Statins and sepsis: multiple modifications at multiple levels

The impact of statin use on sepsis mortality

BACKGROUND

Statins exert pleiotropic anti-inflammatory and antioxidant effects in addition to their cholesterol-lowering properties. This study aimed to investigate whether statin use is associated with improved outcomes of sepsis.

METHODS

Data from sepsis patients were extracted from the Medical Information Mart for Intensive Care IV database. Patients with a history of receiving prescriptions for statins (i.e. atorvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, or simvastatin) were matched with non-users using propensity-score matching, to balance confounding factors between the groups. Mendelian Randomization (MR) analyses were performed using information from the UK Biobank dataset to explore the potential causal link between low-density lipoprotein cholesterol (LDL-C) levels and LDL-C lowering effects via genetically inhibiting β‑hydroxy β-methylglutaryl-coenzyme A reductase and the susceptibility to sepsis, and the sepsis-related 28-day mortality.

MAIN RESULTS

90-day mortality rate was lower among the 10,323 statin users when compared to matched non-users [hazard ratio (HR): 0.612, 95 % CI: 0.571 to 0.655]. In-hospital mortality was also lower for statin users compared to non-users (11.3% vs. 17.8 %, p < 0.0001, HR: 0.590, 95 % CI: 0.548 to 0.634). Statin use was associated with better outcome in all investigated subpopulations apart from patients with severe liver disease. MR analyses further pointed toward pleiotropic effects beyond lipid-lowering effects of statins on sepsis-related outcomes.

CONCLUSIONS

Statin use is associated with improved outcomes following sepsis-related ICU admission, most likely from its pleiotropic properties, characterized by lower 90-day and in-hospital mortality among statin users.

Effect of statins on sepsis and inflammatory factors: A Mendelian randomization study

BACKGROUND

As inhibitors of 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR), statins can reduce the synthesis of low-density lipoptrotein cholesterol (LDL-C), and are clinically used as first-line lipid-lowering drugs to prevent cardiovascular diseases. However, the effect of statins on sepsis is controversial. Therefore, we intend to explore the effects of statins on sepsis and inflammatory factors through Mendelian randomization (MR).

METHOD

We obtained sepsis, inflammatory factors, and LDL-C data from open and free genome-wide association study (GWAS) for subsequent analysis. Inverse-variance weighted (IVW) was the main method, MR-Egger, MR-PRESSO and Cochrane's Q-test were used as sensitive analysis to evaluate the robustness of MR results.

RESULTS

Statins were associated with a reduced risk of sepsis under 75 (sepsis in individuals under 75 years old) (OR: .716, 95% CI: .572-.896, p = .003), elevated circulating IL-18 (OR: .762, 95% CI: .643-.903, p = .002) and elevated circulating CCL2 (OR: .416, 95% CI: .279-.620, p = 1.685e-5).

CONCLUSION

Statins may have a protective effect on sepsis and this may provide a new idea for the treatment of sepsis.

Investigational pharmacological agents for the treatment of ARDS

INTRODUCTION

Acute Respiratory Distress Syndrome (ARDS) is a heterogeneous form of lung injury with severe hypoxemia and bilateral infiltrates after an inciting event that results in diffuse lung inflammation with a high mortality rate. While research in COVID-related ARDS has resulted in several pharmacotherapeutic agents that have undergone successful investigation, non-COVID ARDS studies have not resulted in many widely accepted pharmacotherapeutic agents despite exhaustive research.

AREAS COVERED

The aim of this review is to discuss adjuvant pharmacotherapies targeting non-COVID Acute Lung Injury (ALI)/ARDS and novel therapeutics in COVID associated ALI/ARDS. In ARDS, variable data may support selective use of neuromuscular blocking agents, corticosteroids and neutrophil elastase inhibitors, but are not yet universally used. COVID-ALI/ARDS has data supporting the use of IL-6 monoclonal antibodies, corticosteroids, and JAK inhibitor therapy.

EXPERT OPINION

Although ALI/ARDS modifying pharmacological agents have been identified in COVID-related disease, the data in non-COVID ALI/ARDS has been less compelling. The increased use of more specific molecular phenotyping based on physiologic parameters and biomarkers, will ensure equipoise between groups, and will likely allow more precision in confirming pharmacological agent efficacy in future studies.

Effects of Serum Cholesterol on Severity of Stroke and Dosage of Statins on Functional Outcome in Acute Ischemic Stroke

Background

A high dose of statin is used to obtain an intensive lipid-lowering in stroke patients, even in patients with normal lipid levels. There are limited data on effect of dosage of statins and functional outcome in stroke patients.

Objectives

To compare serum cholesterol levels with severity of stroke measured by infarct volume. To compare functional outcome measured by mRS at day 90 with the dose of statin.

Materials and Methods

This retrospective observational study was conducted in KMC Hospital Manipal, India between 2016 and 2018.

Result

A total of 100 consecutive patients were included in the study, out of which 60 (60.0%) were males. Hyperlipidemia was present in 65 (65.0%) patients. On comparing the serum cholesterol levels with infarct volume using MRI, patients with low volume of ≤70 ml had higher mean serum total cholesterol concentration (223.83 mg/dl), whereas patients with high volume of >70 ml had low mean cholesterol level (218.70 mg/dl). The patients were divided into those who received low dose (≤20 mg) versus high dose (≥40 mg equivalent) of Atorvastatin. On comparing the mRS values at baseline and on day 90 with the dose of statins, patients who received a higher dosage had a statistically significant fall in mRS (p-0.045) at day 90.

Conclusion

It was found that serum cholesterol levels were inversely related to the stroke severity. However, a higher the dose of statins resulted in better functional outcome and survival in post-stroke patients, possibly due to its neuroprotective effect.

The Relationship between Delirium and Statin Use According to Disease Severity in Patients in the Intensive Care Unit

Objective

The aim of this study was to investigate the association between the use of statins and the occurrence of delirium in a large cohort of patients in the intensive care unit (ICU), considering disease severity and statin properties.

Methods

We obtained clinical and demographical information from 3,604 patients admitted to the ICU from January 2013 to April 2020. This included information on daily statin use and delirium state, as assessed by the Confusion Assessment Method for ICU. We used inverse probability of treatment weighting and categorized the patients into four groups based on the Acute Physiology and Chronic Health Evaluation II score (group 1: 0-10 - mild; group 2: 11-20 - mild to moderate; group 3: 21-30 - moderate to severe; group 4: > 30 - severe). We analyzed the association between the use of statin and the occurrence of delirium in each group, while taking into account the properties of statins.

Results

Comparisons between statin and non-statin patient groups revealed that only in group 2, patients who were administered statin showed significantly higher occurrence of delirium (p = 0.004, odds ratio [OR] = 1.58) compared to the patients who did not receive statin. Regardless of whether statins were lipophilic (p = 0.036, OR = 1.47) or hydrophilic (p = 0.032, OR = 1.84), the occurrence of delirium was higher only in patients from group 2.

Conclusion

The use of statins may be associated with the increases in the risk of delirium occurrence in patients with mild to moderate disease severity, irrespective of statin properties.

Association of Prior to Intensive Care Unit Statin Use With Outcomes on Patients With Acute Kidney Injury

Purpose: To evaluate the association of prior to intensive care unit (ICU) statin use with the clinical outcomes in critically ill patients with acute kidney injury (AKI).

Materials and Methods: Patients with AKI were selected from the Medical Information Mart for Intensive Care IV (version 1.0) database for this retrospective observational study. The primary outcome was 30-day intensive care unit (ICU) mortality. A 30-day in-hospital mortality and ICU length of stay (LOS) were considered as secondary outcomes. Comparison of mortality between pre-ICU statin users with non-users was conducted by the multivariate Cox proportional hazards model. Comparison of ICU LOS between two groups was implemented by multivariate linear model. Three propensity score methods were used to verify the results as sensitivity analyses. Stratification analyses were conducted to explore whether the association between pre-ICU statin use and mortality differed across various subgroups classified by sex and different AKI stages.

Results: We identified 3,821 pre-ICU statin users and 9,690 non-users. In multivariate model, pre-ICU statin use was associated with reduced 30-day ICU mortality rate [hazard ratio (HR) 0.68 (0.59, 0.79); p < 0.001], 30-day in-hospital mortality rate [HR 0.64 (0.57, 0.72); p < 0.001] and ICU LOS [mean difference −0.51(−0.79, −0.24); p < 0.001]. The results were consistent in three propensity score methods. In subgroup analyses, pre-ICU statin use was associated with decreased 30-day ICU mortality and 30-day in-hospital mortality in both sexes and AKI stages, except for 30-day ICU mortality in AKI stage 1.

