Statin treatment and reduced risk of pneumonia in patients with diabetes

The Association between Statins Intake and Risk of Post Stroke Pneumonia: A Systematic Review and Meta-Analysis

AIM

This research aimed to examine the relationship between the intake of statins and the risk of post-stroke pneumonia in a systematic review and meta-analysis study.

METHODS

An extensive search of published articles on March 21st, 2023, was done in several databases, like Web of Science (ISI), PubMed, Cochrane Library, Embase, Scopus, and Google Scholar. The Newcastle Ottawa Scale (NOS) checklist was employed to evaluate the quality of observational studies. Statistical tests (Chi-square test and I2) and graphical techniques (Forest plot) were used to determine whether heterogeneity existed in the meta-analysis studies. Funnel plots and Begg and Egger's tests were used to assess the publication bias.

RESULTS

Seven studies (5 cohort and 2 case-control studies) were retrieved to examine the association between statins and post-stroke pneumonia. The sample size of the studies compiled in the meta- analysis was obtained to be 68,966 participants. Meta-analysis demonstrated that the overall odds of post-stroke pneumonia in the statin group was equal to 0.87 (95% CI: 0.67 - 1.13; p-value 0.458). Subgroup analysis indicated that the odds of post-stroke pneumonia in the statin group was equal to 0.93 (95% CI: 0.73-1.18; p-value = 0.558) in the cohort studies, and equal to 0.92 (95% CI: 0.37-2.26; p-value = 0.857) in the case-control studies. The examination of the association between the intake of statins and post-stroke pneumonia showed no evidence of publication bias (Begg's test, p-value = 0.368; Eggers test, p-value = 0.282).

CONCLUSION

In this study, no relationship has been observed between receiving statins and the risk of post-stroke pneumonia.

Effect of Stress Ulcers Prophylaxis, Sedative and Statin on Ventilator-Associated Pneumonia: A Retrospective Analysis Based on MIMIC Database

Background: The use of MV can easily lead to VAP especially in ICU patients. SUP, sedatives, statin and insulin have been proved to prevent VAP and improve the prognosis of patients. Our aim was to analyze the effects of SUP, sedative, statin, and insulin on patients with MV.

Methods: The occurrence of VAP and death in MV patients and VAP patients were explored by multivariate logistic regression and Cox regression to analyze analyses.

Results: Totally, 5277 cases who received MV in ICU from MIMIC IV database were included. There were 826 (15.7%) cases in VAP-group and 4451 (84.3%) cases in non-VAP group and there were 1914 (36.3%) cases in hospital mortalities altogether. No protective effect of drugs on VAP was found in MV patients. The risk of death was 1.43 times higher in MV patients taking midazolam than in propofol (aHR = 1.43 95% CI: 1.04,1.97). No protective effect of drugs on death was found in VAP patients.

Conclusion: Compared with midazolam, propofol is more recommended as sedation regimen in ICU patients with MV. Further high-quality studies are needed to confirm this finding.

Could prokinetic agents protect long-term nasogastric tube-dependent patients from being hospitalized for pneumonia? A nationwide population-based case-crossover study

Background

Some studies have indicated that the use of prokinetic agents may reduce pneumonia risk in some populations. Nasogastric tube insertion is known to increase the risk of pneumonia because it disrupts lower esophageal sphincter function. The aim of this study was to evaluate whether prokinetic agents could protect long-term nasogastric tube-dependent patients in Taiwan from being hospitalized for pneumonia.

Methods

A case-crossover study design was applied in this study. Long-term nasogastric tube-dependent patients who had a first-time admission to a hospital due to pneumonia from 1996 to 2013 that was recorded in the Taiwan National Health Insurance Research Database were included. The case period was set to be 30 days before admission, and two control periods were selected for analysis. Prokinetic agent use during those three periods was then assessed for the included patients. Conditional logistic regression was used to calculate the odds ratio (OR) for pneumonia admission with the use of prokinetic agents.

Results

A total of 639 first-time hospitalizations for pneumonia among patients with long-term nasogastric tube dependence were included. After adjusting the confounding factors for pneumonia, no negative association between prokinetic agent use and pneumonia hospitalization was found, and the adjusted OR was 1.342 (95% CI 0.967–1.86). In subgroup analysis, the adjusted ORs were 1.401 (0.982–1.997), 1.256 (0.87–1.814), 0.937 (0.607–1.447) and 2.222 (1.196–4.129) for elderly, stroke, diabetic and parkinsonism patients, respectively.

Conclusion

Prokinetic agent use had no negative association with pneumonia admission among long-term nasogastric tube-dependent patients in Taiwan.

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.

Impact of prior statin use on clinical outcomes in COVID-19 patients: data from tertiary referral hospitals during COVID-19 pandemic in Italy

BACKGROUND

Epidemiological evidence suggests that anti-inflammatory and immunomodulatory properties of statins may reduce the risk of infections and infection-related complications.

OBJECTIVE

We aimed to assess the impact of prior statin use on coronavirus disease (COVID-19) severity and mortality.

METHODS

In this observational multicenter study, consecutive patients hospitalized for COVID-19 were enrolled. In-hospital mortality and severity of COVID-19 assessed with National Early Warning Score (NEWS) were deemed primary and secondary outcomes, respectively. Propensity score (PS) matching was used to obtain balanced cohorts.

RESULTS

Among 842 patients enrolled, 179 (21%) were treated with statins before admission. Statin patients showed more comorbidities and more severe COVID-19 (NEWS 4 [IQR 2-6] vs 3 [IQR 2-5], p < 0.001). Despite having similar rates of intensive care unit admission, noninvasive ventilation, and mechanical ventilation, statin users appeared to show higher mortality rates. After balancing pre-existing relevant clinical conditions that could affect COVID-19 prognosis with PS matching, statin therapy confirmed its association with a more severe disease (NEWS ≥5 61% vs. 48%, p = 0.025) but not with in-hospital mortality (26% vs. 28%, p = 0.185). At univariate logistic regression analysis, statin use was confirmed not to be associated with mortality (OR 0.901; 95% CI: 0.537 to 1.51; p = 0.692) and to be associated with a more severe disease (NEWS≥5 OR 1.7; 95% CI 1.067-2.71; p = 0.026).

CONCLUSIONS

Our results did not confirm the supposed favorable effects of statin therapy on COVID-19 outcomes. Conversely, they suggest that statin use should be considered as a proxy of underlying comorbidities, which indeed expose to increased risks of more severe COVID-19.

