Statins and outcomes in patients admitted to hospital with community acquired pneumonia: population based prospective cohort study

Investigating the Relationship Between Lipid-Lowering Agents and the Complications of Diabetic Retinopathy

BACKGROUND AND OBJECTIVE

As the therapeutic efficacy of lipid-lowering agents (LLA) against diabetic retinopathy (DR) remains controversial, this study aimed to evaluate whether various LLA therapies are associated with a reduced risk of DR progression.

PATIENTS AND METHODS

This retrospective study of the medical records of adults with type 2 diabetes mellitus and DR compared the risk of adverse progression of DR between patients who received statins, fibrates, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, and no LLA (control).

RESULTS

Patients in the statin cohort had a reduced rate of progression to proliferative DR compared to controls (HR = 0.30, CI = 0.11 to 0.83). The PCSK9 inhibitor cohort had a reduced risk of progressing to other secondary complications of DR compared to the control (RR = 0.52, CI = 0.43 to 0.64), statin (RR = 0.69, CI = 0.61 to 0.79), and fibrate (RR = 0.67, CI = 0.59 to 0.77) cohorts.

CONCLUSIONS

These findings suggest use of statins and PCSK9 inhibitors are associated with a reduced risk of adverse progression of DR. [Ophthalmic Surg Lasers Imaging Retina 2024;55:XX-XX.].

Protective Effects Against Dementia Undergo Different Statin Type, Intensity, and Cumulative Dose in Older Adult Type 2 Diabetes Mellitus Patients

OBJECTIVES

This study investigated the relationship between statin use and dementia risk in older adults with type 2 diabetes (T2DM). It also assessed the impact of various statin types, dosage intensity, and cumulative doses on dementia risk.

DESIGN

Employing the inverse probability of treatment weighting (IPTW) Cox hazards model, this research explored the influence of statin utilization on dementia incidence.

SETTING AND PARTICIPANTS

The study included older adult T2DM patients aged 60 years or older who received statins (case group) and those who did not (control group) during the follow-up period.

METHODS

The IPTW Cox hazards model quantified the association between statin use and dementia incidence. Subgroup analyses investigated different statin types, usage intensity, and cumulative dose-dependent relationships with dementia risk, measured by adjusted hazard ratios (aHRs) with corresponding 95% CIs.

RESULTS

Statin users experienced a significant reduction in dementia risk (aHR: 0.47, 95% CI: 0.46-0.48). Subgroup analysis using IPTW Cox regression revealed varying dementia incidence reductions among users of different statin types, with aHRs (95% CIs) ranging from 0.09 to 0.69. Multivariate analyses unveiled a dose-dependent relationship, showing reduced dementia incidence based on cumulative defined daily doses (cDDDs) per year. The corresponding aHRs (95% CIs) were 0.20 to 0.72 across quartiles 4 to 1 of cDDD-years, with a significant trend (P < .001). The optimal daily statin use was 0.88 defined daily doses (DDDs), associated with the lowest dementia risk.

CONCLUSIONS AND IMPLICATIONS

Statins significantly reduced dementia risk in older adult T2DM patients. Higher cumulative defined daily doses (cDDD-years) were linked to more substantial risk reductions. This research underscores the clinical benefits of statin use in preventing dementia in this population and calls for further investigation into the underlying mechanisms. It also raises the possibility of influencing policy decisions to manage dementia risk in this vulnerable group.

Protective Effects of Different Classes, Intensity, Cumulative Dose-Dependent of Statins Against Primary Ischemic Stroke in Patients with Type 2 Diabetes Mellitus

PURPOSE OF REVIEW

The aim of this study is to investigate the protective effects of different statin classes, intensity, and cumulative dose-dependent against primary ischemic stroke in patients with T2DM.

RECENT FINDINGS

The Cox hazards model was used to evaluate statin use on primary ischemic stroke. Case group: T2DM patients who received statins; control group: T2DM patients who received no statins during the follow-up. Adjusted hazard ratio (aHR) for primary ischemic stroke was 0.45 (95% CI: 0.44 to 0.46). Cox regression analysis showed significant reductions in primary ischemic stroke incidence in users of different statin classes. Corresponding aHRs (95% CI) were 0.09 to 0.79 for pitavastatin, rosuvastatin, atorvastatin, pravastatin, simvastatin, fluvastatin, and lovastatin. Multivariate analyses indicated significant reductions in primary ischemic stroke incidence for patients who received different cumulative defined daily doses (cDDDs) per year (cDDD-year). Corresponding aHRs (95% CI) were 0.17 to 0.77 for quartiles 4 to 1 of cDDD-years, respectively (P for trend < .0001). Optimal intensity daily dose of statin use was 0.89 DDD with the lowest aHR of primary ischemic stroke compared with other DDDs. Persistent statin use reduces the risk of primary ischemic stroke in T2DM patients. Higher cDDD-year values are associated with higher reductions in primary ischemic stroke risk in T2DM patients.

Optimal statin use for prevention of sepsis in type 2 diabetes mellitus

PURPOSE

To investigate the dose-dependent protective effects of statins, specific classes of statins, and different intensities of statin use on sepsis risk in patients with type 2 diabetes mellitus (T2DM).

METHODS

We included patients with T2DM aged  ≥ 40 years. Statin use was defined as the use of statin on most days for  > 1 months with a mean statin dose of  ≥ 28 cumulative defined daily doses (cDDDs) per year (cDDD-year). An inverse probability of treatment-weighted Cox hazard model was used to investigate the effects of statin use on sepsis and septic shock while considering statin use status as a time-dependent variable.

RESULTS

From 2008 to 2020, a total of 812 420 patients were diagnosed as having T2DM. Among these patients, 118,765 (27.79%) statin nonusers and 50 804 (12.03%) statin users developed sepsis. Septic shock occurred in 42,755 (10.39%) individuals who did not use statins and 16,765 (4.18%) individuals who used statins. Overall, statin users had a lower prevalence of sepsis than did nonusers. The adjusted hazard ratio (aHR) of statin use was 0.37 (95% CI 0.35, 0.38) for sepsis compared with no statin use. Compared with the patients not using statins, those using different classes of statins exhibited a more significant reduction in sepsis, with aHRs (95% CIs) of sepsis being 0.09 (0.05, 0.14), 0.32 (0.31, 0.34), 0.34 (0.32, 0.36), 0.35 (0.32, 0.37), 0.37 (0.34, 0.39), 0.42 (0.38, 0.44), and 0.54 (0.51, 0.56) for pitavastatin, pravastatin, rosuvastatin, atorvastatin, simvastatin, fluvastatin, and lovastatin use, respectively. In the patients with different cDDD-years of statins, multivariate analysis indicated a significant reduction in sepsis, with aHRs of 0.53 (0.52, 0.57), 0.40 (0.39, 0.43), 0.29 (0.27, 0.30), and 0.17 (0.15, 0.19) for Q1, Q2, Q3, and Q4 cDDD-years (P for trend < 0.0001). The optimal daily statin dose of 0.84 DDD was associated with the lowest aHR. Similar trends of higher cDDD-year and specific statin types use were associated with a decrease in septic shock when compared to statin non-users.

CONCLUSION

Our real-world evidence demonstrated that the persistent use of statins reduced sepsis and septic shock risk in patients with T2DM and a higher cDDD-year of statin use was associated with an increased reduction of sepsis and septic shock risk in these patients.

Pneumolysin as a target for new therapies against pneumococcal infections: A systematic review

BACKGROUND

This systematic review evaluates pneumolysin (PLY) as a target for new treatments against pneumococcal infections. Pneumolysin is one of the main virulence factors produced by all types of pneumococci. This toxin (53 kDa) is a highly conserved protein that binds to cholesterol in eukaryotic cells, forming pores that lead to cell destruction.