Conclusion: Patients with AKI who were administered statins prior to ICU admission might have lower mortality during ICU and hospital stay and shorter ICU LOS.

Statin Treatment in the Acute Phase and the Risk of Post-stroke Pneumonia: A Retrospective Cohort Study

Background: We aimed to investigate the impact of statin treatment in the acute phase on the risk and severity of post-stroke pneumonia because of the uncertain effects of statins on post-stroke pneumonia. Methods: Consecutive cases of acute ischemic stroke (AIS) between January 2014 and February 2019 were retrospectively analyzed. Additionally, the association of statin treatment in the acute phase with the risk and severity of post-stroke pneumonia was estimated with logistic regression. We registered the present study in the Chinese Clinical Trial Registry (ChiCTR 2000032838). Results: Of the 1,258 enrolled patients, no significant difference was observed in post-stroke pneumonia risk between the two groups (with/without statin treatment in the acute phase) after propensity score matching (35.1 vs. 27.9%, p = 0.155). We did not find statin treatment in the acute phase to significantly increase the risk of post-stroke pneumonia both before and after matched analysis [odds ratio (OR) = 1.51, 95% confidence interval (CI) = 0.85-2.67, p = 0.157; OR = 1.57, 95% CI = 0.77-3.18, p = 0.213, respectively]. In the 271 patients with post-stroke pneumonia, no significant difference was found in its severity between two groups (19.6 vs. 19.4%, p = 0.964). No significant association was found between statin treatment and post-stroke pneumonia severity (OR = 0.95, 95% CI = 0.39-2.31, p = 0.918). Conclusions: There appeared to be no additional benefits of statin treatment in the acute phase for post-stroke pneumonia reduction among AIS patients. Clinical Trial Registration:http://www.chictr.org.cn, identifier: ChiCTR2000032838.

Association Between Preoperative Statin Use and Respiratory Complications After Noncardiac Surgery: A Retrospective Cohort Analysis

BACKGROUND

Statins possess pleiotropic effects, which potentially benefit noncardiovascular conditions. Previous work suggests that statins reduce inflammation and prevent acute respiratory distress syndrome and infections. However, there is a paucity of data regarding potential benefits of statins on respiratory and infectious complications, particularly after noncardiac surgery. We therefore evaluated respiratory and other complications in noncardiac surgery patients taking or not taking statins preoperatively.

METHODS

We obtained data from the Cleveland Clinic Perioperative Health Documentation System and evaluated medical records of 92,139 inpatients who had noncardiac surgery. Among these, 31,719 patients took statins preoperatively. Statin patients were compared to nonstatin patients on incidence of intraoperative use of albuterol and postoperative respiratory complications for primary analysis. Infectious complications, cardiovascular complications, in-hospital mortality, and duration of hospitalization were compared for secondary analyses, using inverse probability of treatment weighting to control for potential confounding.

RESULTS

Statin use was associated with lower odds of intraoperative albuterol treatment (odds ratio [OR] = 0.89; 97.5% confidence interval [CI], 0.82-0.97; P = .001; number needed to treat [NNT] = 216). Postoperative respiratory complications were also less common (OR = 0.82; 98.75% CI, 0.78-0.87; P < .001). Secondarily, statin use was associated with lower odds of infections, cardiovascular complications, in-hospital mortality, and shorter duration of hospitalization. The interaction between statin use and sex was significant (with significance criteria P < .10) for all primary and secondary outcomes except intraoperative use of albuterol.

CONCLUSIONS

Preoperative statin use in noncardiac surgical patients was associated with slightly reduced odds of postoperative respiratory, infectious, and cardiovascular complications. However, the NNTs were high. Thus, despite the fact that statins appeared to be associated with lower odds of various complications, especially cardiovascular complications, our results do not support using statins specifically to reduce noncardiovascular complications after noncardiac surgery.

Association of Preadmission Statin Use and Mortality in Critically Ill Patients: A Meta-Analysis of Cohort Studies

Background: A large number of studies have been conducted to determine whether there is an association between preadmission statin use and improvement in outcomes following critical illness, but the conclusions are quite inconsistent. Therefore, this meta-analysis aims to include the present relevant PSM researches to examine the association of preadmission use of statins with the mortality of critically ill patients. Methods: The PubMed, Web of Science, Embase electronic databases, and printed resources were searched for English articles published before March 6, 2020 on the association between preadmission statin use and mortality in critically ill patients. The included articles were analyzed in RevMan 5.3. The Newcastle-Ottawa Scale (NOS) was used to conduct quality evaluation, and random/fixed effects modeling was used to calculate the pooled ORs and 95% CIs. We also conducted subgroup analysis by outcome indicators (30-, 90-day, hospital mortality). Results: All six PSM observational studies were assessed as having a low risk of bias according to the NOS. For primary outcome-overall mortality, the pooled OR (preadmission statins use vs. no use) across the six included studies was 0.86 (95% CI, 0.76-0.97; P = 0.02). For secondary outcome-use of mechanical ventilation, the pooled OR was 0.94 (95% CI, 0.91-0.97; P = 0.0005). The corresponding pooled ORs were 0.67 (95% CI, 0.43-1.05; P = 0.08), 0.91 (95% CI, 0.83-1.01; P = 0.07), and 0.86 (95% CI, 0.83-0.89; P < 0.00001) for 30-, 90-day, and hospital mortality, respectively. Conclusions: Preadmission statin use is associated with beneficial outcomes in critical ill patients, indicating a lower short-term mortality, less use of mechanical ventilation, and an improvement in hospital survival. Further high-quality original studies or more scientific methods are needed to draw a definitive conclusion.

Prior Statin Therapy and Mortality After Extracorporeal Membrane Oxygenation Therapy: A Retrospective, Population-Based, Cohort Study

OBJECTIVE

To investigate whether prior statin therapy is associated with an improvement in mortality among patients who undergo extracorporeal membrane oxygenation (ECMO) therapy.

DESIGN

Retrospective, population-based, cohort study.

SETTING

Health records were obtained from the National Health Insurance Service database in South Korea.

PATIENTS

All adult patients (≥18 y) who underwent ECMO therapy in the intensive care unit between 2005 and 2018 were enrolled.

EXPOSURES

Statin users were defined as patients who were prescribed continuous oral statins ≥90 days before ECMO.

MEASUREMENTS AND MAIN RESULTS

The primary endpoint of this study was 90-day mortality. A total of 21,129 adult patients from 128 hospitals were included (4,737 [22.4%] statin users and 16,392 [77.6%] nonusers). After propensity score matching, 9,474 ECMO patients (4,737 in each group) were included in the final analysis. In the propensity-score-matched cohort, statin users exhibited lower 90-day mortality than did nonusers (58.6% [2,774/4,737] in statin users v 65.6% [3,106/4,737] in nonusers). In addition, on Cox regression, 90-day mortality in statin users was 14% less than that in nonusers (hazard ratio 0.86, 95% confidence interval 0.81-0.90; p < 0.001).

CONCLUSION

Among patients who underwent ECMO in South Korea, prior statin therapy was found to be associated with lower 90-day mortality rates after ECMO therapy. However, because this study had a retrospective design, future prospective trials are needed to confirm the findings.

Effect of Pravastatin Pretreatment and Hypercapnia on Intestinal Microvascular Oxygenation and Blood Flow During Sepsis

INTRODUCTION

In septic patients, adequate microvascular oxygenation (μHBO2) of the intestine is vital for their outcome. Recent studies suggest that statins can ameliorate septic microcirculation in a variety of tissues. However, the effect on intestinal microvascular oxygenation and blood flow is largely unknown. Furthermore, there are indications that statin therapy might not be beneficial in the presence of hypercapnia, as observed in septic acute respiratory distress syndrome (ARDS) patients. Therefore, the present study explores the effect of pravastatin with and without additional moderate acute hypercapnia on intestinal microvascular oxygenation and blood flow in experimental sepsis.