Atorvastatin in combination with conventional antimicrobial treatment of Helicobacter pylori eradication: A randomized controlled clinical trial

BACKGROUND AND AIM

Helicobacter pylori is one of the main causes of digestive diseases, which is difficult to treat and requires the administration of several antimicrobial agents. Considering the anti-inflammatory and antibacterial effect of atorvastatin, the present study aimed at adding this agent to a four-drug regimen in order to eradicate H. pylori.

METHODS

A total of 220 patients with H. pylori infection were included in the current randomized controlled clinical trial. In the current study, 110 patients in the control group received a 14-day regimen of amoxicillin, clarithromycin, bismuth, and esomeprazole, and 110 patients in the intervention group received 40 mg of atorvastatin daily plus the antibiotic regimen for 14 weeks. The treatment results were evaluated 1 month later using H. pylori stool antigen test. Data were collected using checklist and analyzed using chi-squared and Fisher's exact tests with spss version 18.

RESULTS

Helicobacter pylori eradication rate in the intervention and control groups was 78.18% and 65.45%, respectively (P = 0.025), and there was a significant difference in terms of non-ulcer dyspepsia between the groups (P = 0.049), but there was no significant difference in age, gender, and body mass index between the two groups (P < 0.05).

CONCLUSION

The present study results showed that adding atorvastatin to the four-drug regimen of omeprazole, clarithromycin, bismuth, and amoxicillin is effective in the eradication of H. pylori. Also, the addition of atorvastatin to H. pylori eradication therapy is more effective in patients with non-ulcer dyspepsia.

Diabetic lung disease: fact or fiction?

Diabetes mellitus is a chronic, progressive, incompletely understood metabolic disorder whose prevalence has been increasing steadily worldwide. Even though little attention has been paid to lung disorders in the context of diabetes, its prevalence has recently been challenged by newer studies of disease development. In this review, we summarize and discuss the role of diabetes mellitus involved in the progression of pulmonary diseases, with the main focus on pulmonary fibrosis, which represents a chronic and progressive disease with high mortality and limited therapeutic options.

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.

Effect of atorvastatin on humoral immune response to 23-valent pneumococcal polysaccharide vaccination in healthy volunteers: The StatVax randomized clinical trial

BACKGROUND

The immunomodulatory effects of statins on vaccine response remain uncertain. Therefore, the objective of this study was to determine if atorvastatin enhances pneumococcal-specific antibody titer following 23-valent pneumococcal polysaccharide vaccination.

METHODS

Double-blind, placebo-controlled, single-center randomized clinical trial entitled StatVax. Subjects were enrolled between June and July 2014 and followed up through September 2014. 33 healthy volunteers signed informed consent after volunteer sampling. 11 participants were excluded; 22 healthy volunteers without prior pneumococcal vaccination were enrolled and completed the study. Participants were randomized to receive a 28-day course of 40 mg atorvastatin (n = 12) or matching lactose placebo (n = 10). On day 7 of treatment, Pneumovax 23 was administered intramuscularly. The primary outcome was fold change in total pneumococcal-specific antibody titer determined by a ratio of post-vaccination titer over baseline titer. Secondary outcomes included serotype-specific pneumococcal antibody titer, seroconversion, complete blood counts (CBC), erythrocyte sedimentation rate (ESR), and serum cytokine analysis.

RESULTS

Of the 22 randomized patients (mean age, 23.86; SD, 4.121; 11 women [50%]), 22 completed the trial. Total anti-pneumococcal antibody titer in the atorvastatin group went from a baseline mean of 32.58 (SD, 15.96) to 147.7 (SD, 71.52) μg/mL at 21 days post-vaccination while titer in the placebo group went from a mean of 30.81 (SD, 13.04) to 104.4 (SD, 45) μg/mL. When comparing fold change between treatment groups, there was a significant increase in fold change of total anti-pneumococcal antibody titer in the atorvastatin group compared to the placebo group (2-way ANOVA, p = .0177).

CONCLUSIONS

Atorvastatin enhances antigen-specific primary humoral immune response to a T cell-independent pneumonia vaccination. Pending confirmation by larger cohort studies of target populations, peri-vaccination conventional doses of statins can become a novel adjuvant for poorly-immunogenic polysaccharide-based vaccines.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02097589.

Effect of statins in preventing hospitalizations for infections: A population study

PURPOSE

To investigate whether the hospitalization rate for bacterial infections was modified by statin therapy in a population retrospectively followed up, over years 2011 to 2015.

METHODS

By using administrative databases, the 5-year hospitalization rate due to bacterial infections in population living in Tuscany, Italy exposed to statin therapy (n = 52,049) was stratified by 5 prescribed daily doses classes (0%-20%, 20%-50%, 50%-80%, 80%-100%, ≥100% of DDD) and subsequently compared with that of a population of untreated individuals (n = 3 300 ,675), matched through a propensity score accounting for all available covariates potentially able to modulate risk of infections such as age, gender, previous hospitalizations for infections, cardiovascular events, previous co-morbidities, diabetes, as well as general practitioners' proactive behaviour of care delivery according to current guidelines.

RESULTS

Unmatched individuals of each treatment-class had significantly more hospitalizations than controls, while matched treated people, apart from those in class 0% to 20%, had a decrease of hospitalizations, as large as the increase in prescribed drug. Statin effect in reducing hospitalizations translated into a number needed to treat (NNT) ranging across treatment strata from 102 to 54.

CONCLUSIONS

Compliance to statin prescribed daily doses above the threshold 20% of DDD, along a 5-year follow-up, prevented hospitalizations due to infectious diseases in a large unselected population, after adjusting for covariates able to modulate baseline risk of infections. The NNTs to avoid 1 hospitalization for infections resulted on average not too dissimilar from a value lying between the 95% CI of NNTs previously found for primary prevention of 1 incident coronary ischemic event (72 to 119).

Protective Capacity of Statins during Pneumonia Is Dependent on Etiological Agent and Obesity

Acute respiratory infections are a leading cause of death worldwide. Clinical data is conflicted regarding whether statins improve outcomes for pneumonia. Potential confounding factors including specific etiology of pneumonia as well as obesity could potentially mask protective benefit. Obesity is a risk factor for high cholesterol, the main target for statin therapy. We demonstrate that statin intervention conferred no protective benefit in the context of wild-type mice regardless of infectious agent. Statin intervention conferred either a protective benefit, during influenza infection, or detrimental effect, in the case of pneumococcal infection, in obese animals. These data suggest etiology of pneumonia in the context of obesity could be dramatically altered by the protective effects of statin therapy during bacterial and viral pneumonia.