METHODS

The databases consulted were MEDLINE, Web of Science, and Scopus. Articles were independently screened by title, abstract, and full text by two researchers, and using consensus to resolve any disagreements that occurred. Articles in other languages different from English, patents, cases report, notes, chapter books and reviews were excluded. Searches were restricted to the years 2000 to 2021. Methodological quality was evaluated using OHAT framework.

RESULTS

Forty-one articles describing the effects of different molecules that inhibit PLY were reviewed. Briefly, the inhibitory molecules found were classified into three main groups: those exerting a direct effect by binding and/or blocking PLY, those acting indirectly by preventing its effects on host cells, and those whose mechanisms are unknown. Although many molecules are proposed as toxin blockers, only some of them, such as antibiotics, peptides, sterols, and statins, have the probability of being implemented as clinical treatment. In contrast, for other molecules, there are limited studies that demonstrate efficacy in animal models with sufficient reliability.

DISCUSSION

Most of the studies reviewed has a good level of confidence. However, one of the limitations of this systematic review is the lack of homogeneity of the studies, what prevented to carry out a statistical comparison of the results or meta-analysis.

CONCLUSION

A panel of molecules blocking PLY activity are associated with the improvement of the inflammatory process triggered by the pneumococcal infection. Some molecules have already been used in humans for other purposes, so they could be safe for use in patients with pneumococcal infections. These patients might benefit from a second line treatment during the initial stages of the infection preventing acute respiratory distress syndrome and invasive pneumococcal diseases. Additional research using the presented set of compounds might further improve the clinical management of these patients.

Comparison of the prognostic performance of the CURB-65 and a modified version of the pneumonia severity index designed to identify high-risk patients using the International Community-Acquired Pneumonia Collaboration Cohort

BACKGROUND

Although the PSI and CURB-65 represent well-validated prediction rules for pneumonia prognosis, PSI was designed to identify patients at low risk and CURB- 65 patients at high risk of mortality. We compared the prognostic performance of a modified version of the PSI designed to identify high-risk patients (i.e., PSI-HR) to CURB-65 in predicting short-term mortality.

METHODS

Using data from 6 pneumonia cohorts, we designed PSI-HR as a 6-class prediction rule using the original prognostic weights of all PSI variables and modifying the risk score thresholds to define risk classes. We calculated the proportion of low-risk and high-risk patients using CURB-65 and PSI-HR and 30-day mortality in these subgroups. We compared the rules' sensitivity, specificity, positive and negative predictive values for mortality at all risk class thresholds and assessed discriminatory power using areas under their receiver operating characteristic curves (AUROCs).

RESULTS

Among 13,874 patients with pneumonia, 1,036 (7.5%) died. For PSI-HR versus CURB-65, aggregate mortality was lower in low-risk patients (1.6% vs. 2.2%, p = 0.005) and higher in high-risk patients (36.5% vs. 32.2%, p = 0.27). PSI-HR had higher sensitivities than CURB-65 at all thresholds; PSI-HR also had higher specificities at the 3 lowest thresholds and specificities within 0.5% points of CURB-65 at the 2 highest thresholds. The AUROC was larger for PSI-HR than CURB- 65 (0.82 vs. 0.77, p < 0.0001).

CONCLUSIONS

PSI-HR demonstrated superior prognostic accuracy to CURB-65 at the lower end of the severity spectrum and identified high-risk patients with nonsignificant higher short-term mortality at the higher end.

Atorvastatin does not display an antimicrobial activity on its own nor potentiates the activity of other antibiotics against Acinetobacter baumannii ATCC17978 or A. baumannii AB030

With the current arsenal of antibiotics increasingly becoming ineffective against bacteria, there is an increasing interest in the possibility of using previously approved non-antibiotic drugs as antimicrobials. Statins have recently been investigated for their antimicrobial activity and their ability to potentially synergize with current treatment options. Atorvastatin had been shown previously to be the most promising candidate for effectivity against Acinetobacter baumannii ATCC17978. In this study, we tested atorvastatin for its activity against an extensively drug-resistant (XDR) strain A. baumannii AB030. However, our data show that atorvastatin has no effect A. baumannii AB030. Intriguingly, atorvastatin was also ineffective against our laboratory's A. baumannii ATCC17978. This lack of atorvastatin activity against A. baumannii ATCC17978 cannot be attributed to RND efflux pumps as a strain deficient in the three most clinically relevant RND efflux systems in A. baumannii showed no change in susceptibility compared to its parent strain ATCC17978. Further, atorvastatin failed to potentiate the activity of tobramycin and ciprofloxacin. While it is not clear to us why atorvastatin is not active against A. baumannii ATCC17978 used in our study, our study shows that evaluation of compounds for their antibacterial activity should involve multiple strains to account for strain-to-strain variation.

Preadmission Antihypertensive Drug Use and Sepsis Outcome: Impact of Angiotensin-Converting Enzyme Inhibitors (ACEIs) and Angiotensin Receptor Blockers (ARBs)

BACKGROUND

Several studies have reported improved sepsis outcomes when certain preadmission antihypertensive drugs, namely, calcium channel blockers (CCBs), are used. This study aims to determine whether preadmission antihypertensive drug use, especially angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), is associated with decreased total hospital mortality in sepsis.

METHODS

This study was conducted using the unique database of a sepsis cohort from the National Health Insurance Research Database in Taiwan. Frequency matching for age and sex between preadmission antihypertensive drug users (study cohort) and nonusers (comparison cohort) was conducted. The primary outcome was total hospital mortality. Logistic regression analyses were performed to calculate the odds ratios (ORs) of important variables. Further joint effect analyses were carried out to examine the impacts of different combinations of antihypertensive drugs.

RESULTS

A total of 33,213 sepsis antihypertensive drug use patients were retrieved as the study cohort, and an equal number of matched sepsis patients who did not use antihypertensive drugs were identified as the comparison cohort. The study cohort had a higher incidence rate of being diagnosed with septic shock compared with the comparison cohort (4.36%-2.31%, P < 0.001) and a higher rate of total hospital mortality (38.42%-24.57%, P < 0.001). In the septic shock condition, preadmission antihypertensive drug use was associated with a decreased adjusted OR (OR = 0.66, 95% confidence interval [CI], 0.55-0.80) for total hospital mortality, which was not observed for the nonseptic shock condition. Compared with antihypertensive drug nonusers, both ACEI and ARB users had decreased adjusted ORs for total hospital mortality in sepsis (adjusted OR = 0.93, 95% CI, 0.88-0.98 and adjusted OR = 0.85, 95% CI, 0.81-0.90); however, CCB, beta-blocker, and diuretic users did not. In the septic shock condition, ACEI, ARB, CCB, and beta-blocker users all had decreased ORs for total hospital mortality. Joint effect analysis showed ACEI use, except in combination with diuretics, to be associated with a decreased adjusted OR for total hospital mortality in sepsis. Similar results were observed for ARB users.

CONCLUSIONS

Preadmission ACEI or ARB use is associated with a decreased risk of total hospital mortality, regardless of a nonshock or septic shock condition.

Statin use is associated with reduced mortality after respiratory viral infection

Background

Several studies suggest that statins, besides reducing cardiovascular disease, have anti-inflammatory properties which might provide a benefit in downregulating the immune response after a respiratory viral infection (RVI) and, hence, decreasing subsequent complications. We aim to analyse the effect of statins on mortality after RVI.

Methods

A single-centre, observational and retrospective study was carried out including all adult patients with a RVI confirmed by PCR tests from October 2, 2017 to May 20, 2018. Patients were divided between statin users and non-statin users and followed-up for 1 year, and all causes of death were recorded. In order to analyse the effect of statin treatment on mortality after RVI we planned two different approaches, a multivariate Cox regression model with the overall population and a univariate Cox model with a propensity-score matched population.