METHODS

Forty male Wistar rats were randomized into four groups. Half of the animals received 0.2 mg • kg pravastatin s.c., the other half received the same volume as vehicle (NaCl 0.9%). After 18 h, colon ascendens stent peritonitis surgery was conducted in all animals to induce sepsis. Twenty-four hours after surgery, baseline was established and the animals were subjected to either 120 min of normocapnic (pCO2 40 ± 6 mm Hg) or moderate hypercapnic (pCO2 72 ± 10 mm Hg) ventilation. Microcirculatory oxygenation (μHBO2) and perfusion (μflow) of the colon were continuously recorded using tissue reflectance spectrophotometry and laser Doppler, respectively.

RESULTS

In normocapnic septic animals μHBO2 decreased over time (-8.4 ± 8.7%; P < 0.05 vs. baseline), whereas after pravastatin pretreatment μHBO2 remained constant (-1.9 ± 5.7% vs. baseline). However, in hypercapnic septic animals pretreated with pravastatin μHBO2 declined significantly over time (-8.9 ± 11.8%; P < 0.05 vs. baseline) and was significantly lower compared with normocapnic pravastatin-pretreated animals. μflow did not change over time in any group.

CONCLUSION

Pravastatin pretreatment ameliorates the intestinal microvascular oxygenation in sepsis and thus seems to prevent intestinal hypoxia. Furthermore, we demonstrated that additional hypercapnia abolishes this effect, indicating why septic ARDS patients might not benefit from pravastatin therapy.

Neuroimmune crosstalk and evolving pharmacotherapies in neurodegenerative diseases

Neurodegeneration is characterized by gradual onset and limited availability of specific biomarkers. Apart from various aetiologies such as infection, trauma, genetic mutation, the interaction between the immune system and CNS is widely associated with neuronal damage in neurodegenerative diseases. The immune system plays a distinct role in disease progression and cellular homeostasis. It induces cellular and humoral responses, and enables tissue repair, cellular healing and clearance of cellular detritus. Aberrant and chronic activation of the immune system can damage healthy neurons. The pro-inflammatory mediators secreted by chief innate immune components, the complement system, microglia and inflammasome can augment cytotoxicity. Furthermore, these inflammatory mediators accelerate microglial activation resulting in progressive neuronal loss. Various animal studies have been carried out to unravel the complex pathology and ascertain biomarkers for these harmful diseases, but have had limited success. The present review will provide a thorough understanding of microglial activation, complement system and inflammasome generation, which lead the healthy brain towards neurodegeneration. In addition to this, possible targets of immune components to confer a strategic treatment regime for the alleviation of neuronal damage are also summarized.

Prior statin therapy and 30-day mortality in South Korean patients with acute respiratory distress syndrome

BACKGROUND

The effect of prior statin therapy on mortality in patients with acute respiratory distress syndrome (ARDS) remains controversial. This study aimed to investigate whether prior statin therapy was associated with lower 30-day mortality compared to non-statin use.

METHODS

This population-based cohort study used nationwide data procured from the National Health Insurance service in South Korea, and included all the adult patients admitted to a hospital for ARDS treatment between January 1, 2013 and December 31, 2017.

RESULTS

In total, 14,600 patients with ARDS were included: 4,319 were statin users and 10,281 were non-statin users. After propensity score matching, 6,046 patients with ARDS (3,023 patients in each group) were included in the analysis. The 30-day mortality of statin users was 44.4% (1,331 of 3,023), while that of non-statin users was 45.2% (1,331 of 3,023). On Cox regression analysis in the propensity score matched cohort, 30-day mortality was not significantly associated with statin use compared to non-statin use (hazard ratio: 0.95, 95% confidence interval: 0.88 to 1.02; P = .165). On Kaplan-Meier estimation, the median survival time in statin users was 45 days (95% CI: 39 to 50), while that in non-statin users was 42 days (95% CI: 37 to 47) after propensity score matching, and there was no statistical difference with the log-rank test (P = .215).

CONCLUSION

This population-based cohort study in South Korea showed that prior statin therapy was not significantly associated with 30-day mortality in patients with ARDS. Our findings should be confirmed in future prospective studies.

Statins in patients with COVID-19: a retrospective cohort study in Iranian COVID-19 patients

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has profoundly affected the lives of millions of people. To date, there is no approved vaccine or specific drug to prevent or treat COVID-19, while the infection is globally spreading at an alarming rate. Because the development of effective vaccines or novel drugs could take several months (if not years), repurposing existing drugs is considered a more efficient strategy that could save lives now. Statins constitute a class of lipid-lowering drugs with proven safety profiles and various known beneficial pleiotropic effects. Our previous investigations showed that statins have antiviral effects and are involved in the process of wound healing in the lung. This triggered us to evaluate if statin use reduces mortality in COVID-19 patients.

RESULTS

After initial recruitment of 459 patients with COVID-19 (Shiraz province, Iran) and careful consideration of the exclusion criteria, a total of 150 patients, of which 75 received statins, were included in our retrospective study. Cox proportional-hazards regression models were used to estimate the association between statin use and rate of death. After propensity score matching, we found that statin use appeared to be associated with a lower risk of morbidity [HR = 0.85, 95% CI = (0.02, 3.93), P = 0.762] and lower risk of death [(HR = 0.76; 95% CI = (0.16, 3.72), P = 0.735)]; however, these associations did not reach statistical significance. Furthermore, statin use reduced the chance of being subjected to mechanical ventilation [OR = 0.96, 95% CI = (0.61-2.99), P = 0.942] and patients on statins showed a more normal computed tomography (CT) scan result [OR = 0.41, 95% CI = (0.07-2.33), P = 0.312].

CONCLUSIONS

Although we could not demonstrate a significant association between statin use and a reduction in mortality in patients with COVID19, we do feel that our results are promising and of clinical relevance and warrant the need for prospective randomized controlled trials and extensive retrospective studies to further evaluate and validate the potential beneficial effects of statin treatment on clinical symptoms and mortality rates associated with COVID-19.

Nanotechnological strategies for systemic microbial infections treatment: A review

Systemic infections is one of the major causes of mortality worldwide, and a shortage of drug approaches applied for the rapid and necessary treatment contribute to increase the levels of death in affected patients. Several drug delivery systems based in nanotechnology such as metallic nanoparticles, liposomes, nanoemulsion, microemulsion, polymeric nanoparticles, solid lipid nanoparticles, dendrimers, hydrogels and liquid crystals can contribute in the biological performance of active substances for the treatment of microbial diseases triggered by fungi, bacteria, virus and parasites. In the presentation of these statements, this review article present and demonstrate the effectiveness of these drug delivery systems for the treatment of systemic diseases caused by several microorganisms, through a review of studies on scientific literature worldwide that contributes to better information for the most diverse professionals from the areas of health sciences. The studies demonstrated that the drug delivery systems described can contribute to the therapeutic scenario of these diseases, being classified as safe, active platforms and with therapeutic versatility.

Simvastatin Posttreatment Controls Inflammation and Improves Bacterial Clearance in Experimental Sepsis

Sepsis is characterized by a life-threatening organ dysfunction caused by an unbalanced host response to microbe infection that can lead to death. Besides being currently the leading cause of death in intensive care units worldwide, sepsis can also induce long-term consequences among survivors, such as cognitive impairment. Statins (lipid-lowering drugs widely used to treat dyslipidemia) have been shown to possess pleiotropic anti-inflammatory and antimicrobial effects. These drugs act inhibiting 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase, an enzyme that catalyzes the conversion of HMG-CoA to mevalonate, the limiting step in cholesterol biosynthesis. In this work, we evaluated the therapeutic effects of simvastatin in an animal model of sepsis. In previous study from our group, statin pretreatment avoided cognitive damage and neuroinflammation in sepsis survivors. Herein, we focused on acute inflammation where sepsis was induced by cecal ligation and puncture (CLP), and the animals were treated with simvastatin (2 mg/kg) 6 h after surgery. We measured plasma biochemical markers of organ dysfunction, cell migration, cell activation, bacterial elimination, production of nitric oxide 24 h after CLP, survival rate for 7 days, and cognitive impairment 15 days after CLP. One single administration of simvastatin 6 h after CLP was able to prevent both liver and kidney dysfunction. In addition, this drug decreased cell accumulation in the peritoneum as well as the levels of TNF-α, MIF, IL-6, and IL-1β. Simvastatin diminished the number of bacterial colony forming units (CFU) and increased the production of nitric oxide production in the peritoneum. Simvastatin treatment increased survival for the first 24 h, but it did not alter survival rate at the end of 7 days. Our results showed that posttreatment with simvastatin hampered organ dysfunction, increased local production of nitric oxide, improved bacterial clearance, and modulated inflammation in a relevant model of sepsis.