Effect of statins on hospitalization risk of bacterial infections in patients with or without diabetes

AIMS

To investigate whether statins reduce the risk to first hospitalization of bacterial infections, in patients with or without diabetes taking into account prior or incident comorbidities.

METHODS

By using administrative databases, the effect of current statin use was measured on the risk of first hospitalizations due to bacterial infections in people living in Tuscany, Italy, in the period January 1, 2011-December 31, 2015, after excluding those with previous statins use. Population was stratified as with (n = 128,207) or without diabetes (n = 3,304,906), and the hospitalization risk was analyzed by a Cox proportional hazards regression analysis after adjusting for age, gender, previous comorbidities, chronic renal failure, and prior or incident cardiovascular diseases.

RESULTS

During the 5-year follow-up, 31,543 hospitalizations for bacterial infections were observed: 2.08(2.06-2.10) per 1000 person-year in non-diabetic and 5679: 9.13(8.94-9.32) per 1000 person-year in diabetic population. Diabetes conferred a greater risk of hospitalizations, independently from confounders [adjusted HR (95% CI) 2.04 (1.97-2.10); P < 0.0001]. Statin use decreased the risk by about 2.5% for each one month of therapy, at the same extent in subjects with or without diabetes, after adjusting for all covariates.

CONCLUSIONS

In this population, diabetes was associated by a twofold increase in the 5-year risk of hospitalizations for bacterial infections. Statin use decreased this risk to a same extent in subjects without or with diabetes, after adjusting for main confounders including comorbidities, and previous or incident cardiovascular events.

The Use of Statins and Risk of Community-Acquired Pneumonia

PURPOSE OF THE REVIEW

Community-acquired pneumonia (CAP) is still associated with a large burden and causes significant morbidity and mortality. Besides universal vaccination and antibiotic treatment, statins as adjunctive therapy may also have a beneficial role in the prevention and treatment of CAP. Our goal from this review is to discuss the epidemiology of CAP, and role of statins as adjunctive therapy in the development of CAP.

RECENT FINDINGS

Statins are lipid-lowering medications characterized by their ability to control hypercholesterolemia in addition to other pleiotropic effects that could explain their role in the pathogenesis of CAP. While most observational studies have shown that statins reduce risk of pneumonia in the general population, patients with diabetes, and recently in patients with myocardial infarction, no randomized controlled trial (RCT) to date has been conducted to assess the efficacy of statins to prevent development of CAP. Given the paucity of robust randomized evidence to assess statin use and the development of CAP, and considering conflicting results of the observational studies, we are not in favor of initiation of statins for either the prevention or treatment of CAP.

Age-Related Changes in Immunological and Physiological Responses Following Pulmonary Challenge

This review examines the current status of knowledge of sepsis and pneumonia in the elderly population and how the dynamics of the pulmonary challenge affects outcome and consequences. Led by an unprecedented shift in demographics, where a larger proportion of the population will reach an older age, clinical and experimental research shows that aging is associated with certain pulmonary changes, but it is during infectious insult of the lungs, as in the case of pneumonia, that the age-related differences in responsiveness and endurance become obvious and lead to a worse outcome than in the younger population. This review points to the neutrophil, and the endothelium as important players in understanding age-associated changes in responsiveness to infectious challenge of the lung. It also addresses how the immunological set-point influences injury-repair phases, remote organ damage and how intake of drugs may alter the state of responsiveness in the users. Further, it points out the importance of considering age as a factor in inclusion criteria in clinical trials, in vitro/ex vivo experimental designs and overall interpretation of results.

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.

Effect on non-vascular outcomes of lowering LDL cholesterol in patients with chronic kidney disease: results from the Study of Heart and Renal Protection

Background

Reducing LDL cholesterol (LDL-C) with statin-based therapy reduces the risk of major atherosclerotic events among patients with chronic kidney disease (CKD), with no evidence of an excess risk of cancer or death from any non-vascular cause. However, non-randomized data have suggested that statin therapy may have effects (both adverse and beneficial) on particular non-vascular conditions that do not cause death.

Methods

The Study of Heart and Renal Protection (SHARP) randomized patients with CKD to simvastatin 20 mg plus ezetimibe 10 mg (simvastatin/ezetimibe) daily versus matching placebo. Participants were followed up at least 6 monthly and all post-randomization serious adverse events (SAEs) were recorded. This supplementary analysis reports the effects of treatment on non-vascular SAEs, overall, by system of disease, by baseline characteristics, and by duration of follow-up.

Results

During a median of 4.9 years follow-up, similar numbers of participants in the two groups experienced at least one non-vascular SAE (3551 [76.4%] simvastatin/ezetimibe vs 3537 [76.6%] placebo; risk ratio [RR] 0.99, 95% confidence interval [CI] 0.95–1.04). There was no good evidence of any significant effect of simvastatin/ezetimibe on SAEs attributed to any particular nonvascular disease system (of 43 comparisons, only 3 yielded an uncorrected p value < 0.05, of which the smallest was p = 0.02). The relative risk of any nonvascular SAE did not vary significantly among particular prognostic subgroups or by duration of follow-up.

Conclusions

In the SHARP trial, allocation to simvastatin/ezetimibe combination therapy was not associated with any significant non-vascular hazard.

Trials registration

SHARP was retrospectively registered after the first participant was enrolled in 2003 at ISRCTN (ISRCTN54137607 on 31 January 2005: http://www.isrctn.com/ISRCTN54137607) and ClinicalTrials.gov (NCT00125593 on 29 July 2005: https://clinicaltrials.gov/ct2/show/NCT00125593).

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-017-0545-2) contains supplementary material, which is available to authorized users.

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.

Statin potency and the risk of hospitalization for community-acquired pneumonia

AIM

Previous studies suggest that statins may have beneficial respiratory effects. However, it is unclear if these purported benefits vary with statin potency. Our objective was to determine if higher potency statins, compared with lower potency statins, were associated with a reduced risk of hospitalization for community-acquired pneumonia (HCAP).

METHODS

We conducted a nested case-control analysis of a retrospective, population-based cohort of new users of statins using data extracted from the UK's Clinical Practice Research Datalink and Hospital Episode Statistics. For each HCAP case, we used risk set sampling to randomly select up to 10 controls, matched on sex, age, cohort entry date and follow-up duration. We used conditional logistic regression with high-dimensional propensity scores to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for HCAP with current use of higher potency statin vs. lower potency statins.