Results

We included 448 patients, 154 (34.4%) of whom were under statin treatment. Statin users had a worse clinical profile (older population with more comorbidities). During the 1-year follow-up, 67 patients died, 17 (11.0%) in the statin group and 50 (17.1%) in the non-statin group. Multivariate Cox analysis showed that statins were associated with mortality benefit (HR 0.47, 95% CI 0.26–0.83; p=0.01). In a matched population (101 statins users and 101 non-statins users) statins also remained associated with mortality benefit (HR 0.32, 95% CI 0.14–0.72; p=0.006). Differences were mainly driven by non-cardiovascular mortality (HR 0.31, 95% CI 0.13–0.73; p=0.004).

Conclusions

Chronic statin treatment was associated with reduced 1-year mortality in patients with laboratory-confirmed RVI. Further studies are needed to determine the exact role of statin therapy after RVI.

Statin treatment is associated with reduced 1-year mortality after respiratory viral infections, despite the higher risk profile of patients on statins. Statins seem a good candidate to be tested during the current global pandemic.https://bit.ly/36t0tDh

The impact of statin use prior to intensive care unit admission on critically ill patients with sepsis

OBJECTIVE

To evaluate the impact of pre-intensive care unit admission (pre-ICU) statin use on all-cause in-hospital mortality and ICU length of stay (LOS).

DESIGN

Retrospective cohort study.

SETTING

Adult ICUs at tertiary hospitals.

PATIENTS

Adult critically ill patients diagnosed with sepsis admitted to the ICUs.

INTERVENTION

The exposure was pre-ICU statin prescription (statin users); unexposed represented absence of pre-ICU prescription (non-users).

MEASUREMENT AND MAIN RESULTS

We used the 2001-2012 Medical Information Mart for Intensive Care-III (MIMIC-III) database to determine average treatment effect (ATE) of pre-ICU statin use on 30-day ICU mortality, ICU LOS, and 30-day in-hospital mortality using the Augmented Inverse Propensity Weighted technique (AIPW), after adjusting for confounding factors (age, race, health insurance, corticosteroids use, vital signs, laboratory tests, and Sequential Organ Failure Assessment score (SOFA). We measured 30-day ICU mortality as deaths within 30 days of admission to the ICU, and ICU LOS was measured in fractional days. A 30-day in-hospital mortality was measured as death within 30 days of hospital admission. A total of 8200 patients with sepsis were identified; 19.8% (1623) were statin users, and 80.2% (6577) were non-users. Most were Caucasian, aged 80 years and above, and male. After adjusting for confounding factors, pre-ICU statin use decreased 30-day ICU mortality (ATE, -0.026; 95% confidence interval [CI], -0.048 to -0.009); ICU LOS (ATE, -0.369; 95% Cl, -0.849 to -0.096); and 30-day in-hospital mortality (ATE, -0.039; 95% CI, -0.084 to -0.026) on average compared with non-statin use, respectively. In a stratified analysis, the result for ICU LOS (ATE, -0.526; 95% CI, -0.879 to -0.241) and 30-day in-hospital mortality (ATE, -0.023; 95% CI, -0.048 to -0.002) was consistent among patients admitted to the medical ICU.

CONCLUSIONS

Among patients with sepsis admitted to the medical ICU, pre-ICU statin use is causally associated with a decrease in 30-day ICU mortality, ICU LOS, and 30-day in-hospital mortality compared to non-use. This study adds to the totality of evidence on the pleiotropic effect of statin use in patients with sepsis.

Effects of statins on clinical outcomes in hospitalized patients with community-acquired pneumonia

Objective

We evaluated the effect of chronic use of statins based on C-reactive protein (CRP) levels and hospital length of stay (LOS) in patients admitted with community-acquired pneumonia (CAP).

Methods

We conducted a retrospective study over 12 months at a teaching hospital in Lebanon comparing patients with CAP taking chronic statins with patients not taking statins. Included patients with CAP were older than age 18 years and had two CRP level measures during hospitalization. CURB-65 criteria were used to assess the severity of pneumonia. A decrease in CRP levels on days 1 and 3, LOS, and normalization of fever were used to assess the response to antibiotics.

Results

Sixty-one patients were taking statins and 90 patients were not taking statins. Patients on statins had significantly more comorbid conditions; both groups had comparable CURB-65 scores. In both groups, no statistically significant difference was seen for the decrease in CRP level on days 1 and 3 and LOS. No difference in days to normalization of fever was detected in either group.

Conclusion

No association was found between the chronic use of statins and CRP levels, LOS, or days to fever normalization in patients with CAP.

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.

Developing Novel Host-Based Therapies Targeting Microbicidal Responses in Macrophages and Neutrophils to Combat Bacterial Antimicrobial Resistance

Antimicrobial therapy has provided the main component of chemotherapy against bacterial pathogens. The effectiveness of this strategy has, however, been increasingly challenged by the emergence of antimicrobial resistance which now threatens the sustained utility of this approach. Humans and animals are constantly exposed to bacteria and have developed effective strategies to control pathogens involving innate and adaptive immune responses. Impaired pathogen handling by the innate immune system is a key determinant of susceptibility to bacterial infection. However, the essential components of this response, specifically those which are amenable to re-calibration to improve host defense, remain elusive despite extensive research. We provide a mini-review focusing on therapeutic targeting of microbicidal responses in macrophages and neutrophils to de-stress reliance on antimicrobial therapy. We highlight pre-clinical and clinical data pointing toward potential targets and therapies. We suggest that developing focused host-directed therapeutic strategies to enhance "pauci-inflammatory" microbial killing in myeloid phagocytes that maximizes pathogen clearance while minimizing the harmful consequences of the inflammatory response merits particular attention. We also suggest the importance of One Health approaches in developing host-based approaches through model development and comparative medicine in informing our understanding of how to deliver this strategy.

Repurposing of Existing Statin Drugs for Treatment of Microbial Infections: How Much Promising?

Today's microbial infections' resistance to approved drugs, the emergence of new infectious diseases and lack of vaccines, create a huge threat to human health. Thus, there is an urgent need to create novel antimicrobial agents, but the high cost and prolonged timeline of novel drug discovery and development is the major barrier to make new drugs. Therefore, there is a need for specific cost effective approaches in order to identify new drugs for the treatment of various microbial infections. Drug repurposition is an alternative technique to find existing clinically approved drugs for other indications. This approach may enhance the portfolio of Pharmaceutical companies by reducing the time and money required for the development of new chemical entity. In literature, various studies have reported some encouraging results regarding the antimicrobial use of existing statin drugs. Further, some clinical studies have also shown the protective effect of statin drugs in reduction of the morbidity and mortality due to many infectious diseases but complete understanding is still lacking. Thus, there is a need for better understanding of the use of statin drugs, especially in the context of antimicrobial effects. In this review, we try to summarize the use of statin drugs in various infectious diseases and their proposed antimicrobial mechanism of action. Further, current challenges and future perspectives of repurposition of statin drugs as antimicrobial agents have also been discussed.

Statins: a viable candidate for host-directed therapy against infectious diseases

Statins were first identified over 40 years ago as lipid-lowering drugs and have been remarkably effective in treating cardiovascular diseases. As research advanced, the protective effects of statins were additionally attributed to their anti-inflammatory, antioxidative, anti-thrombotic and immunomodulatory functions rather than lipid-lowering abilities alone. By promoting host defence mechanisms and inhibiting pathological inflammation, statins increase survival in human infectious diseases. At the cellular level, statins inhibit the intermediates of the host mevalonate pathway, thus compromising the immune evasion strategies of pathogens and their survival. Here, we discuss the potential use of statins as an inexpensive and practical alternative or adjunctive host-directed therapy for infectious diseases caused by intracellular pathogens, such as viruses, protozoa, fungi and bacteria.