Pharmacological management of adult patients with acute respiratory distress syndrome

INTRODUCTION

There is still no definite drug for acute respiratory distress syndrome (ARDS) that is capable of reducing either short-term or long-term mortality. Therefore, great efforts are being made to identify a pharmacological approach that can be really effective.

AREAS COVERED

This review focuses on current challenges and future directions in the pharmacological management of ARDS, regardless of anti-infective treatments. The authors have excluded small randomized controlled trials (RCTs) with less than 60 patients because those studies do not have statistical power for outcome data, and also anecdotal trials but have considered the last meta-analysis on any drug.

EXPERT OPINION

There has been substantial progress in our knowledge of ARDS over the past two decades and many drugs have been used in its treatment. Nevertheless, effective targeted pharmacological treatments for ARDS are still lacking. The likely reason why a pharmacological approach is beneficial for some patients, but harmful for others is that ARDS is an extremely heterogeneous syndrome. To overcome this issue, a precision approach for ARDS, whereby therapies are specifically targeted to patients most likely to benefit, has been proposed. At present, however, the application of this approach seems to be a difficult task.

Influenza Vaccine Effectiveness and Statin Use Among Adults in the United States, 2011-2017

BACKGROUND

Statin medications have immunomodulatory effects. Several recent studies suggest that statins may reduce influenza vaccine response and reduce influenza vaccine effectiveness (VE).

METHODS

We compared influenza VE in statin users and nonusers aged ≥45 years enrolled in the US Vaccine Effectiveness Network study over 6 influenza seasons (2011-2012 through 2016-2017). All enrollees presented to outpatients clinics with acute respiratory illness and were tested for influenza. Information on vaccination status, medical history, and statin use at the time of vaccination were collected by medical and pharmacy records. Using a test-negative design, we estimated VE as (1 - OR) × 100, in which OR is the odds ratio for testing positive for influenza virus among vaccinated vs unvaccinated participants.

RESULTS

Among 11692 eligible participants, 3359 (30%) were statin users and 2806 (24%) tested positive for influenza virus infection; 78% of statin users and 60% of nonusers had received influenza vaccine. After adjusting for potential confounders, influenza VE was 36% (95% confidence interval [CI], 22%-47%) among statin users and 39% (95% CI, 32%-45%) among nonusers. We observed no significant modification of VE by statin use. VE against influenza A(H1N1)pdm09, A(H3N2), and B viruses were similar among statin users and nonusers.

CONCLUSIONS

In this large observational study, influenza VE against laboratory-confirmed influenza illness was not affected by current statin use among persons aged ≥45 years. Statin use did not modify the effect of vaccination on influenza when analyzed by type and subtype.

Pneumolysin: Pathogenesis and Therapeutic Target

Streptococcus pneumoniae is an opportunistic pathogen responsible for widespread illness and is a major global health issue for children, the elderly, and the immunocompromised population. Pneumolysin (PLY) is a cholesterol-dependent cytolysin (CDC) and key pneumococcal virulence factor involved in all phases of pneumococcal disease, including transmission, colonization, and infection. In this review we cover the biology and cytolytic function of PLY, its contribution to S. pneumoniae pathogenesis, and its known interactions and effects on the host with regard to tissue damage and immune response. Additionally, we review statins as a therapeutic option for CDC toxicity and PLY toxoid as a vaccine candidate in protein-based vaccines.

Prior statin therapy and mortality among critically ill patients: a systemic review and meta-analysis of cohort studies

The effect of prior statin exposure in critically ill patients remains controversial and has not been established in previous cohort studies. We performed a systematic review of previous cohort studies to evaluate the association of prior statin therapy with mortality in critically ill patients and conducted a meta-analysis. The MEDLINE, EMBASE, and Cochrane CENTRAL databases, from their inception to January 7, 2020, were used for this study. Statin users were defined as patients prescribed statin regularly before intensive care unit admission or diagnosis of a specific disease, such as sepsis. The Cochran chi-square test and I statistics were used to determine heterogeneity between studies. In total, 199,985 critically ill patients from nine studies (44,582 statin users and 155,403 non-statin users) were included in the meta-analysis. According to the random effect model, the 30-day mortality of statin users was 31% lower than that of non-statin users (hazard ratio: 0.69, 95% confidence interval: 0.56 to 0.85). This association was similar in atorvastatin users and simvastatin users. However, hospital mortality in statin users was not significantly associated with that in non-statin users [odds ratios (ORs): 0.71, 95% CI: 0.42 to 1.21]. This study showed that there was a beneficial association of prior statin therapy with 30-day mortality in critically ill patients. However, there was no significant association with hospital mortality. Additional prospective cohort studies with a large sample size should be performed to confirm these findings.

Preoperative Statin Use and 90-Day Mortality after Noncardiac Surgery: A Hospital Registry Study

OBJECTIVE

The aim of this study was to investigate the association between preadmission statin use and 90-day mortality after planned elective noncardiac surgery in adult patients.

SUMMARY BACKGROUND DATA

Statin therapy is known to have pleiotropic effects, which improve the outcomes of various diseases. However, the effect of perioperative statin therapy on postoperative mortality remains controversial.

METHODS

This retrospective cohort study analyzed the medical records of adult patients who were admitted to a single tertiary academic hospital for elective noncardiac surgery between January 2012 and December 2018. The primary endpoint was 90-day mortality, which was defined as any mortality within 90 days after surgery. The secondary endpoint was overall survival.

RESULTS

After propensity score matching, a total of 33,514 patients (16,757 patients in each group) were included in the analysis. The logistic regression analysis of the propensity score-matched cohort indicated that the odds ratio (OR) of 90-day mortality in the statin group was 26% lower than that of the nonstatin group [OR: 0.74; 95% confidence interval (CI): 0.59 to 0.92; P = 0.009]. The sensitivity analysis indicated that the high-dose intensity statin group had a 61% lower 90-day mortality rate than the nonstatin group (OR: 0.39; 95% CI: 0.18-0.84; P = 0.016). The overall survival time was significantly longer in the statin group than in the nonstatin group after propensity score matching (P < 0.001 by log-rank test).

CONCLUSIONS

Preoperative statin use was associated with lower 90-day mortality and longer overall survival for adult patients who underwent elective noncardiac surgery. This association was more evident for high-intensity statin users.

TB-IRIS pathogenesis and new strategies for intervention: Insights from related inflammatory disorders

In almost one in five HIV/tuberculosis (TB) co-infected patients, initiation of antiretroviral therapy (ART) is complicated by TB immune reconstitution inflammatory syndrome (TB-IRIS). Corticosteroids have been suggested for treatment of severe cases, however no therapy is currently licensed for TB-IRIS. Hence, there is a strong need for more specific therapeutics, and therefore, a better understanding of TB-IRIS pathogenesis. Immune reconstitution following ART is a precariously balanced functional restoration of adaptive immunity. In those patients predisposed to disease, an incomplete activation of the innate immune system leads to a hyper-inflammatory response that comprises partially overlapping innate, adaptive and effector arms, eventually leading to clinical symptoms. Interestingly, many of these pathological mechanisms are shared by related inflammatory disorders. We here describe therapeutic strategies that originate from these other disciplines and discuss their potential application in TB-IRIS. These new avenues of interventions range from final-phase treatment of symptoms to early-phase prevention of disease onset. In conclusion, we propose a novel approach for the discovery and development of therapeutics, based on an updated model of TB-IRIS pathogenesis. Further experimental studies validating the causal relationships in the proposed model could greatly contribute to providing a solid immunological basis for future clinical trials on TB-IRIS therapeutics.