RESULTS

A total of 217 721 patients entered the cohort on a lower potency statin and 130 707 entered on a higher potency statin; these patients resulted in 2251 cases of HCAP during 561 886 person-years of observation (rate: 4.0 HCAP per 1000 persons per year, 95% CI: 3.8-4.2). The analysis included 22 178 matched controls. Compared with lower potency statins, higher potency statins were associated with an increased rate of HCAP (HR: 1.14, 95% CI: 1.03-1.27). Higher potency statins were also associated with an increased rate of fatal HCAP (HR: 1.29, 95% CI: 1.04-1.59).

CONCLUSIONS

Higher potency statins were not associated with a decreased risk of HCAP compared with lower potency statins.

Nonantibiotic Adjunctive Therapies for Community-Acquired Pneumonia (Corticosteroids and Beyond): Where Are We with Them?

Community-acquired pneumonia (CAP) is a leading cause of hospitalization, morbidity, and mortality. Despite advances in antibiotic treatments, mortality among patients with CAP is still high. For this reason, interest has been focused on nonantibiotic therapeutic measures directed to the host response rather than the microorganism. The development of an efficacious adjunctive treatment has important implications for reducing mortality in CAP. Some clinical studies performed in the last decade have shown a clinically beneficial effect of corticosteroids, possibly by diminishing local and systemic inflammatory host response. Recent meta-analyses showed faster resolution of symptoms, shorter time to clinically stability, reduction of mechanical ventilation needed, and reduction of mortality in the most severe population, although some methodological limitations must be taken into account. In addition, some studies using statins also suggested improved outcomes due to its anti-inflammatory effect in CAP, although this requires further research. Other adjunctive therapies such as immunoglobulins and stem cells are being explored, but are not yet in the stage of clinical trials. In summary, the use of corticosteroids and other adjuvant treatments are promising in CAP, but more studies are needed to determine their impact on mortality.

Interpretation of the evidence for the efficacy and safety of statin therapy

This Review is intended to help clinicians, patients, and the public make informed decisions about statin therapy for the prevention of heart attacks and strokes. It explains how the evidence that is available from randomised controlled trials yields reliable information about both the efficacy and safety of statin therapy. In addition, it discusses how claims that statins commonly cause adverse effects reflect a failure to recognise the limitations of other sources of evidence about the effects of treatment. Large-scale evidence from randomised trials shows that statin therapy reduces the risk of major vascular events (ie, coronary deaths or myocardial infarctions, strokes, and coronary revascularisation procedures) by about one-quarter for each mmol/L reduction in LDL cholesterol during each year (after the first) that it continues to be taken. The absolute benefits of statin therapy depend on an individual's absolute risk of occlusive vascular events and the absolute reduction in LDL cholesterol that is achieved. For example, lowering LDL cholesterol by 2 mmol/L (77 mg/dL) with an effective low-cost statin regimen (eg, atorvastatin 40 mg daily, costing about £2 per month) for 5 years in 10 000 patients would typically prevent major vascular events from occurring in about 1000 patients (ie, 10% absolute benefit) with pre-existing occlusive vascular disease (secondary prevention) and in 500 patients (ie, 5% absolute benefit) who are at increased risk but have not yet had a vascular event (primary prevention). Statin therapy has been shown to reduce vascular disease risk during each year it continues to be taken, so larger absolute benefits would accrue with more prolonged therapy, and these benefits persist long term. The only serious adverse events that have been shown to be caused by long-term statin therapy-ie, adverse effects of the statin-are myopathy (defined as muscle pain or weakness combined with large increases in blood concentrations of creatine kinase), new-onset diabetes mellitus, and, probably, haemorrhagic stroke. Typically, treatment of 10 000 patients for 5 years with an effective regimen (eg, atorvastatin 40 mg daily) would cause about 5 cases of myopathy (one of which might progress, if the statin therapy is not stopped, to the more severe condition of rhabdomyolysis), 50-100 new cases of diabetes, and 5-10 haemorrhagic strokes. However, any adverse impact of these side-effects on major vascular events has already been taken into account in the estimates of the absolute benefits. Statin therapy may cause symptomatic adverse events (eg, muscle pain or weakness) in up to about 50-100 patients (ie, 0·5-1·0% absolute harm) per 10 000 treated for 5 years. However, placebo-controlled randomised trials have shown definitively that almost all of the symptomatic adverse events that are attributed to statin therapy in routine practice are not actually caused by it (ie, they represent misattribution). The large-scale evidence available from randomised trials also indicates that it is unlikely that large absolute excesses in other serious adverse events still await discovery. Consequently, any further findings that emerge about the effects of statin therapy would not be expected to alter materially the balance of benefits and harms. It is, therefore, of concern that exaggerated claims about side-effect rates with statin therapy may be responsible for its under-use among individuals at increased risk of cardiovascular events. For, whereas the rare cases of myopathy and any muscle-related symptoms that are attributed to statin therapy generally resolve rapidly when treatment is stopped, the heart attacks or strokes that may occur if statin therapy is stopped unnecessarily can be devastating.

Association between statins and infections among patients with diabetes: a cohort and prescription sequence symmetry analysis

Purpose

A previous meta‐analysis of randomized trials did not confirm findings from observational studies that suggested that statins reduce the risk of infection. However, animal experiments indicate that statins may be more effective in reducing the risk and/or the severity of infection among patients with diabetes. Hence, we evaluated the effect of statins on antibiotic prescriptions (a proxy for infections) among patients with drug‐treated type 2 diabetes using two confounding‐reducing observational designs.

Methods

We conducted a prescription sequence symmetry analysis and a cohort study using the IADB.nl pharmacy prescription database. For the prescription sequence symmetry analysis, a sequence ratio was calculated. The matched cohort study, comparing the time to first antibiotic prescription between periods that statins are initiated and non‐use periods, was analyzed using stratified Cox regression.

Results

Prescription sequence symmetry analysis of 4684 patients with drug‐treated type 2 diabetes resulted in an adjusted sequence ratio of 0.86 (95% confidence interval [CI]: 0.81 to 0.91). Corresponding figures for the cohort analysis comparing 9852 statin‐initiation with 4928 non‐use periods showed similar results (adjusted hazard ratio: 0.88, 95%CI: 0.83 to 0.95).

Conclusions

These findings suggest that statins are associated with a reduced risk of infections among patients with drug‐treated type 2 diabetes. © 2016 The Authors. Pharmacoepidemiology and Drug Safety Published by John Wiley & Sons Ltd.