Association of statin use with risk of Gleason score-specific prostate cancer: A hospital-based cohort study

BACKGROUND

Conflicting evidence suggests that statins act chemopreventively against prostate cancer (PCa). Whether the association of statin use with PCa risk is Gleason score-dependent, time-, dose-respondent is not well studied.

METHODS

We conducted a cohort study at a tertiary hospital in the Southeastern US using longitudinal data of electronic medical records (EMR) from 1994 to 2016. Only cancer-free men aged >18 years at baseline with follow-up time of ≥12 months were included. Time-dependent Cox proportional hazards regression was used to estimate adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs).

RESULTS

Among 13 065 men, 2976 were diagnosed with PCa over median follow-up of 6.6 years. Statin use was associated with lower risk of both Gleason low- (score <7: aHR, 0.85; 95% CI, 0.74-0.96) and high-grade PCa (score ≥7: aHR, 0.54; 95% CI, 0.42-0.69). The protective association was observed only when statins had been used for a relatively longer duration (≥11 months) or higher dose (≥121 defined daily doses), and were more pronounced for PCa of higher Gleason score (<7: aHR, 0.85, 95% CI, 0.74-0.96; 7 [3 + 4]: aHR, 0.62, 95% CI, 0.43-0.90; 7 [4 + 3]: aHR, 0.49, 95% CI, 0.29-0.82; 8: aHR, 0.60, 95% CI, 0.37-0.96; 9-10: aHR, 0.24, 95% CI, 0.11-0.54). Lipophilic statins (aHR, 0.83; 95% CI, 0.72-0.95) might be more protective than hydrophilic statins (aHR, 0.91, 95% CI, 0.63-1.33) against PCa.

CONCLUSION

Statin use might be associated with reduced PCa risk only when used for a relatively longer duration, and the risk reduction was higher for PCa of higher Gleason score.

Statin Use and the Point Prevalence of Antibiotics in Ambulatory Patients with Diabetes in the National Health and Nutrition Examination Survey (NHANES) 2003-2012

In patients with diabetes, the risk of infections is increased, hypothesized to be due to alterations in the immune system, among other changes. The pleotropic effects of statins have been investigated to assess their role in reducing the risk of infection and infection-related outcomes with varying results. The aim of this study is to determine if the use of statins is associated with a decrease in the point prevalence of oral antibiotic use in ambulatory patients with diabetes. Using data from the National Health and Nutrition Examination Survey (NHANES) from 2003 to 2012, all adult patients diagnosed with diabetes were analyzed. Patients were grouped into those who were prescribed statins and those who were not. Oral antibiotic use between the two groups was compared. Data were standardized to national estimates. A total of 3240 patients with diabetes were identified, with 1575 statin users and 1665 non-statin users. After controlling for baseline socio-demographic and clinical variables, the overall point prevalence of oral antibiotic use in diabetes population was 3.5% with no difference between statin users and non-statin users (2.9% vs. 4%, p = 0.116). Based on the results of this study, the use of statins in patients with diabetes was not associated with a reduction in the point prevalence of antibiotic use.

Association between Statin Use and Sepsis Risk in Patients with Dementia: A Retrospective Cohort Study

This study investigated the association of statin use with sepsis risk in patients with dementia. This retrospective cohort study was conducted in Taiwan by using data from the National Health Insurance Research Database. We identified and enrolled 308 patients with newly diagnosed dementia who used statin after dementia diagnosis. These patients were individually propensity score matched (1:1) according to age, sex, hypertension, hyperlipidemia, diabetes, cerebrovascular disease, renal disease, liver disease, asthma, malignancy, parkinsonism, and dementia drugs used (donepezil, rivastigmine, galantamine, and memantine) with 251 controls (statin non-users). A Cox proportional hazard model was used to estimate the adjusted hazard ratio for sepsis in statin users and non-users. After adjustment for other confounding factors, the incidence of sepsis in statin users was 1.42-fold higher than that in non-users (95% confidence interval = 0.81–2.5). In conclusion, our analysis showed no positive association of sepsis with statin use in patients with dementia.

Evaluation of Healthy User Effects With Metformin and Other Oral Antihyperglycemia Medication Users in Adult Patients With Type 2 Diabetes

OBJECTIVES

Healthy user bias, whereby health-seeking patients are more likely to initiate preventive therapies and engage in healthy lifestyle behaviours, is well known in observational studies, particularly with statins. However, its influence in studies of oral antihyperglycemic therapies is unknown. We sought to explore the healthy user effects in metformin users vs. nonusers on various health outcomes that should not be associated with metformin use.

METHODS

We conducted a retrospective cohort study using data from Alberta, between 2008 and 2015, to examine the association between metformin use and various health outcomes.

RESULTS

We identified 135,301 new users of oral antihyperglycemic agents. The mean age was 55 years, 75,949 (56%) were men and 130,725 (97%) had had at least 1 metformin prescription during a mean follow-up period of 3.4 years. Metformin users were less likely to be involved in accident-related events (adjusted hazard ratio [aHR] 0.90; 95% CI 0.85 to 0.96), were more likely to have preventive screening services (aHR 1.16; 95% CI 1.11 to 1.21), were less likely to experience other clinical events, such as asthma and gout attacks (aHR 0.90; 95% CI 0.84 to 0.97), and had lower risks for all-cause mortality (aHR 0.57; 95% CI 0.51 to 0.63) compared to nonusers.

CONCLUSIONS

Our results suggest that metformin users are more likely to initiate preventive therapies and engage in other healthy behaviours. Failure to account for these behaviours may introduce healthy user bias into studies evaluating the effects of oral antihyperglycemic therapies.

The effects of statin therapy on mortality in patients with sepsis: A meta-analysis of randomized trials

BACKGROUND

Much controversy persists regarding the role of statins therapy in patients with sepsis. This systematic review and meta-analysis of randomized trials aimed to evaluate the clinical efficacy of statin therapy on mortality from sepsis.

METHODS

We comprehensively searched PubMed, Embase, and Cochrane controlled trials register for relevant clinical studies. Randomized controlled trials reporting the effect of statin therapy on mortality in septic patients were included. Pooled risk estimates were calculated with a fixed-effects model. Heterogeneity was determined by Cochran chi-square test and the I statistic.

RESULTS

Nine trials with a total of 2333 patients were included. Seven randomized trials were eligible for the in-hospital mortality analysis. There were 257 deaths among 1078 individuals in the statin treatment group and 268 deaths among 1081 individuals in the control group. There was no statistically significant difference (RR, 0.96; 95% CI, 0.83-1.11). Five randomized trials reported data on 28 day-hospital mortality. There were 123 deaths among 613 individuals in the statin treatment group and 141 deaths among 633 individuals in the control group. There was no statistically significant difference (RR, 0.90; 95% CI, 0.73-1.11).

CONCLUSION

This systematic review and meta-analysis of randomized trials indicates that statin therapy has no effect on mortality outcomes in patients with sepsis compared with placebo.

Risk of Pneumonia After Vertebral Compression Fracture in Women With Low Bone Density: A Population-Based Study

STUDY DESIGN

Retrospective large population-based study.

OBJECTIVE

The aim of this study is to elucidate the association between vertebral compression fractures (VCFs) and pneumonia.

SUMMARY OF BACKGROUND DATA

VCF is known to be associated with impaired pulmonary function. However, the risk of developing pneumonia after new-onset VCF has not been evaluated.

METHODS

The data source was the National Health Screening Program Cohort, a population-based sample cohort of national health screening enrolees. Elderly women with low bone density identified during the life transition period health check-up were target population. Patients with newly diagnosed isolated VCF after the health check-up except those with cervical VCF were included as exposure group. Matched individuals still free of any type of VCF from the same population were included as control group with case/control ratio 3:1. The time to first occurrence of pneumonia were analyzed with Cox-regression analysis.

