hospital mortality (n = 7), 0.63 (95% CI, 0.55-0.71) for pneumonia-related mortality (n = 7), 0.33 (95% CI, 0.09-0.75) for bacteremia-related mortality (n = 4), 0.40 (95% CI, 0.23-0.57) for sepsis-related mortality (n = 4), and 0.50 (95% CI, 0.18-0.83) for mixed infection-related mortality (n = 4).

CONCLUSIONS

This meta-analysis demonstrated a protective effect for statins in patients with sepsis and/or other infections compared to placebo for various infection-related outcomes. However, our results are limited by the cohort design of the selected studies and the degree of heterogeneity among them, and as a result, further randomized trials are needed to validate the use of statins for sepsis and/or other infections.

Statin use does not affect the outcome of acute infection: a prospective cohort study

Statins are used to prevent atherosclerosis because of their hypolipemic effects. In vitro testing and murine models suggest that statins may affect outcome in sepsis. Our meta-analysis of epidemiological studies in humans confirms that previous statin use appears to have a protective effect on infection rates and outcomes. The studies considered, however, were very different and heterogeneity was high, especially for mortality criteria.

OBJECTIVE

To compare outcome for current statin users and nonusers hospitalized with fever, under pragmatic circumstances.

DESIGN

Prospective cohort study.

SETTING

University Hospital of Brest (France).

PARTICIPANTS

Febrile (>38 degrees C) patients older than 40 years, admitted to the hospital on an emergency basis in 2005. Patients' outcome was compared according to their exposure to statins (current user or nonuser).

MAIN OUTCOME MEASURES

Mortality, length of hospitalization, admission to ICU and to convalescent homes

RESULTS

Of 40 343 patients referred for admission by the emergency department in 2005, 964 patients older than 40 years had a fever higher than 38 degrees C and were included in the study. Statin-user status, however, was available for only 921. The ICU admission rate (relative risk: 4.69; 95% CI: 2.42-9.08) was significantly higher (p=0.009) among statin users (n=139) than nonusers (n=782). The groups had similar lengths of hospitalization and similar rates of mortality and of convalescent home admissions.

CONCLUSION

Our study does not confirm that statin use affects infection outcome and suggests that previous findings may be associated instead with more cautious care or nonspecific cardiovascular prevention rather than with a specific infection-related effect. Thus, these data support the continuation of statin therapy during physiological aggression, including infection.

Statins for sepsis: a critical and updated review

There is increasing discussion of a potential role for statins in the management of sepsis. A search of PubMed, Embase, Scopus and the Cochrane Library databases was performed by combining the terms 'statins', 'infection', 'sepsis', 'bacteraemia', 'pneumonia', and 'ICU infections'. A total of 22 studies were retrieved, which included 177,260 people and compared clinical outcomes between 51,193 statin users and 126,067 non-statin users. Nineteen were cohort studies (seven prospective and 12 retrospective), two were retrospective case-control studies, and one was a randomized controlled study. Nine studies examined the use of statins in sepsis, four in community-acquired pneumonia (CAP), three in bacteraemia, and three in post-operative patients. Mortality data were presented in 15 studies; in ten, mortality was lower among statin users (three of six sepsis studies, five of six CAP studies, and two of three bacteraemia studies). In four studies, there was no difference in mortality (two of six sepsis studies, one of six CAP studies, and one of three bacteraemia studies) and in one study there was increased mortality among septic intensive-care unit patients receiving statins. Five of the nine studies that examined the risk of developing sepsis/infection as a primary outcome (six of nine sepsis studies and all studies in the postoperative setting) found a decreased risk among statin users, whereas the remaining studies found no difference. Irrespective of their design (matched vs. non-matched), the majority of the studies suggested that statins have a beneficial effect on the outcome of infection; however, their observational design does not allow us to draw firm conclusions. The clinical benefit of statin therapy in sepsis remains to be determined by ongoing randomized controlled trials.

Novel uses for statins in surgical patients

BACKGROUND

Aside from their cholesterol-lowering effects statins are known to have a range of other 'pleiotropic' effects. We present an overview of the basic science behind these effects and then review clinical trials and the current role of statins relevant to modern surgical practice.

METHODS

A systematic review of the literature was performed using the keywords surgery and the MeSH term for statins. All clinical studies relating to statin use in surgical patients were evaluated. An overview of the literature on statin use and cardiac outcomes was performed.

CONCLUSIONS

Statins are safe and have a wide range of pleiotropic effects relevant to surgical practice. Strongest evidence for their clinical use comes in primary cardiac risk reduction in many types of vascular surgery. There is a large body of evidence showing their benefit perioperatively in high-risk vascular and cardiac surgery but the picture is less clear for low-risk patients. Further studies are needed to evaluate exact dosage regimes and timing of administration. Novel uses of their anti-inflammatory properties in sepsis and vasomotor properties in subarachnoid haemorrhage are being further investigated by randomised trials.

Statin therapy is associated with decreased mortality in patients with infection

OBJECTIVES

The objective was to investigate the association between statin therapy and mortality in emergency department (ED) patients with suspected infection.

METHODS

A secondary analysis of a prospective, observational cohort study was conducted at an urban, academic ED with approximately 50,000 annual visits. Data were collected between December 2003 and September 2004. Inclusion criteria consisted of age > or = 18 years, clinical suspicion of infection, and hospital admission. Patients were divided by those receiving statin therapy and those not receiving statins while hospitalized. Medication data were collected from an inpatient pharmacy database. Comparisons were conducted with Fisher's exact test or Wilcoxon rank sum test. To adjust for baseline differences, multivariable logistic regression analysis controlling for gender, severity of illness (Mortality in Emergency Department Sepsis [MEDS] score), Charlson Comorbidity Index, and duration of statin therapy was performed.

RESULTS

Of 2,132 patients with suspected infection, 2,036 (95%) had interpretable pharmacy data and were analyzed. The cohort had a median age of 61 years (interquartile range [IQR] = 46-78 years) and a mortality of 3.9% (95% confidence interval [CI] = 3.1% to 4.8%). Patients who received statins (n = 474) had a lower unadjusted crude mortality (1.9%; 95% CI = 0.6% to 3.3%) compared to those who did not (4.5%; 95% CI = 3.4% to 5.4%; p </= 0.01). When adjusting for gender, MEDS score, Charlson Comorbidity Index, and duration of statin therapy, the odds of death for statin patients was 0.27 (95% CI = 0.1 to 0.72; p < or = 0.01).

CONCLUSIONS

Patients who were admitted to the hospital with infection and received statin therapy while hospitalized had a significantly lower in-hospital mortality compared to patients who did not receive a statin.