Protocol for analyses of adverse event data from randomized controlled trials of statin therapy

The Cholesterol Treatment Trialists' (CTT) Collaboration was originally established to conduct individual participant data meta-analyses of major vascular events, cause-specific mortality, and site-specific cancers in large, long-term, randomized trials of statin therapy (and other cholesterol-modifying treatments). The results of the trials of statin therapy and their associated meta-analyses have shown that statins significantly reduce the risk of major vascular events without any increase in the risk of nonvascular causes of death or of site-specific cancer, but do produce small increases in the incidence of myopathy, diabetes, and, probably, hemorrhagic stroke. The CTT Collaboration has not previously sought data on other outcomes, and so a comprehensive meta-analysis of all adverse events recorded in each of the eligible trials has not been conducted. This protocol prospectively describes plans to extend the CTT meta-analysis data set so as to provide a more complete understanding of the nature and magnitude of any other effects of statin therapy.

Statin use associated with a reduced risk of pneumonia requiring hospitalization in patients with myocardial infarction: a nested case-control study

BACKGROUND

Statins have been reported to prevent adverse cardiovascular events in patients with myocardial infarction (MI). However, the association of statin use and the risk of pneumonia requiring hospitalization in MI patients remains unclear.

METHODS

A nested case-control study was conducted by using data from the National Health Insurance Research Database of Taiwan. Among 24,975 patients with MI, 2686 case patients with pneumonia requiring hospitalization were age- and sex-matched with 10,726 control patients using the incidence density sampling approach. Duration and dosage of statin use were obtained from pharmaceutical claims. Conditional logistic regression analyses were used to estimate the risk of hospitalization for pneumonia associated with statin use adjusted for patient's demographics, medical conditions and prescribed medications.

RESULTS

Statin use was associated with a 15% reduced risk of pneumonia requiring hospitalization among MI patients (adjusted odds ratio [aOR] = 0.85, 95% confidence interval [CI] = 0.77-0.95, P = 0.004). The association was more significant for MI patients unexposed to statin pretreatment (aOR = 0.76, 95% CI = 0.64-0.90, P = 0.001). Statins also exhibited favorable benefits in a time- and dose-dependent manner. The results were consistent in various subgroup analysis of the patients who were female, age ≥ 65 years, a low CHADS2 (i.e. congestive heart failure, hypertension, diabetes mellitus, previous stroke and age > 75 years old) score, and fewer comorbidities. Atorvastatin, fluvastatin and simvastatin were the most common prescribed statins and had similar effects.

CONCLUSIONS

Statins might be considered as an adjunctive therapy to reduce the risk of hospitalization for pneumonia for MI patients under thorough evaluation of individual comorbidities, previous statin use and optimal dosage.

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.

Use of Dipeptidyl-Peptidase-4 Inhibitors and the Risk of Pneumonia: A Population-Based Cohort Study

Background

Dipeptidyl-peptidase-4 inhibitors (DPP4Is) are drugs for the treatment of type 2 diabetes mellitus (T2DM). There is increasing evidence that DPP4Is may result in suppression of the immune system and may increase the risk of infections such as pneumonia. Aim of this study was to evaluate the association between the use of DPP4Is and the risk of pneumonia in a population-based study.

Methods

We conducted a population-based cohort study using data from the world’s largest primary care database, the UK Clinical Practice Research Datalink (CPRD). We selected all users of non-insulin antidiabetic drugs (NIADs), including DPP4Is, between 2007 and 2012. To each NIAD user, we matched randomly selected non-users. The NIAD user’s first prescription defined the index date, which was then assigned to the matched non-users. Patients were followed from their first prescription until end of data collection or the first event of pneumonia, whichever came first. Cox regression analysis estimated the association between pneumonia and current use of DPP4Is versus 1) current use of other NIADs and 2) non-users. DPP4I use was then stratified to daily and cumulative dose. Analyses were statistically adjusted for age, sex, lifestyle factors and comorbidities and concomitant use of various other drugs.

Results

Risk of pneumonia was not increased with current DPP4I use versus use of other NIADs, adjusted Hazard Ratio (HR) 0.70; 95% Confidence Interval (CI) 0.55–0.91. Also higher cumulative doses or daily doses did not further increase risk of pneumonia.

Conclusion

We found no increased risk of pneumonia in T2DM patients using DPP4Is compared to T2DM patients using other NIADs. Our finding is in line with direct and indirect evidence from observational studies and RCTs. There is probably no need to avoid prescribing of DPP4Is to elderly patients who are at risk of pneumonia.

Risk of community-acquired pneumonia with outpatient proton-pump inhibitor therapy: a systematic review and meta-analysis

BACKGROUND

Proton-pump inhibitors (PPIs) are among the most frequently prescribed medications. Community-acquired pneumonia (CAP) is a common cause of morbidity, mortality and healthcare spending. Some studies suggest an increased risk of CAP among PPI users. We conducted a systematic review and meta-analysis to determine the association between outpatient PPI therapy and risk of CAP in adults.

METHODS

We conducted systematic searches of MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Scopus and Web of Science on February 3, 2014. Case-control studies, case-crossover, cohort studies and randomized controlled trials reporting outpatient PPI exposure and CAP diagnosis for patients ≥18 years old were eligible. Our primary outcome was the association between CAP and PPI therapy. A secondary outcome examined the risk of hospitalization for CAP and subgroup analyses evaluated the association between PPI use and CAP among patients of different age groups, by different PPI doses, and by different durations of PPI therapy.

RESULTS

Systematic review of 33 studies was performed, of which 26 studies were included in the meta-analysis. These 26 studies included 226,769 cases of CAP among 6,351,656 participants. We observed a pooled risk of CAP with ambulatory PPI therapy of 1.49 (95% CI 1.16, 1.92; I2 99.2%). This risk was increased during the first month of therapy (OR 2.10; 95% CI 1.39, 3.16), regardless of PPI dose or patient age. PPI therapy also increased risk for hospitalization for CAP (OR 1.61; 95% CI: 1.12, 2.31).

DISCUSSION

Outpatient PPI use is associated with a 1.5-fold increased risk of CAP, with the highest risk within the first 30 days after initiation of therapy. Providers should be aware of this risk when considering PPI use, especially in cases where alternative regimens may be available or the benefits of PPI use are uncertain.