RESULTS

From the target population (N = 24,773), we matched 867 patients exposed to new-onset isolated VCFs with 2601 controls. In a multivariable Cox-regression analysis, isolated VCF was identified as an independent risk factor for development of a pneumonia (adjusted hazard ratio, 1.48; 95% confidence interval 1.14-1.91). Among the subtypes of VCF, thoracic/thoracolumbar VCF was independently associated with increased risk of pneumonia (adjusted hazard ratio, 2.13; 95% confidence interval 1.47-3.08).

CONCLUSION

Isolated VCF, especially those involving thoracic region, was associated with increased risk of pneumonia.

LEVEL OF EVIDENCE

4.

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.

Atorvastatin and diacerein reduce insulin resistance and increase disease tolerance in rats with sepsis

Background

Sepsis is one of the leading causes of death among hospitalized patients. At the onset of this condition, there is an over-production of pro-inflammatory mediators that contribute to organ failure and death. The excess production of pro-inflammatory mediators also impairs insulin signaling, which may be a pathophysiological tissue marker of proinflammatory cytokine action before organ failure. Statins and diacerein have pleiotropic effects, such as the blockage of inflammatory signaling pathways, suggesting that these drugs may be an attractive therapeutic or prophylactic strategy against sepsis. The aim of the present study was to investigate whether a statin or diacerein can improve insulin signaling, disease tolerance and survival in sepsis by inhibiting inflammatory pathways.

Methods

We investigated the effect of these drugs on survival, tissue insulin signaling and inflammatory pathways in the liver and muscle of rats with sepsis induced by cecal ligation and puncture (CLP).

Results

The results showed that administration of medications, with anti-inflammatory ability, to septic animals increased survival and improved disease tolerance and insulin resistance in the liver and muscle. The treatment also attenuated ER stress, NF-κB, JNK activation and restored glucose-6-phosphatase (G6Pase) levels in the liver.

Conclusions

Our results indicate that atorvastatin and diacerein treatment can modulate inflammatory pathways and, in parallel, attenuate insulin resistance in sepsis. Since these two drugs have safety profiles and minimal side effects, we suggest that these drugs may be alternative therapies for the prevention or therapies for the treatment of insulin resistance in sepsis, which could potentially reduce mortality in patients with sepsis.

Electronic supplementary material

The online version of this article (10.1186/s12950-018-0184-9) contains supplementary material, which is available to authorized users.

Comparing methods to address bias in observational data: statin use and cardiovascular events in a US cohort

Background

The theoretical conditions under which causal estimates can be derived from observational data are challenging to achieve in the real world. Applied examples can help elucidate the practical limitations of methods to estimate randomized-controlled trial effects from observational data.

Methods

We used six methods with varying design and analytic features to compare the 5-year risk of incident myocardial infarction among statin users and non-users, and used non-cardiovascular mortality as a negative control outcome. Design features included restriction to a statin-eligible population and new users only; analytic features included multivariable adjustment and propensity score matching.

Results

We used data from 5294 participants in the Cardiovascular Health Study from 1989 to 2004. For non-cardiovascular mortality, most methods produced protective estimates with confidence intervals that crossed the null. The hazard ratio (HR) was 0.92, 95% confidence interval: 0.58, 1.46 using propensity score matching among eligible new users. For myocardial infarction, all estimates were strongly protective; the propensity score-matched analysis among eligible new users resulted in a HR of 0.55 (0.29, 1.05)-a much stronger association than observed in randomized controlled trials.

Conclusions

In designs that compare active treatment with non-treated participants to evaluate effectiveness, methods to address bias in observational data may be limited in real-world settings by residual bias.

Population-Based Case-Control Study Assessing the Association between Statins Use and Pulmonary Tuberculosis in Taiwan

Background and Objectives: Little evidence is available about the relationship between statins use and pulmonary tuberculosis in Taiwan. The aim of the study was to explore this issue.

Methods: Using the database of the Taiwan National Health Insurance Program, we conducted a population-based case-control study to identify 8,236 subjects aged 20 years and older with newly diagnosed pulmonary tuberculosis from 2000 to 2013 as the cases. We randomly selected 8,236 sex-matched and age-matched subjects without pulmonary tuberculosis as the controls. Subjects who had at least one prescription of statins before the index date were defined as “ever use.” Subjects who never had one prescription of statins before the index date were defined as “never use.” The odds ratio (OR) and 95% confidence interval (CI) for pulmonary tuberculosis associated with statins use was estimated by a multivariable logistic regression model.

Results: After adjustment for co-variables, the adjusted OR of pulmonary tuberculosis was 0.67 for subjects with ever use of statins (95% CI 0.59, 0.75). In a sub-analysis, the adjusted ORs of pulmonary tuberculosis were 0.87 (95% CI 0.69, 1.10) for subjects with cumulative duration of statins use <3 months, 0.77 (95% CI 0.58, 1.03) for 3–6 months, and 0.59 (95% CI 0.51, 0.68) for ≥6 months, compared with subjects with never use of statins.

Conclusions: Statins use correlates with a small but statistically significant risk reduction of pulmonary tuberculosis. The protective effect is stronger for longer duration of statins use. Due to a case-control design, a causal-relationship cannot be established in our study. A prospective cohort design is needed to confirm our findings.

Using cluster analysis of cytokines to identify patterns of inflammation in hospitalized patients with community-acquired pneumonia: a pilot study

INTRODUCTION

Patients with severe community-acquired pneumonia (CAP) are believed to have an exaggerated inflammatory response to bacterial infection. Therapies aiming to modulate the inflammatory response have been largely unsuccessful, perhaps reflecting that CAP is a heterogeneous disorder that cannot be modulated by a single anti-inflammatory approach. We hypothesize that the host inflammatory response to pneumonia may be characterized by distinct cytokine patterns, which can be harnessed for personalized therapies.

METHODS

Here, we use hierarchical cluster analysis of cytokines to examine if patterns of inflammatory response in 13 hospitalized patients with CAP can be defined. This was a secondary data analysis of the Community-Acquired Pneumonia Inflammatory Study Group (CAPISG) database. The following cytokines were measured in plasma and sputum on the day of admission: interleukin (IL)-1β, IL-1 receptor antagonist (IL-1ra), IL-6, CXCL8 (IL-8), IL-10, IL-12p40, IL-17, interferon (IFN)γ, tumor necrosis factor (TNF)α, and CXCL10 (IP-10). Hierarchical agglomerative clustering algorithms were used to evaluate clusters of patients within plasma and sputum cytokine determinations.

RESULTS

A total of thirteen patients were included in this pilot study. Cluster analysis identified distinct inflammatory response patterns of cytokines in the plasma, sputum, and the ratio of plasma to sputum.

CONCLUSIONS

Inflammatory response patterns in plasma and sputum can be identified in hospitalized patients with CAP. Characterization of the local and systemic inflammatory response may help to better discriminate patients for enrollment into clinical trials of immunomodulatory therapies.