Pravastatin and Gemfibrozil Modulate Differently Hepatic and Colonic Mitochondrial Respiration in Tissue Homogenates from Healthy Rats

Statins and fibrates are widely used for the management of hypertriglyceridemia but they also have limitations, mostly due to pharmacokinetic interactions or side effects. It is conceivable that some adverse events like liver dysfunction or gastrointestinal discomfort are caused by mitochondrial dysfunction. Data about the effects of statins and fibrates on mitochondrial function in different organs are inconsistent and partially contradictory. The aim of this study was to investigate the effect of pravastatin (statin) and gemfibrozil (fibrate) on hepatic and colonic mitochondrial respiration in tissue homogenates. Mitochondrial oxygen consumption was determined in colon and liver homogenates from 48 healthy rats after incubation with pravastatin or gemfibrozil (100, 300, 1000 μM). State 2 (substrate dependent respiration) and state 3 (adenosine diphosphate: ADP-dependent respiration) were assessed. RCI (respiratory control index)—an indicator for coupling between electron transport chain system (ETS) and oxidative phosphorylation (OXPHOS) and ADP/O ratio—a parameter for the efficacy of OXPHOS, was calculated. Data were presented as a percentage of control (Kruskal–Wallis + Dunn’s correction). In the liver both drugs reduced state 3 and RCI, gemfibrozil-reduced ADP/O (complex I). In the colon both drugs reduced state 3 but enhanced ADP/O. Pravastatin at high concentration (1000 µM) decreased RCI (complex II). Pravastatin and gemfibrozil decrease hepatic but increase colonic mitochondrial respiration in tissue homogenates from healthy rats.

Preadmission Statin Use and 90-day Mortality in the Critically Ill

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

This study aimed to examine the association between preadmission statin use and 90-day mortality in critically ill patients and to investigate whether this association differed according to statin type and dose. We hypothesized that preadmission statin use was associated with lower 90-day mortality.

Methods

This retrospective cohort study analyzed the medical records of all adult patients admitted to the intensive care unit in a single tertiary academic hospital between January 2012 and December 2017. Data including preadmission statin use, statin subtype, and daily dosage were collected, and the associations between these variables and 90-day mortality after intensive care unit admission were examined. The primary endpoint was 90-day mortality.

Results

A total of 24,928 patients (7,396 statin users and 17,532 non–statin users) were included. After propensity score matching, 5,354 statin users and 7,758 non–statin users were finally included. The 90-day mortality rate was significantly higher in non–statin users (918 of 7,758; 11.8%) than in statin users (455 of 5,354; 8.5%; P &lt; 0.001). In Cox regression analysis, the 90-day mortality rate was lower among statin users than among non–statin users (hazard ratio: 0.70, 95% CI: 0.63 to 0.79; P &lt; 0.001). Rosuvastatin use was associated with 42% lower 90-day mortality (hazard ratio: 0.58, 95% CI: 0.47 to 0.72; P &lt; 0.001). There were no specific significant differences in the association between daily statin dose and 90-day mortality. In competing risk analysis, the risk of noncardiovascular 90-day mortality in statin users was 32% lower than that in non–statin users (hazard ratio: 0.68, 95% CI: 0.60 to 0.78; P &lt; 0.001). Meanwhile, cardiovascular 90-day mortality was not significantly associated with statin use.

Conclusions

Preadmission statin use was associated with a lower 90-day mortality. This association was more evident in the rosuvastatin group and with noncardiovascular 90-day mortality; no differences were seen according to daily dosage intensity.

Impact of prior statin use on mortality in patients with type 2 diabetes mellitus and bloodstream infection

Objective

This study assessed the effect of prior statin use on the 28-day mortality of patients with type 2 diabetes mellitus (DM) who develop bloodstream infections.

Methods

This retrospective cohort study included all adult type 2 DM patients with bacteremia and verified prior medication history who visited the emergency department of a single tertiary hospital between January 2007 and December 2013. All major adverse consequences including septic shock events, use of mechanical ventilation, intensive care unit admission, and 28-day mortality were assessed.

Results

A total of 1,979 patients were enrolled in the study, of whom 507 were taking statins. Statin users had less severe disease presentation and lower levels of sepsis biomarkers such as bandemia (1.3 ± 3.1 vs 1.8 ± 4.2). After adjustment for confounding variables using a Cox regression model, only older age (adjusted hazard ratio [HR]: 1.04, 95% confidence interval [CI], 1.01–1.04), urinary tract infection (adjusted HR: 0.56, 95% CI, 0.43–0.75), and prior statin use (adjusted HR: 0.58, 95% CI: 0.42–0.85) were significantly associated with 28-day in-hospital mortality.

Conclusion

Prior statin treatment in patients with type 2 DM and bacteremia was associated with a lower 28-day in-hospital mortality rate.

Host-defense peptides AC12, DK16 and RC11 with immunomodulatory activity isolated from Hypsiboas raniceps skin secretion

Inflammation is a natural defense mechanism of the immune system; however, when unregulated, it can lead to chronic illness. Glucocorticoids are the most commonly used agents to effectively treat inflammatory conditions, including autoimmune diseases, however these substances can trigger a number of side effects. Thus, viable alternatives to the use of these drugs would be advantageous. In this study, we have analyzed the anti-inflammatory profile of three synthetic peptides first identified in skin secretion of the tree frog Hypsiboas raniceps. Structural characterization was performed using NMR spectroscopy and Mass Spectrometry, and the peptides were tested in vitro in RAW 264.7 cells and in vivo in Balb/c mice for their functional properties. The samples did not show a significant antimicrobial profile. NMR spectroscopy indicated that AC12 (ACFLTRLGTYVC) has a disulfide bond between C2 and C11 and a β-sheet-turn-β-sheet conformation in aqueous solution. This peptide showed no cytotoxic effect in mammalian cells and it was the most effective in reducing anti-inflammatory markers, such as NO, TNF-α and IL-12. Peptide DK16 (DKERPICSNTFRGRKC) demonstrated anti-inflammatory properties in vitro, while RC11 (RCFRRRGKLTC) significantly altered the cell viability in RAW 264.7 but was shown to be safe in Balb/c erythrocytes. Our results indicate that, of the three peptides studied, AC12 is the most efficient in reducing anti-inflammatory markers, and it could be a potential agent for the treatment of inflammatory diseases.

Preadmission Statin Therapy Is Associated with a Lower Incidence of Acute Kidney Injury in Critically Ill Patients: A Retrospective Observational Study

This study aimed to investigate the association between preadmission statin use and acute kidney injury (AKI) incidence among critically ill patients who needed admission to the intensive care unit (ICU) for medical care. Medical records of patients admitted to the ICU were reviewed. Patients who continuously took statin for >1 month prior to ICU admission were defined as statin users. We investigated whether preadmission statin use was associated with AKI incidence within 72 h after ICU admission and whether the association differs according to preadmission estimated glomerular filtration rate (eGFR; in mL min⁻¹ 1.73 m⁻²). Among 21,236 patients examined, 5756 (27.1%) were preadmission statin users and 15,480 (72.9%) were non-statin users. Total AKI incidence within 72 h after ICU admission was 31% lower in preadmission statin users than in non-statin users [odds ratio (OR), 0.69; 95% confidence interval (CI), 0.61–0.79; p < 0.001]. This association was insignificant among individuals with eGFR <30 mL min⁻¹ 1.73 m⁻² (p > 0.05). Our results suggested that preadmission statin therapy is associated with a lower incidence of AKI among critically ill patients; however, this effect might not be applicable for patients with eGFR <30 mL min⁻¹ 1.73 m⁻².

Use of statins and the risk of delirium in critically ill and surgical patients: Protocol of a systematic review and meta-analysis

BACKGROUND

The critically ill and surgical patients are at significant risk of delirium, which is associated with a high morbidity and mortality. The association between statin use and the incidence of delirium is still controversial. In this article, we will perform a systematic review and meta-analysis of published studies to evaluate the effectiveness of statins for the prophylaxis of delirium among critically ill and surgical patients.

METHODS

We will conduct a systematic literature search in EMBASE, PubMed, and the Cochrane Library from inception date to October 2018 for randomized controlled trials (RCTs) and observational studies (either cohort or case-control studies) investigating the association between use of statins and delirium risk. The Cochrane Collaboration's tool for evaluating the risk of bias and Newcastle-Ottawa scale (NOS) will be used to assess the methodological quality of RCTs and observational studies, separately. The primary outcome will be the risk of incident delirium associated with statin use. Pooled odds ratios (ORs) with corresponding 95% confidence intervals (CIs) will be calculated by a random-effects or fixed-effects model according to heterogeneity among included studies. Subgroup analyses, meta-regression method, and assessment of publication bias will be also performed. Statistical analyses will be conducted with RevMan (version 5.3.5) and Stata (version 14.0) software. In addition, the grading of recommendations assessment, development and evaluation (GRADE) approach will be applied to evaluate the quality of evidence.