Modulation of sterol biosynthesis regulates viral replication and cytokine production in influenza A virus infected human alveolar epithelial cells

Highly pathogenic H5N1 viruses continue to transmit zoonotically, with mortality higher than 60%, and pose a pandemic threat. Antivirals remain the primary choice for treating H5N1 diseases and have their limitations. Encouraging findings highlight the beneficial effects of combined treatment of host targeting agents with immune-modulatory activities. This study evaluated the undefined roles of sterol metabolic pathway in viral replication and cytokine induction by H5N1 virus in human alveolar epithelial cells. The suppression of the sterol biosynthesis by Simvastatin in human alveolar epithelial cells led to reduction of virus replication and cytokine production by H5N1 virus. We further dissected the antiviral role of different regulators of the sterol metabolism, we showed that Zometa, FPT inhibitor III, but not GGTI-2133 had anti-viral activities against both H5N1 and H1N1 viruses. More importantly, FPT inhibitor III treatment significantly suppressed cytokine production by H5N1 virus infected alveolar epithelial cells. Since both viral replication itself and the effects of viral hyper-induction of cytokines contribute to the immunopathology of severe H5N1 disease, our findings highlights the therapeutic potential of FPT inhibitor III for severe human H5N1 diseases. Furthermore, our study is the first to dissect the roles of different steps in the sterol metabolic pathway in H5N1 virus replication and cytokine production.

Rethinking risk for pneumococcal disease in adults: the role of risk stacking

Using data from 3 private healthcare claims repositories, we evaluated the incidence of pneumococcal disease among adults with US Advisory Committee on Immunization Practices (ACIP) defined at-risk conditions or rheumatoid arthritis, lupus, Crohn's disease, and neuromuscular disorder/seizures and those with traditional high-risk conditions. We observed that adults with ≥2 concurrent comorbid conditions had pneumococcal disease incidence rates that were as high as or higher than rates observed in those with traditional high-risk conditions.

Prognostic impact of statin use in patients with heart failure and preserved ejection fraction

BACKGROUND

The effectiveness of statins remains to be examined in patients with heart failure (HF) with preserved ejection fraction (EF). METHODS AND RESULTS: Among 4,544 consecutive HF patients registered in the Chronic Heart Failure Registry and Analysis in the Tohoku district-2 (CHART-2) between 2006 and 2010, 3,124 had EF ≥50% (HFpEF; mean age 69 years; male 65%) and 1,420 had EF <50% (HF with reduced EF (HFrEF); mean age 67 years; male 75%). The median follow-up was 3.4 years. The 3-year mortality in HFpEF patients was lower in patients receiving statins [8.7% vs. 14.5%, adjusted hazard ratio (HR) 0.74; 95% confidence interval (CI), 0.58-0.94; P<0.001], which was confirmed in the propensity score-matched cohort (HR, 0.72; 95% CI, 0.49-0.99; P=0.044). The inverse probability of treatment weighted further confirmed that statin use was associated with reduced incidence of all-cause death (HR, 0.71; 95% CI, 0.62-0.82, P<0.001) and noncardiovascular death (HR, 0.53; 95% CI, 0.43-0.66, P<0.001), specifically reduction of sudden death (HR, 0.59; 95% CI, 0.36-0.98, P=0.041) and infection death (HR, 0.53; 95% CI, 0.35-0.77, P=0.001) in HFpEF. In the HFrEF cohort, statin use was not associated with mortality (HR, 0.87; 95% CI, 0.73-1.04, P=0.12), suggesting a lack of statin benefit in HFrEF patients.

CONCLUSIONS

These results suggest that statin use is associated with improved mortality rates in HFpEF patients, mainly attributable to reductions in sudden death and noncardiovascular death.

Potential effect of PCV13 introduction on Emergency Department accesses for lower respiratory tract infections in elderly and at risk adults

Liguria, an administrative region in northern Italy characterized by a decade of high PCV coverage in paediatric age group, has issued new PCV13 recommendations for free active immunization in adults with risk factors and subjects aged ≥ 70 years old. Main aims of this study are: (1) a descriptive epidemiology of the clinical burden of lower respiratory tract infections (LRTI) in adults ≥18 years of age; and (2) a crossover evaluation of the effect of introduction of PCV13 vaccination in adults aged ≥70 years old, in terms of ED accesses for LRTI, obtained by a Syndrome Surveillance System (SSS). The ED access, chief complaint based SSS will allow an active surveillance of a population cohort of >430 000 individuals resident in Genoa metropolitan area, aged ≥18 years old, for a period of 60 months. During pre-PCV period, annual cumulative incidence of ED accesses for LRTI was equal to 7/1000 and 2% in ≥65 and ≥85 year adults, respectively. In ≥65 years adults, more than 70% of subjects identified by the SSS has at least one risk condition, with a peak of 87% in ≥85 year cohort. New Ligurian PCV13 recommendations can potentially reach more than 75% of ED accesses for LRTI. Data highlights the heavy impact of LRTI in terms of ED accesses, especially in the elderly and subjects with chronic conditions and the usefulness of SSS tool for monitoring PCV vaccination effect.

Preoperative statin therapy and infectious complications in cardiac surgery

AIM

To assess whether preoperative statin therapy is associated with the risk of postoperative infection in patients undergoing cardiac surgery.

METHODS

520 patients undergoing cardiac surgery in 2010 were retrospectively examined. Data regarding statin and antibiotic use prior to and after surgery were available from the hospital pharmacy information system. Cultures and clinical data of patients on postoperative antibiotics other than standard prophylactic therapy were studied to identify postoperative infections up to 30 days from day of surgery.

RESULTS

370 (71.2 %) patients were on preoperative statin therapy. Overall, 82 patients (15.8 %) suffered from postoperative infection of which 11 were surgical site infections. In multivariable regression analysis, statin therapy was associated with a reduced risk of postoperative infection (adjusted odds ratio: 0.329, 95 %: CI 0.19-0.57; P < 0.001).

CONCLUSIONS

Preoperative statin use was associated with a considerable reduced risk of postoperative infections following cardiac surgery. Randomised controlled trials are required to clarify the role of statin therapy in the prevention of postoperative infections.

Role of statin on mortality outcome in pneumonia patients: A meta-analysis

AIM: To determine the role of statin on mortality outcome in patient with pneumonia.

METHODS: For the present meta-analysis, we search the published literatures online through PubMed, Embase, Scopus and the Cochrane Library databases and the search words used were “statins’”, “bacteraemia”, “pneumonia”, and “ICU infections”. During the online search our focus was on full text articles, peer-reviewed, observational cohort or case control studies and randomized controlled trials. Those studies were selected whose outcome was hospital mortality among patients with pneumonia whether or not on statins. In this meta-analysis, 30 d mortality was used as the primary outcome as it has been demonstrated in the previous research that 30 d mortality is primarily because of community acquired pneumonia. As all studies were observational, where statin users were compared with historical rather than randomized controls, odds ratio for in-hospital or all-cause 30 d mortality was used as the primary effect measure used in the meta-analysis.