Statin Use Correlates with Reduced Risk of Pyogenic Liver Abscess: A Population-Based Case-Control Study

Little research is available on the relationship between statin use and pyogenic liver abscess. The objective of the study was to determine whether prior use of statins is associated with pyogenic liver abscess. This case-control study was conducted to analyse the claim data of the Taiwan National Health Insurance Program. There were 1828 participants aged 20-84 years with first episode of pyogenic liver abscess from 2000 to 2013 as the cases and 1828 randomly selected participants without pyogenic liver abscess matched with sex, age and index year as the controls. Statin use was defined as 'current', 'recent' or 'past' if the statin prescription was filled ≤3 months, 3-6 months or >6 months before the date of pyogenic liver abscess diagnosis, respectively. Relative risk of pyogenic liver abscess associated with statin use was estimated by the odds ratio (OR) with 95% confidence interval (CI) using the multivariable logistic regression model. After controlling for potential confounders, the adjusted ORs of pyogenic liver abscess were 0.65 for participants with current use of statins (95% CI 0.50, 0.84), 0.74 for participants with recent use of statins (95% CI 0.49, 1.11), and 1.10 for participants with past use of statins (95% CI 0.90, 1.34), compared with participants with never use of statins. In the further analysis, the adjusted ORs of pyogenic liver abscess were 0.65 for participants with cumulative duration of statin use ≥12 months (95% CI 0.48, 0.88) and 0.68 for participants with cumulative duration of statin use <12 months (95% CI 0.43, 1.07), compared with participants with never use of statins. Our findings provide strong evidence that patients with current use of statins are associated with a 35% reduced odds of pyogenic liver abscess. The protective effect is stronger for longer duration of statin use.

Effect of Prior Atorvastatin Treatment on the Frequency of Hospital Acquired Pneumonia and Evolution of Biomarkers in Patients with Acute Ischemic Stroke: A Multicenter Prospective Study

Objective. To investigate whether prior treatment of atorvastatin reduces the frequency of hospital acquired pneumonia (HAP). Methods. Totally, 492 patients with acute ischemic stroke and Glasgow Coma Scale ≤ 8 were enrolled in this study. Subjects were assigned to prior atorvastatin treatment group (n = 268, PG) and no prior treatment group (n = 224, NG). All the patients were given 20 mg atorvastatin every night during their hospital stay. HAP frequency and 28-day mortality were measured. Levels of inflammatory biomarkers [white blood cell (WBC), procalcitonin (PCT), tumor necrosis factor-alpha (TNF-α), and interleukin-6 (IL-6)] were tested. Results. There was no significant difference in the incidence of HAP between PG and NG (25.74% versus. 24.55%, p > 0.05) and 28-day mortality (50.72% versus 58.18%, p > 0.05). However, prior statin treatment did modify the mortality of ventilator associated pneumonia (VAP) (36.54% versus 58.14%, p = 0.041) and proved to be a protective factor (HR, 0.564; 95% CI, 0.310~0.825, p = 0.038). Concentrations of TNF-α and IL-6 in PG VAP cases were lower than those in NG VAP cases (p < 0.01). Conclusions. Prior atorvastatin treatment in patients with ischemic stroke was associated with a lower concentration of IL-6 and TNF-α and improved the outcome of VAP. This clinical study has been registered with ChiCTR-ROC-17010633 in Chinese Clinical Trial Registry.

Evidence To Support Continuation of Statin Therapy in Patients with Staphylococcus aureus Bacteremia

In addition to cholesterol-lowering capabilities, statins possess anti-inflammatory and immunomodulatory effects. We sought to quantify the real-world impact of different statin exposure patterns on clinical outcomes in Staphylococcus aureus bacteremia. We conducted a retrospective cohort study among hospitalized patients with positive S. aureus blood cultures receiving appropriate antibiotics within 48 h of culture collection (Veterans Affairs hospitals, 2002 to 2013). Three statin exposure groups were compared to nonusers: pretreated statin users initiating therapy in the 30 days prior to culture and either (i) continuing statin therapy after culture or (ii) not continuing after culture, and (iii) de novo users initiating at culture. Nonusers included patients without statins in the year prior to culture through discharge. Propensity score-matched Cox proportional hazards regression models were developed. We were able to balance significantly different baseline characteristics using propensity score matching for pretreated without continuation (n = 331), pretreated with continuation (n = 141), and de novo (n = 177) statin users compared to nonusers. We observed a significantly lower 30-day mortality rate (hazard ratio [HR], 0.46; 95% confidence interval [CI], 0.25 to 0.84; number needed to treat [NNT], 10) among pretreated and continued statin users, while protective effects were not observed in de novo (HR, 1.04; 95% CI, 0.60 to 1.82; NNT, undefined) or pretreated but not continued (HR, 0.92; 95% CI, 0.64 to 1.32; NNT, 47) users. In our national cohort study among patients with S. aureus bacteremia, continuation of statin therapy among incident statin users was associated with significant beneficial effects on mortality, including a 54% lower 30-day mortality rate.

Using cluster analysis of cytokines to identify patterns of inflammation in hospitalized patients with community-acquired pneumonia: a pilot study

INTRODUCTION

Patients with severe community-acquired pneumonia (CAP) are believed to have an exaggerated inflammatory response to bacterial infection. Therapies aiming to modulate the inflammatory response have been largely unsuccessful, perhaps reflecting that CAP is a heterogeneous disorder that cannot be modulated by a single anti-inflammatory approach. We hypothesize that the host inflammatory response to pneumonia may be characterized by distinct cytokine patterns, which can be harnessed for personalized therapies.

METHODS

Here, we use hierarchical cluster analysis of cytokines to examine if patterns of inflammatory response in 13 hospitalized patients with CAP can be defined. This was a secondary data analysis of the Community-Acquired Pneumonia Inflammatory Study Group (CAPISG) database. The following cytokines were measured in plasma and sputum on the day of admission: interleukin (IL)-1β, IL-1 receptor antagonist (IL-1ra), IL-6, CXCL8 (IL-8), IL-10, IL-12p40, IL-17, interferon (IFN)γ, tumor necrosis factor (TNF)α, and CXCL10 (IP-10). Hierarchical agglomerative clustering algorithms were used to evaluate clusters of patients within plasma and sputum cytokine determinations.

RESULTS

A total of thirteen patients were included in this pilot study. Cluster analysis identified distinct inflammatory response patterns of cytokines in the plasma, sputum, and the ratio of plasma to sputum.

CONCLUSIONS

Inflammatory response patterns in plasma and sputum can be identified in hospitalized patients with CAP. Characterization of the local and systemic inflammatory response may help to better discriminate patients for enrollment into clinical trials of immunomodulatory therapies.

The Role of Statin Therapy in Sepsis

Objective:

To systematically review the evidence evaluating the role of statin therapy in sepsis.

Data Sources:

MEDLINE, EMBASE, and PubMed were searched (1980–January 2007) for English-language clinical trials that evaluated the use of statins and the development and treatment of sepsis in human subjects. Search terms included statin, HMG-CoA reductase inhibitor, bacteremia, sepsis, septic shock, septicemia, and severe sepsis. In addition, pertinent references from identified articles were obtained.

Study Selection and Data Extraction:

Only clinical trials with primary efficacy outcomes of mortality, incidence of sepsis, and severe sepsis were included.

Data Synthesis:

Seven retrospective and 2 prospective cohort studies were included in this review. One was excluded because the patient population was not experiencing sepsis. Three studies demonstrated a reduced mortality with statin use while 2 other studies did not demonstrate this mortality benefit. One study suggested increased mortality with statin use in sepsis. Three studies showed a reduced incidence of development of sepsis or sepsis-related outcomes, while one study did not. The observational and retrospective nature of these studies and the higher rate of cardiovascular comorbidities in the statin groups may have allowed for a confounding influence. The conflicting results and heterogeneity between the studies makes the observed association between statin use and incidence of sepsis and sepsis-related mortality inconclusive. The clinical benefit of statin therapy in sepsis remains to be determined.

Conclusions:

There is an association between statin use and a lower incidence of sepsis and sepsis-related mortality. However, a causal relationship between stalin use and reduced sepsis-related mortality has not yet been established. Currently, statins cannot be recommended for sepsis prevention or treatment until controlled trials are performed.