RESULTS

The study will provide a high-quality synthesis and evaluate the effectiveness of statins for delirium prevention among critically ill and surgical patients.

CONCLUSIONS

The systematic review and meta-analysis will provide convincing evidence concerning the effect of statins against delirium in critically ill and surgical patients.

Hydroxymethylglutaryl-CoA reductase inhibitors (statins) for the treatment of sepsis in adults - A systematic review and meta-analysis

OBJECTIVES

The pleiotropic effect of hydroxymethylglutaryl-CoA reductase inhibitors (statins) might have a beneficial effect in sepsis through several mechanisms. The aim was to assess the efficacy and safety of statins, compared with placebo, for the treatment of sepsis in adults.

METHODS

We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 2017, Issue 12), OVID MEDLINE (from 1966 to January 2018), Embase (Ovid SP, from 1974 to January 2018), and LILACS (from 1986 to January 2018). We also searched the trial registries ISRCTN and ClinicalTrials.gov to January 2018. The eligibility criteria were randomized controlled trials comparing the treatment of statins versus placebo in adult patients who were hospitalized due to sepsis. Participants were adults (16 years and older) hospitalized because of sepsis or who developed sepsis during admission. Interventions were treatment with hydroxymethylglutaryl-CoA reductase inhibitors (statins) versus no treatment or placebo. We performed a systematic review of all randomized controlled trials published until January 2018, assessing the efficacy and safety of statins in sepsis treatment. Two primary outcomes were assessed: 30-day overall mortality and deterioration to severe sepsis during management. Secondary outcomes were hospital mortality, need for mechanical ventilation and drug related adverse events.

RESULTS

Fourteen trials evaluating 2628 patients were included. Statins did not reduce 30-day all-cause mortality neither in all patients (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.83-1.10), nor in a subgroup of patients with severe sepsis (RR 0.97, 95% CI 0.84-1.12). The certainty of evidence for both outcomes was high. There was no change in the rate of adverse events between study arms (RR 1.24, 95% CI 0.94 to 1.63). The certainty of evidence for this outcome was high.

CONCLUSIONS

The use of statin therapy in adults for the indication of sepsis is not recommended.

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.

Statins increase the risk of herpes zoster: A propensity score-matched analysis

OBJECTIVES

Statins, which are lipid-lowering agents, have anti-inflammatory and immunomodulatory properties that may affect the occurrence of various infectious diseases. We assessed whether statins increase the risk of herpes zoster (HZ) with propensity score-matching.

METHODS

The study was based on the National Health Insurance database and its subset database of the "medical check-up" population of South Korea. These cohorts consist of about one million and 570,000 people, respectively, representative of the entire population of South Korea. We identified 103,930 statin users and 430,685 non-statin users. After propensity score-matching, 25,726 statin users and the same number of non-statin users were finally analyzed. The development of HZ was monitored in these matched pairs over the 11 years from 2003 to 2013.

RESULTS

Statin users had a significantly higher risk of HZ than non-statin users: hazard ratio (HR) 1.25 (95% CI, 1.15 to 1.37) (p < .0001). The risk of HZ associated with statins was especially high in the elderly: HR 1.39 (95% CI, 1.12 to 1.73) in the over 70-year-olds (p = 0.003) and HR 1.18 (95% CI, 1.00 to 1.39) in the 60-to-69-year-olds (p = 0.056). Furthermore, there was a significant p for trend in terms of cumulative dose effect between the risk of HZ and the duration of statin use (p < .0001).

CONCLUSIONS

These epidemiologic findings provide strong evidence for an association between HZ and statin use, and suggest that unnecessary statins should be avoided.

Anti-inflammatory effects and mechanism of the total flavonoids from Artemisia scoparia Waldst. et kit. in vitro and in vivo

Artemisia scoparia Waldst. et Kit. is traditionally used for the treatment of jaundice urinary retention, itching wet sores, infectious icteric hepatitis and influenza in Uighur medicine. This study aimed to further illuminate the anti-inflammatory effects and mechanism of the total flavonoids (ASTF) from Artemisia scoparia Waldst. et Kit. In vitro, RAW 264.7 cells were pretreated with ASTF 1 h before stimulation with LPS (1 μg/mL) for 24 h. Then, the concentrations of NO, PGE₂, TNF-α, IL-6 and MCP-1 in the medium were determined. Intracellular oxidative stress was detected using DCFH-DA. Immunofluorescent analysis, western blot and qRT-PCR were carried out to illuminate the mechanism of anti-inflammatory effects of ASTF. In vivo, mice were given an intragastric administration of ASTF 1 h before an intranasal administration of LPS. After 24 h, bronchoalveolar lavage fluid (BALF) was collected to measure the number of total cells, macrophage and neutrophils. The levels of TNF-α and IL-6 in BALF were quantified by ELISA kits. Lung specimens were isolated for histopathological examinations and lung wet-to-dry weight (W/D) ratio. We found that ASTF significantly inhibited the production of NO, PGE₂, TNF-α, IL-6, MCP-1 and reactive oxygen species (ROS) in LPS-stimulated RAW 264.7 cells. ASTF can obviously inhibit the degredation of IκBa and inhibit the nucleus translocations of p-NF-κB p65, p-ERK1/2 and p-p38 in RAW 264.7 cells stimulated by LPS. ASTF also markedly decreased the protein and mRNA expression of TNF-α and IL-6 in a dose-dependent manner. When pretreated with ASTF, alveolar hemorrhage and neutrophil infiltration, as well as pulmonary histopathologic changes, were substantially suppressed in lung tissues in the murine acute lung injury model. The lung wet-to-dry weight (W/D) ratio was strongly decreased. These results suggested that ASTF showed important anti-inflammatory activity and might provide protective effects against LPS-induced ALI. The anti-inflammatory effect of ASTF might attribute to its suppression of NF-κB and MAPK signaling pathway.

Effects of simvastatin on the function of splenic CD4+ and CD8+ T cells in sepsis mice

Simvastatin may be beneficial for treating sepsis due to its immune-regulating properties, although the mechanisms remain elusive. Herein, we hypothesized simvastatin may attenuate T cell dysfunction induced by sepsis. To test this hypothesis, we used a model based on cecal ligation and puncture (CLP) to induce sepsis in mice. Male C57BL/6 mice were pre-treated with simvastatin (0.2 μg/g of body weight) before CLP. The expression of B and T lymphocyte attenuator (BTLA) on splenic CD4⁺ T cells and T cell apoptosis, CD4⁺ and CD8⁺ T cells were quantified by flow cytometry. Immunohistochemical staining was performed to evaluate the loss of immune effector cells. Formation of TNF-α and interleukin 10 (IL-10) in the spleen and plasma levels of presepsin, IL-1β, and IL-6 were determined using enzyme-linked immunosorbent assay. Simvastatin markedly inhibited the reduction in cytokine secretion from lipopolysaccharide (LPS)-stimulated splenocytes. Simvastatin-treated mice had significantly decreased the percentages of negative costimulatory receptor BTLA on CD4 T cell expression. Simvastatin markedly reduced T cell apoptosis through downregulating the Fas/FasL expression and decrease the percentage of caspase-3 activity in spleen tissue. There was significantly less depletion of splenic CD4⁺ and CD8⁺ T cells in simvastatin-treated mice. Simvastatin reduced plasma levels of presepsin, IL-1β, and IL-6. Simvastatin can be a powerful regulator of immune function under sepsis conditions by improving T cell function in sepsis.

The host response in critically ill sepsis patients on statin therapy: a prospective observational study

Background

Statins can exert pleiotropic anti-inflammatory, vascular protective and anticoagulant effects, which in theory could improve the dysregulated host response during sepsis. We aimed to determine the association between prior statin use and host response characteristics in critically ill patients with sepsis.

Methods

We performed a prospective observational study in 1060 patients admitted with sepsis to the mixed intensive care units (ICUs) of two hospitals in the Netherlands between January 2011 and July 2013. Of these, 351 patients (33%) were on statin therapy before admission. The host response was evaluated by measuring 23 biomarkers providing insight into key pathways implicated in sepsis pathogenesis and by analyzing whole-blood leukocyte transcriptomes in samples obtained within 24 h after ICU admission. To account for indication bias, a propensity score-matched cohort was created (N = 194 in both groups for protein biomarkers and N = 95 in both groups for gene expression analysis).