RESULTS: We came across the total 25 studies comprising 35355 patients (2734 statin users and 32621 statin non-users) during the electronic search. Four studies out of 25 were included in the final analysis. In this meta-analysis, when data regarding the use of statin in pneumonia patients on mortality was pooled, its results showed the non-significant effect of the statin on mortality outcome.

CONCLUSION: Although statins seems to be useful in the treatment of pneumonia patients but for statistical conclusion, further randomized controlled trials needs to be done or their results still waited to be published of ongoing trials, with the conclusion that presently statins showing no clinical benefit in the pneumonia patients.

Do the omeprazole family compounds exert a protective effect against influenza-like illness?

BACKGROUND

Infections by influenza viruses place a heavy burden on public health and economies worldwide. Although vaccines are the best weapons against influenza, antiviral drugs could offer an opportunity to alleviate the burden of influenza. Since omeprazole family compounds block the "proton pump", we hypothesized that they could interfere with the mechanism of fusion of the virus envelope and endosomal membrane, thereby hindering the M2 proton pump mechanism of influenza viruses.

METHODS

A matched case-control study was performed in 2010-2011 in Italy. Cases were subjects aged over 18 years with a diagnosis of Influenza-like Illness (ILI); 254 case-control pairs were recruited. A multivariable conditional logistic regression analysis was used to assess the association between the prevention of ILI and the administration of omeprazole family compounds. The interaction between omeprazole family compounds and influenza vaccination was also examined.

RESULTS

After control for potential confounders, subjects treated with omeprazole family compounds displayed a lower risk of catching ILI (ORadj = 0.29, 95% CI: 0.15-0.52). The risk of ILI in unvaccinated non-OFC users was about six times than that in vaccinated OFC users.

CONCLUSIONS

Although confirmation is necessary, these results suggest that omeprazole family compounds could be profitably used in the prevention of ILI.

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

BACKGROUND

Statins have been postulated to prevent infection through immunomodulatory effects.

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Risk factors for community-acquired pneumonia in adults in Europe: a literature review

Background

Community-acquired pneumonia (CAP) causes considerable morbidity and mortality in adults, particularly in the elderly.

Methods

Structured searches of PubMed were conducted to identify up-to-date information on the incidence of CAP in adults in Europe, as well as data on lifestyle and medical risk factors for CAP.

Results

The overall annual incidence of CAP in adults ranged between 1.07 to 1.2 per 1000 person-years and 1.54 to 1.7 per 1000 population and increased with age (14 per 1000 person-years in adults aged ≥65 years). Incidence was also higher in men than in women and in patients with chronic respiratory disease or HIV infection. Lifestyle factors associated with an increased risk of CAP included smoking, alcohol abuse, being underweight, having regular contact with children and poor dental hygiene. The presence of comorbid conditions, including chronic respiratory and cardiovascular diseases, cerebrovascular disease, Parkinson's disease, epilepsy, dementia, dysphagia, HIV or chronic renal or liver disease all increased the risk of CAP by twofold to fourfold.

Conclusion

A range of lifestyle factors and underlying medical conditions are associated with an increased risk of CAP in European adults. Understanding of the types of individual at greatest risk of CAP can help to ensure that interventions to reduce the risk of infection and burden of disease are targeted appropriately.

Epidemiology and long-term clinical and biologic risk factors for pneumonia in community-dwelling older Americans: analysis of three cohorts

BACKGROUND

Preventing pneumonia requires better understanding of incidence, mortality, and long-term clinical and biologic risk factors, particularly in younger individuals.

METHODS

This was a cohort study in three population-based cohorts of community-dwelling individuals. A derivation cohort (n = 16,260) was used to determine incidence and survival and develop a risk prediction model. The prediction model was validated in two cohorts (n = 8,495). The primary outcome was 10-year risk of pneumonia hospitalization.

RESULTS

The crude and age-adjusted incidences of pneumonia were 6.71 and 9.43 cases/1,000 person-years (10-year risk was 6.15%). The 30-day and 1-year mortality were 16.5% and 31.5%. Although age was the most important risk factor (range of crude incidence rates, 1.69-39.13 cases/1,000 person-years for each 5-year increment from 45-85 years), 38% of pneumonia cases occurred in adults < 65 years of age. The 30-day and 1-year mortality were 12.5% and 25.7% in those < 65 years of age. Although most comorbidities were associated with higher risk of pneumonia, reduced lung function was the most important risk factor (relative risk = 6.61 for severe reduction based on FEV1 by spirometry). A clinical risk prediction model based on age, smoking, and lung function predicted 10-year risk (area under curve [AUC] = 0.77 and Hosmer-Lemeshow [HL] C statistic = 0.12). Model discrimination and calibration were similar in the internal validation cohort (AUC = 0.77; HL C statistic, 0.65) but lower in the external validation cohort (AUC = 0.62; HL C statistic, 0.45). The model also calibrated well in blacks and younger adults. C-reactive protein and IL-6 were associated with higher pneumonia risk but did not improve model performance.

CONCLUSIONS

Pneumonia hospitalization is common and associated with high mortality, even in younger healthy adults. Long-term risk of pneumonia can be predicted in community-dwelling adults with a simple clinical risk prediction model.

Pneumonia risk and use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers

Background

Recent studies have shown that use of angiotensin-converting enzyme (ACE) inhibitors may decrease pneumonia risk in various populations. We investigated the effect of ACE inhibitors and angiotensin II receptor blockers (ARBs) on pneumonia hospitalization in the general population of Taiwan.

Methods

We conducted a case-crossover study using the Taiwan Longitudinal Health Insurance Database for the year 2005. Data from patients hospitalized for the first time for pneumonia during 1997–2007 were analyzed. The case period was defined as the 30 days before admission; the periods 90 to 120 days and 180 to 210 days before admission were used as control periods. Prescribing status of ACE inhibitors and ARBs during the 3 periods was assessed for each patient. Conditional logistic regression was used to estimate the odds ratio (OR) for pneumonia associated with use of ACE inhibitors and ARBs.

Results

We identified 10 990 cases of hospitalization for new pneumonia. After adjustment for time-variant confounding factors, pneumonia was not associated with use of ACEI or ARBS: the ORs were 0.99 (95% CI, 0.81–1.21) and 0.96 (0.72–1.28), respectively. No association was seen for cumulative defined daily doses (DDDs), as compared with nonusers, for 0 to 30, 31 to 60, or more than 60 DDDs. The results were found to be robust in sensitivity analysis.