Prognostic factors associated with mortality and major in-hospital complications in patients with bacteremic pneumococcal pneumonia: Population-based study

Bacteremic pneumococcal pneumonia (BPP) causes considerable mortality and morbidity. We aimed to identify prognostic factors associated with mortality and major in-hospital complications in BPP.A prospective, population-based clinical registry of 1636 hospitalized adult patients (≥18 years) with BPP was established between 2000 and 2010 in Northern Alberta, Canada. Prognostic factors for mortality and major in-hospital complications (e.g., cardiac events, mechanical ventilation, aspiration) were evaluated using multivariable logistic regression.Average age was 54 (standard deviation 18) years, 57% males, and 59% had high case-fatality rate (CFR) serotypes. Overall, 14% (226/1636) of patients died and 22% (315/1410) of survivors developed at least 1 complication. Independent prognostic factors for mortality were age (adjusted odds ratio [aOR], 1.5 per decade; 95% confidence interval [CI], 1.3-1.7), nursing home residence (aOR, 3.7; 95% CI 1.8-7.4), community-dwelling dementia (aOR 3.7; 95% CI, 1.6-8.6), alcohol abuse (aOR, 2.2; 95% CI, 1.4-3.4), acid-suppressing drugs (aOR, 1.5; 95% CI, 1.0-2.3), guideline-discordant antibiotics (aOR, 3.4; 95% CI, 2.4-4.8), multilobe pneumonia (aOR, 2.6; 95% CI, 1.8-3.6), and high CFR serotypes (aOR, 1.8; 95% CI, 1.2-2.8). Similar prognostic factors were observed for major in-hospital complications. Pneumococcal vaccination was associated with reduced in-hospital mortality (aOR, 0.2; 95% CI, 0.05-0.9) but not major complications (P = 0.2).Older and frailer patients, and those who abuse alcohol or take acid-suppressing drugs, are at increased risk of BPP-related mortality and complications, as are those with high CFR serotypes. Beyond identifying those at highest risk, our findings demonstrate the importance of guideline-concordant antibiotics and pneumococcal vaccination in those with BPP.

Host-directed therapies for infectious diseases: current status, recent progress, and future prospects

Despite extensive global efforts in the fight against killer infectious diseases, they still cause one in four deaths worldwide and are important causes of long-term functional disability arising from tissue damage. The continuing epidemics of tuberculosis, HIV, malaria, and influenza, and the emergence of novel zoonotic pathogens represent major clinical management challenges worldwide. Newer approaches to improving treatment outcomes are needed to reduce the high morbidity and mortality caused by infectious diseases. Recent insights into pathogen–host interactions, pathogenesis, inflammatory pathways, and the host's innate and acquired immune responses are leading to identification and development of a wide range of host-directed therapies with different mechanisms of action. Host-directed therapeutic strategies are now becoming viable adjuncts to standard antimicrobial treatment. Host-directed therapies include commonly used drugs for non-communicable diseases with good safety profiles, immunomodulatory agents, biologics (eg monoclonal antibodies), nutritional products, and cellular therapy using the patient's own immune or bone marrow mesenchymal stromal cells. We discuss clinically relevant examples of progress in identifying host-directed therapies as adjunct treatment options for bacterial, viral, and parasitic infectious diseases.

Is There Potential for Repurposing Statins as Novel Antimicrobials?

Statins are members of a class of pharmaceutical widely used to reduce high levels of serum cholesterol. In addition, statins have so-called "pleiotropic effects," which include inflammation reduction, immunomodulation, and antimicrobial effects. An increasing number of studies are emerging which detail the attenuation of bacterial growth and in vitro and in vivo virulence by statin treatment. In this review, we describe the current information available concerning the effects of statins on bacterial infections and provide insight regarding the potential use of these compounds as antimicrobial therapeutic agents.

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.

Modulating antibiotic activity towards respiratory bacterial pathogens by co-medications: a multi-target approach

Non-antibiotic drugs can modulate bacterial physiology and/or antibiotic activity, opening perspectives for innovative therapeutic strategies. Focusing on respiratory pathogens and considering in vitro, in vivo, and clinical data, here we examine the effect of these drugs on the expression of resistance mechanisms, biofilm formation, and intracellular survival, as well as their influence on the activity of antibiotics on bacteria. Beyond the description of the effects observed, we also comment on concentrations that are active and discuss the mechanisms of drug-drug or drug-target interactions. This discussion should be helpful in defining useful targets for adjuvant therapy and establishing the corresponding pharmacophores for further drug fine-tuning.

Recurrent pneumonia: a review with focus on clinical epidemiology and modifiable risk factors in elderly patients

Community-acquired pneumonia (CAP) is one of the most common reasons for physician visits and hospitalizations in North America. Rates of CAP increase with age and CAP is associated with significant morbidity and mortality, especially in the elderly. Though there is much written about the epidemiology and risk factors of incident (first episode) pneumonia, much less is known about recurrent pneumonia. Rates of recurrent pneumonia within 3-5-years of an episode of CAP are 9-12% with a median time to recurrence of 123-317 days and mortality ranging from 4 to 10%. Age ≥65-years-old and impaired functional status are the only patient characteristics that are independently associated with increased risk of recurrence. In terms of modifiable risk factors, only the use of proton-pump inhibitors and systemic and inhaled corticosteroids have consistently been associated with increased risk of recurrent pneumonia, while angiotensin-converting enzyme (ACE) inhibitors may exert a protective effect. Many chronic medical conditions typically associated with increased incident pneumonia-such as chronic obstructive pulmonary disease (COPD), neurological disease (resulting in dysphagia or silent aspiration), and heart failure-were not associated with increased risk of recurrent pneumonia. However, those who are immune-suppressed (e.g., immunoglobulin deficiencies) may be at increased risk of recurrent pneumonia. In summary, among those who survive an episode of pneumonia, recurrence is not uncommon, particularly in the elderly. Following recovery from an episode of pneumonia, patients should be evaluated for risk factors that would predispose to a second episode including seeking evidence of immunosuppression in younger patients and medication optimization, particularly in the elderly.

The active comparator, new user study design in pharmacoepidemiology: historical foundations and contemporary application

Better understanding of biases related to selective prescribing of, and adherence to, preventive treatments has led to improvements in the design and analysis of pharmacoepidemiologic studies. One influential development has been the "active comparator, new user" study design, which seeks to emulate the design of a head-to-head randomized controlled trial. In this review, we first discuss biases that may affect pharmacoepidemiologic studies and describe their direction and magnitude in a variety of settings. We then present the historical foundations of the active comparator, new user study design and explain how this design conceptually mitigates biases leading to a paradigm shift in pharmacoepidemiology. We offer practical guidance on the implementation of the study design using administrative databases. Finally, we provide an empirical example in which the active comparator, new user study design addresses biases that have previously impeded pharmacoepidemiologic studies.

Precision medicine for the treatment of severe pneumonia in intensive care

Despite advances in its management, community-acquired pneumonia (CAP) remains the most important cause of sepsis-related mortality and the reason for many ICU admissions. Severity assessment is the cornerstone of CAP patient management and the attempts to ensure the best site of care and therapy. Survival depends on a combination of host factors (genetic, age, comorbidities, defenses), pathogens (virulence, serotypes) and drugs. To reduce CAP mortality, early adequate antibiotic therapy is fundamental. The use of combination therapy with a macrolide seems to improve the clinical outcome in the subset of patients with high inflammation due to immunomodulation. Guidelines on antibiotic therapy have been associated with beneficial effects, and studies of newer adjunctive drugs have produced promising results. This paper discusses the current state of knowledge regarding of precision medicine and the treatment of severe CAP patients.