Results

Prior statin use was not associated with an altered mortality up to 90 days after admission (38.0 vs. 39.7% in the non-statin users in the propensity-matched analysis). Statin use did not modify systemic inflammatory responses, activation of the vascular endothelium or the coagulation system. The blood leukocyte genomic response, characterized by over-expression of genes involved in inflammatory and innate immune signaling pathways as well as under-expression of genes associated to T cell function, was not different between patients with and without prior statin use.

Conclusions

Statin therapy is not associated with a modified host response in sepsis patients on admission to the ICU.

Electronic supplementary material

The online version of this article (10.1186/s13613-017-0349-3) contains supplementary material, which is available to authorized users.

Linezolid and atorvastatin impact on pneumonia caused by Staphyloccocus aureus in rabbits with or without mechanical ventilation

Pneumonia may involve methicillin-resistant Staphylococcus aureus (MRSA), with elevated rates of antibiotics failure. The present study aimed to assess the effect of statins given prior to pneumonia development. Spontaneously breathing (SB) or mechanically ventilated (MV) rabbits with pneumonia received atorvastatin alone, linezolid (LNZ) alone, or a combination of both (n = 5 in each group). Spontaneously breathing and MV untreated infected animals (n = 11 in each group), as well as uninfected animals (n = 5 in each group) were used as controls. Microbiological features and inflammation were evaluated. Data are presented as medians (interquartile range). Linezolid alone tended to reduce pulmonary MRSA load in both SB and MV rabbits, but failed to prevent bacteremia (59%) in the latter. Linezolid alone dampened TNF-α lung production in both SB and MV rabbits (e.g., 2226 [789] vs. 11478 [10251] pg/g; p = 0.022). Statins alone did the same in both SB and MV animals (e.g., 2040 [133]; p = 0.016), and dampened systemic inflammation in the latter, possibly through TLR2 down-regulation within the lung. However, the combination of LNZ and statin led to an increased rate of bacteremia in MV animals up to 75%. Statins provide an anti-inflammatory effect in rabbits with MRSA pneumonia, especially in MV ones. However, dampening the systemic inflammatory response with statins could impede blood defenses against MRSA.

Statins: antimicrobial resistance breakers or makers?

Introduction

The repurposing of non-antibiotic drugs as adjuvant antibiotics may help break antimicrobial resistance (AMR). Statins are commonly prescribed worldwide to lower cholesterol. They also possess qualities of AMR “breakers”, namely direct antibacterial activity, synergism with antibiotics, and ability to stimulate the host immune system. However, statins’ role as AMR breakers may be limited. Their current extensive use for cardiovascular protection might result in selective pressures for resistance, ironically causing statins to be AMR “makers” instead. This review examines statins’ potential as AMR breakers, probable AMR makers, and identifies knowledge gaps in a statin-bacteria-human-environment continuum. The most suitable statin for repurposing is identified, and a mechanism of antibacterial action is postulated based on structure-activity relationship analysis.

Methods

A literature search using keywords “statin” or “statins” combined with “minimum inhibitory concentration” (MIC) was performed in six databases on 7th April 2017. After screening 793 abstracts, 16 relevant studies were identified. Unrelated studies on drug interactions; antifungal or antiviral properties of statins; and antibacterial properties of mevastatin, cerivastatin, antibiotics, or natural products were excluded. Studies involving only statins currently registered for human use were included.

Results

Against Gram-positive bacteria, simvastatin generally exerted the greatest antibacterial activity (lowest MIC) compared to atorvastatin, rosuvastatin, and fluvastatin. Against Gram-negative bacteria, atorvastatin generally exhibited similar or slightly better activity compared to simvastatin, but both were more potent than rosuvastatin and fluvastatin.

Discussion

Statins may serve as AMR breakers by working synergistically with existing topical antibiotics, attenuating virulence factors, boosting human immunity, or aiding in wound healing. It is probable that statins’ mechanism of antibacterial activity involves interference of bacterial cell regulatory functions via binding and disrupting cell surface structures such as wall teichoic acids, lipoteichoic acids, lipopolysaccharides, and/or surface proteins. The widespread use of statins for cardiovascular protection may favor selective pressures or co-selection for resistance, including dysbiosis of the human gut microbiota, sublethal plasma concentrations in bacteremic patients, and statin persistence in the environment, all possibly culminating in AMR.

Conclusion

Simvastatin appears to be the most suitable statin for repurposing as a novel adjuvant antibiotic. Current evidence better supports statins as potential AMR breakers, but their role as plausible AMR makers cannot be excluded. Elucidating the mechanism of statins’ antibacterial activity is perhaps the most important knowledge gap to address as this will likely clarify statins’ role as AMR breakers or makers.

Lack of Association between Preoperative Statin Use and Respiratory and Neurologic Complications after Cardiac Surgery

Background

Statins may reduce the risk of pulmonary and neurologic complications after cardiac surgery.

Methods

The authors acquired data for adults who had coronary artery bypass graft, valve surgery, or combined procedures. The authors matched patients who took statins preoperatively to patients who did not. First, the authors assessed the association between preoperative statin use and the primary outcomes of prolonged ventilation (more than 24 h), pneumonia (positive cultures of sputum, transtracheal fluid, bronchial washings, and/or clinical findings consistent with the diagnosis of pneumonia), and in-hospital all-cause mortality, using logistic regressions. Second, the authors analyzed the collapsed composite of neurologic complications using logistic regression. Intensive care unit and hospital length of stay were evaluated with Cox proportional hazard models.

Results

Among 14,129 eligible patients, 6,642 patients were successfully matched. There was no significant association between preoperative statin use and prolonged ventilation (statin: 408/3,321 [12.3%] vs. nonstatin: 389/3,321 [11.7%]), pneumonia (44/3,321 [1.3%] vs. 54/3,321 [1.6%]), and in-hospital mortality (52/3,321 [1.6%] vs. 43/3,321 [1.3%]). The estimated odds ratio was 1.06 (98.3% CI, 0.88 to 1.27) for prolonged ventilation, 0.81 (0.50 to 1.32) for pneumonia, and 1.21 (0.74 to 1.99) for in-hospital mortality. Neurologic outcomes were not associated with preoperative statin use (53/3,321 [1.6%] vs. 56/3,321 [1.7%]), with an odds ratio of 0.95 (0.60 to 1.50). The length of intensive care unit and hospital stay was also not associated with preoperative statin use, with a hazard ratio of 1.04 (0.98 to 1.10) for length of hospital stay and 1.00 (0.94 to 1.06) for length of intensive care unit stay.

Conclusions

Preoperative statin use did not reduce pulmonary or neurologic complications after cardiac surgery.

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.

Simvastatin pre-treatment improves survival and mitochondrial function in a 3-day fluid-resuscitated rat model of sepsis

Statins may offer protective effects in sepsis through anti-inflammatory, mitochondrial protection and other actions. We thus evaluated the effects of simvastatin on survival, organ and mitochondrial function, tissue and plasma ubiquinone levels and liver transcriptomics in a 3-day rat model of sepsis. Comparisons of rat plasma simvastatin and ubiquinone levels were made against levels sampled in blood from patients with acute lung injury (ALI) enrolled into a trial of statin therapy. Animals received simvastatin by gavage either pre- or post-induction of faecal peritonitis. Control septic animals received vehicle alone. Seventy-two-hour survival was significantly greater in statin pre-treated animals (43.7%) compared with their statin post-treated (12.5%) and control septic (25%) counterparts (P<0.05). Sepsis-induced biochemical derangements in liver and kidney improved with statin therapy, particularly when given pre-insult. Both simvastatin pre- and post-treatment prevented the fall in mitochondrial oxygen consumption in muscle fibres taken from septic animals at 24 h. This beneficial effect was paralleled by recovery of genes related to fatty acid metabolism. Simvastatin pre-treatment resulted in a significant decrease in myocardial ubiquinone. Patients with ALI had a marked variation in plasma simvastatin acid levels; however, their ubiquinone/low-density lipoprotein (LDL) cholesterol ratio did not differ regardless of whether they were receiving statin or placebo. In summary, despite protective effects seen with statin treatment given both pre- and post-insult, survival benefit was only seen with pre-treatment, reflecting experiences in patient studies.