Statin-conferred enhanced cellular resistance against bacterial pore-forming toxins in airway epithelial cells

Statins are widely used to prevent cardiovascular disease. In addition to their inhibitory effects on cholesterol synthesis, statins have beneficial effects in patients with sepsis and pneumonia, although molecular mechanisms have mostly remained unclear. Using human airway epithelial cells as a proper in vitro model, we show that prior exposure to physiological nanomolar serum concentrations of simvastatin (ranging from 10-1,000 nM) confers significant cellular resistance to the cytotoxicity of pneumolysin, a pore-forming toxin and the main virulence factor of Streptococcus pneumoniae. This protection could be demonstrated with a different statin, pravastatin, or on a different toxin, α-hemolysin. Furthermore, through the use of gene silencing, pharmacological inhibitors, immunofluorescence microscopy, and biochemical and metabolic rescue approaches, we demonstrate that the mechanism of protection conferred by simvastatin at physiological nanomolar concentrations could be different from the canonical mevalonate pathways seen in most other mechanistic studies conducted with statins at micromolar levels. All of these data are integrated into a protein synthesis-dependent, calcium-dependent model showing the interconnected pathways used by statins in airway epithelial cells to elicit an increased resistance to pore-forming toxins. This research fills large gaps in our understanding of how statins may confer host cellular protection against bacterial infections in the context of airway epithelial cells without the confounding effect from the presence of immune cells. In addition, our discovery could be potentially developed into a host-centric strategy for the adjuvant treatment of pore-forming toxin associated bacterial infections.

The Effect of Statins Use on the Risk and Outcome of Acute Bacterial Infections in Adult Patients

BACKGROUND

Beyond their lipid-lowering abilities, statins have anti-inflammatory and immunomodulatory properties. In view of these effects, a growing interest has emerged in the possible role of statins, in preventing or decreasing morbidity and mortality from infection.

OBJECTIVES

The aim of this study was to determine whether previous statin use is associated with reduced risk of acute bacterial infections and better outcome of these infections.

MATERIALS AND METHODS

In this historical cohort study, consecutive adult patients admitted with acute bacterial infection were enrolled. Control group were selected from adult outpatient and without history of acute bacterial infections. Acute bacterial infections included in this study were; pneumonia, acute pyelonephritis, cellulitis and sepsis with unknown origin. Data about baseline characteristics, co-morbidities and statins use of two groups was obtained.

RESULTS

Finally 144 patients met inclusion criteria and were enrolled. Same numbers of controls were selected. Two groups were matched based on most baseline characteristics and co-morbidities. The patients' categories were as follows: pneumonia 42.3%, acute pyelonephritis 23.6%, cellulitis 16% and sepsis 18%. From all participants 29.9% of patients and 45.8% controls were statin users. There was significant association between previous statin use and reduced risk of acute bacterial infections (Mantel Haenszel Weighted Odds Ratio=0.51, 95% CI: 0.30-0.85, p=0.009). Duration of hospitalization was significantly shorter in statin users (p=0.002). Hospital mortality rate was lower (14.6%) in statins users when compared with non-users (18.8%) with significant difference (p=0.028).

CONCLUSION

Prior therapy with statins is associated with considerably reduced onset of acute bacterial infections and better outcome in adult patients.

The active comparator, new user study design in pharmacoepidemiology: historical foundations and contemporary application

Better understanding of biases related to selective prescribing of, and adherence to, preventive treatments has led to improvements in the design and analysis of pharmacoepidemiologic studies. One influential development has been the "active comparator, new user" study design, which seeks to emulate the design of a head-to-head randomized controlled trial. In this review, we first discuss biases that may affect pharmacoepidemiologic studies and describe their direction and magnitude in a variety of settings. We then present the historical foundations of the active comparator, new user study design and explain how this design conceptually mitigates biases leading to a paradigm shift in pharmacoepidemiology. We offer practical guidance on the implementation of the study design using administrative databases. Finally, we provide an empirical example in which the active comparator, new user study design addresses biases that have previously impeded pharmacoepidemiologic studies.

Lipidome and transcriptome profiling of pneumolysin intoxication identifies networks involved in statin-conferred protection of airway epithelial cells

Pneumonia remains one of the leading causes of death in both adults and children worldwide. Despite the adoption of a wide variety of therapeutics, the mortality from community-acquired pneumonia has remained relatively constant. Although viral and fungal acute airway infections can result in pneumonia, bacteria are the most common cause of community-acquired pneumonia, with Streptococcus pneumoniae isolated in nearly 50% of cases. Pneumolysin is a cholesterol-dependent cytolysin or pore-forming toxin produced by Streptococcus pneumonia and has been shown to play a critical role in bacterial pathogenesis. Airway epithelium is the initial site of many bacterial contacts and its barrier and mucosal immunity functions are central to infectious lung diseases. In our studies, we have shown that the prior exposure to statins confers significant resistance of airway epithelial cells to the cytotoxicity of pneumolysin. We decided to take this study one step further, assessing changes in both the transcriptome and lipidome of human airway epithelial cells exposed to toxin, statin or both. Our current work provides the first global view in human airway epithelial cells of both the transcriptome and the lipid interactions that result in cellular protection from pneumolysin.

Statin therapy and mortality from sepsis: a meta-analysis of randomized trials

BACKGROUND

Statin therapy for sepsis has been suggested by observational studies. However, randomized controlled trials have not demonstrated this benefit. We conducted a systematic review and meta-analysis of randomized trials to evaluate the effect of statin therapy on mortality in patients with sepsis.

METHODS

We searched 6 electronic databases for articles published before August 2014. Randomized trials reporting the effect of statin therapy on mortality in patients with sepsis were included. The primary outcome of interest was in-hospital or 28-day mortality. Two independent reviewers searched and identified studies and extracted data. Risk ratios (RRs) were pooled across studies using random-effects models and were verified using fixed-effects models.

RESULTS

Seven randomized trials were included in the analyses, comprising 1720 patients. Statin therapy did not significantly decrease in-hospital mortality (RR, 1.04; 95% confidence interval, 0.87-1.24; I(2) = 0%; P = .68) or 28-day mortality (RR, 0.93; 95% confidence interval, 0.46-1.89; I(2) = 57%; P = .85) in patients with sepsis. Study quality of the included trials was high; the median Jadad score was 4.5 (range, 4-5).

CONCLUSIONS

This systematic review and meta-analysis of randomized trials suggests that statin therapy does not improve mortality outcomes in patients with sepsis compared with placebo.

Increased statin prescribing does not lower pneumonia risk

BACKGROUND

Investigators have attributed protective effects of statins against pneumonia and other infections. However, these reports are based on observational data where treatments are not assigned randomly. We aimed to determine if the protective effects of statins against pneumonia are due to nonrandom treatment assignment.

METHODS

We built a cohort consisting of 124 695 Medicare beneficiaries diagnosed with an acute myocardial infarction (AMI) for which we had complete claims data. We considered patients who survived at least 30 days post-AMI (full sample), or who survived for 1 year post-AMI (survivors). First, we used ordinary least squares (OLS) and logit models to determine if receiving a statin was protective against pneumonia. Second, to control for nonrandom treatment assignment, we performed an instrumental variables analysis using geographic treatment rates as an instrument. All models included patient demographics, medications, diagnoses, length of hospital stay, and out-of-pocket drug costs as covariates. Our outcome measure was a pneumonia diagnosis during the 1 year following AMI.

RESULTS

A total of 76 994 patients (61.9%) filled a statin prescription, and 19 078 (15.3%) were diagnosed with pneumonia. Using OLS, the statin coefficient was -0.016 (P < .001), indicating that statins are associated with a reduction in pneumonia. Using instrumental variables, we find that statin prescriptions are not associated with a reduction in pneumonia. For the full sample, statin coefficients ranged from -0.001 to -0.01 (P > .6).

CONCLUSIONS

For patients with AMI, the protective effect of statins against pneumonia is most likely the result of nonrandom treatment assignment (ie, a healthy-user bias).