Causes and Predictors of Death in Patients With Coronary Heart Disease (from the Heart and Soul Study)

Although the prevalence of coronary heart disease (CHD) in the United States has increased during the past 25 years, cardiovascular mortality has decreased due to advances in CHD therapy and prevention. We sought to determine the proportion of patients with CHD who die from cardiovascular versus noncardiovascular causes and the causes and predictors of death, in a cohort of patients with CHD. The Heart and Soul Study enrolled 1,024 participants with stable CHD from 2000 to 2002 and followed them for 10 years. Causes of mortality were assigned based on detailed review of medical records, death certificates, and coroner reports by blinded adjudicators. During 7,680 person-years of follow-up, 401 participants died. Of these deaths, 42.4% were cardiovascular and 54.4% were noncardiovascular. Myocardial infarction, stroke, and sudden death accounted for 72% of cardiovascular deaths. Cancer, pneumonia, and sepsis accounted for 67% of noncardiovascular deaths. Independent predictors of cardiac mortality were older age, inducible ischemia on stress echocardiography, higher heart rate at rest, smoking, lower hemoglobin, and higher N-terminal pro-brain natriuretic peptide (all p values <0.05); independent predictors of noncardiac mortality included older age, inducible ischemia, higher heart rate, lower exercise capacity, and nonuse of statins (all p values <0.05). In conclusion, mortality in this cohort was more frequently due to noncardiovascular causes, and predictors of noncardiovascular mortality included factors traditionally associated with cardiovascular mortality.

Roles of the Mevalonate Pathway and Cholesterol Trafficking in Pulmonary Host Defense

The mevalonic acid synthesis pathway, cholesterol, and lipoproteins play fundamental roles in lung physiology and the innate immune response. Recent literature investigating roles for cholesterol synthesis and trafficking in host defense against respiratory infection was critically reviewed. The innate immune response and the cholesterol biosynthesis/trafficking network regulate one another, with important implications for pathogen invasion and host defense in the lung. The activation of pathogen recognition receptors and downstream cellular host defense functions are critically sensitive to cellular cholesterol. Conversely, microorganisms can co-opt the sterol/lipoprotein network in order to facilitate replication and evade immunity. Emerging literature suggests the potential for harnessing these insights towards therapeutic development. Given that >50% of adults in the U.S. have serum cholesterol abnormalities and pneumonia remains a leading cause of death, the potential impact of cholesterol on pulmonary host defense is of tremendous public health significance and warrants further mechanistic and translational investigation.

Systematic review of statins in sepsis: There is no evidence of dose response

Objectives:

Sepsis is a common cause of morbidity and mortality and is associated with significant costs to the healthcare organizations. We performed a systematic review and meta-analysis to assess whether high or low-dose statin therapy improved mortality in patients with sepsis.

Methods:

The trials analyzed in this study were multicenter or single center randomized control studies using statins for sepsis in a hospital setting. The patients included were adults with suspected or confirmed infection.

Interventions:

This study found eight randomized controlled trials where participants were given either a statin or placebo daily for 14–28 days, the duration of their illness, or until their death or discharge, which ever occurred first.

Primary and Secondary Outcomes Measured:

This meta-analysis measured the effect of statin therapy on in hospital and 28 days mortality.

Results:

In unselected patients, there was no demonstrable difference in the 28 days mortality (relative risk [RR] 0.88 95% confidence interval [CI], 0.70–1.12 and P = 0.16). There was also no significant difference between statin versus placebo for in-hospital mortality (RR 0.98 95% CI, 0.85–1.14 P = 0.36). When the studies where divided into low-dose and high-dose groups, there were no statistically significant differences for in-hospital mortality between low-dose statin versus placebo for (RR 0.81 CI 0.44–1.49 P = 0.27) or high-dose statin versus placebo (RR 0.99 95% CI 0.85–1.16, P = 0.28). There was no significant difference in adverse effects between the high- and low-dose groups.

Conclusions:

In this meta-analysis, we found that the use of statins did not significantly improve either in-hospital mortality or 28-day mortality in patients with sepsis. In the low-dose group, there were fewer quality multicenter studies; hence, conclusions based on the results of this subgroup are limited.

Preventive strategies and potential therapeutic interventions for delirium in sepsis

Delirium is the most frequent and severe clinical presentation of brain dysfunction in critically ill septic patients with an incidence ranging from 9% to 71%. Delirium represents a significant burden for patients and relatives, as well as to the health care system, resulting in higher costs, long-term cognitive impairment and significant risk of death after 6 months. Current interventions for the prevention of delirium typically involve early recognition and amelioration of modifiable risk factors and treatment of underlying conditions that predisposes the individual to delirium. Several pharmacological interventions to prevent and treat delirium have been tested, although their effectiveness remains uncertain, especially in larger and more homogeneous subgroups of ICU patients, like in patients with sepsis. To date, there is inconsistent and conflicting data regarding the efficacy of any particular pharmacological agent, thus substantial attention has been paid to non-pharmacological interventions and preventive strategies should be applied to every patient admitted in the ICU. Future trials should be designed to evaluate the impact of these pharmacologic interventions on the prevention and treatment of delirium on clinically relevant outcomes such as length of stay, hospital mortality and long-term cognitive function. The role of specific medications like statins in delirium prevention is also yet to be evaluated.

A population-based case-control study on statin exposure and risk of acute diverticular disease

OBJECTIVE

A reduced risk of perforated diverticular disease among individuals with current statin exposure has been reported. The aim of the present study was to investigate whether statins reduce the risk of acute diverticular disease.

MATERIAL AND METHODS

A nation-wide population-based case-control study was performed, including 13,127 cases hospitalised during 2006-2010 with a first-time diagnosis of colonic diverticular disease, and 128,442 control subjects (matched for sex, age, county of residence and calendar year). Emergency surgery, assumed to be a proxy for complicated diverticulitis, was performed on 906 of the cases during the index admission, with 8818 matched controls. Statin exposure was classified as "current" or "former" if a statin prescription was last dispensed ≤ 125 days or >125 days before index date, respectively. The association between statin exposure and acute diverticular disease was investigated by conditional logistic regression, including models adjusting for country of birth, educational level, marital status, comorbidities, nonsteroidal anti-inflammatory drug/steroid exposure and healthcare utilisation.

RESULTS

A total of 1959 cases (14.9%) and 16,456 controls (12.8%) were current statin users (crude OR 1.23 [95% CI 1.17-1.30]; fully adjusted OR 1.00 [0.94-1.06]). One hundred and thirty-two of the cases subjected to surgery (14.6%), and 1441 of the corresponding controls (16.3%) were current statin users (crude OR 0.89 [95% CI 0.73-1.08]; fully adjusted OR 0.70 [0.55-0.89]).

CONCLUSIONS

The results do not indicate that statins affect the development of symptomatic diverticular disease in general. However, current statin use was associated with a reduced risk of emergency surgery for diverticular disease.

Statin Use and Hospital Length of Stay Among Adults Hospitalized With Community-acquired Pneumonia

BACKGROUND

Prior retrospective studies suggest that statins may benefit patients with community-acquired pneumonia (CAP) due to antiinflammatory and immunomodulatory effects. However, prospective studies of the impact of statins on CAP outcomes are needed. We determined whether statin use was associated with improved outcomes in adults hospitalized with CAP.

METHODS

Adults aged ≥18 years hospitalized with CAP were prospectively enrolled at 3 hospitals in Chicago, Illinois, and 2 hospitals in Nashville, Tennessee, from January 2010-June 2012. Adults receiving statins before and throughout hospitalization (statin users) were compared with those who did not receive statins (nonusers). Proportional subdistribution hazards models were used to examine the association between statin use and hospital length of stay (LOS). In-hospital mortality was a secondary outcome. We also compared groups matched on propensity score.

RESULTS

Of 2016 adults enrolled, 483 (24%) were statin users; 1533 (76%) were nonusers. Statin users were significantly older, had more comorbidities, had more years of education, and were more likely to have health insurance than nonusers. Multivariable regression demonstrated that statin users and nonusers had similar LOS (adjusted hazard ratio [HR], 0.99; 95% confidence interval [CI], .88-1.12), as did those in the propensity-matched groups (HR, 1.03; 95% CI, .88-1.21). No significant associations were found between statin use and LOS or in-hospital mortality, even when stratified by pneumonia severity.

CONCLUSIONS

In a large prospective study of adults hospitalized with CAP, we found no evidence to suggest that statin use before and during hospitalization improved LOS or in-hospital mortality.