Conclusions

Neither the use nor cumulative dose of ACE inhibitors or ARBs was associated with pneumonia among the Taiwanese general population.

The immunomodulatory effects of statins in community-acquired pneumonia: a systematic review

OBJECTIVE

To evaluate the potential immunomodulatory effects of statins in community-acquired pneumonia.

METHODS

We performed a systematic review of available literature on experimental and clinical studies. We used a PubMed/MEDLINE and EMBASE search to identify potential articles.

RESULTS

We identified 34 original studies, 17 experimental and 17 clinical studies, published up to March 2013.

CONCLUSIONS

Statins attenuated pulmonary inflammation by modulating neutrophil function, by reducing cytokine expression and release, and by protecting against disruption of pulmonary integrity. However, additional experimental studies are needed to fully elucidate the exact mechanisms. Several clinical studies suggested a decreased risk of CAP or a reduction in mortality due to CAP for current statin users, but the mostly observational design of these studies hampers the interpretation of their results. Therefore, appropriately designed studies, such as randomised controlled trials, are required to demonstrate the usefulness of statins in the prevention and treatment of CAP.

Incidence and predictors of hospitalization for bacterial infection in community-based patients with type 2 diabetes: the fremantle diabetes study

Background

The few studies that have examined the relationship between diabetes and bacterial infections have utilized administrative databases and/or have had limited/incomplete data including recognized infection risk factors. The aim of this study was to determine the incidence and associates of bacterial infection severe enough to require hospitalization in well-characterized community-based patients with type 2 diabetes.

Methods and Findings

We studied a cohort of 1,294 patients (mean±SD age 64.1±11.3 years) from the longitudinal observational Fremantle Diabetes Study Phase I (FDS1) and 5,156 age-, gender- and zip-code-matched non-diabetic controls. The main outcome measure was incident hospitalization for bacterial infection as principal diagnosis between 1993 and 2010. We also examined differences in statin use in 52 FDS1 pairs hospitalized with pneumonia (cases) or a contemporaneous non-infection-related cause (controls). During 12.0±5.4 years of follow-up, 251 (19.4%) patients were hospitalized on 368 occasions for infection (23.7/1,000 patient-years). This was more than double the rate in matched controls (incident rate ratio (IRR) (95% CI), 2.13 (1.88–2.42), P<0.001). IRRs for pneumonia, cellulitis, and septicemia/bacteremia were 1.86 (1.55–2.21), 2.45 (1.92–3.12), and 2.08 (1.41–3.04), respectively (P<0.001). Among the diabetic patients, older age, male sex, prior recent infection-related hospitalization, obesity, albuminuria, retinopathy and Aboriginal ethnicity were baseline variables independently associated with risk of first hospitalization with any infection (P≤0.005). After adjustment for these variables, baseline statin treatment was not significant (hazard ratio (95% CI), 0.70 (0.39–1.25), P = 0.22). Statin use at hospitalization for pneumonia among the case-control pairs was similar (23.1% vs. 13.5%, P = 0.27).

Conclusions

The risk of severe infection is increased among type 2 diabetic patients and is not reduced by statin therapy. There are a number of other easily-accessible sociodemographic and clinical variables that could be used to optimize infection-related education, prevention and management in type 2 diabetes.

The role of statins in prevention and treatment of community acquired pneumonia: a systematic review and meta-analysis

BACKGROUND

Emerging epidemiological evidence suggests that statins may reduce the risk of community-acquired pneumonia (CAP) and its complications.

PURPOSE

Performed a systematic review to address the role of statins in the prevention or treatment of CAP.

DATA SOURCE

Ovid MEDLINE, Cochrane, EMBASE, ISI Web of Science, and Scopus from inception through December 2011 were searched for randomized clinical trials, cohort and case-control studies.

STUDY SELECTION

Two authors independently reviewed studies that examined the role of statins in CAP.

DATA EXTRACTION

Data about study characteristics, adjusted effect-estimates and quality characteristics was extracted.

DATA SYNTHESIS

Eighteen studies corresponding to 21 effect-estimates (eight and 13 of which addressed the preventive and therapeutic roles of statins, respectively) were included. All studies were of good methodological quality. Random-effects meta-analyses of adjusted effect-estimates were used. Statins were associated with a lower risk of CAP, 0.84 (95% CI, 0.74-0.95), I(2) = 90.5% and a lower short-term mortality in patients with CAP, 0.68 (95% CI, 0.59-0.78), I(2) = 75.7%. Meta-regression did not identify sources of heterogeneity. A funnel plot suggested publication bias in the treatment group, which was adjusted by a novel regression method with a resultant effect-estimate of 0.85 (95% CI, 0.77-0.93). Sensitivity analyses using the rule-out approach showed that it is unlikely that the results were due to an unmeasured confounder.

CONCLUSIONS

Our meta-analysis reveals a beneficial role of statins for the risk of development and mortality associated with CAP. However, the results constitute very low quality evidence as per the GRADE framework due to observational study design, heterogeneity and publication bias.

Is statin use associated with reduced mortality after pneumonia? A systematic review and meta-analysis

OBJECTIVE

The objective of this study was to perform a systematic review and meta-analysis of the effects of statins on mortality following pneumonia.

METHODS

We searched MEDLINE, EMBASE, BIOSIS, Cochrane CENTRAL Register of Controlled Trials, Cambridge Scientific Abstracts, BIOSIS, and Scopus. Studies were included if they involved: participants ≥18 years of age; patients with community-acquired pneumonia; current statin users; and reported overall or adjusted mortality after pneumonia.

RESULTS

Of 491 citations identified, 13 studies involving 254,950 patients met eligibility criteria. Pooled unadjusted data showed that statin use was associated with lower mortality after pneumonia (odds ratio [OR] 0.62, 95% confidence interval [CI], 0.54-0.71). Pooling of adjusted data also showed reduced mortality after pneumonia (OR 0.66, 95% CI, 0.55-0.79). However, this effect was attenuated in subgroup analysis by confounders and in prospective studies.

CONCLUSIONS

Although statin use is associated with decreased mortality after pneumonia, this effect weakens in important subgroups. Only a randomized controlled study can fully explore the link between statins and pneumonia mortality.

Association between statins and infections after coronary artery bypass grafting

BACKGROUND

We determined whether pre-operative statin therapy is associated with a decrease in the incidence of infections after coronary artery bypass grafting (CABG).

METHODS

A retrospective cohort study of 6253 patients undergoing isolated CABG, from the Texas Heart Institute Database from January 1, 2000 to December 31, 2010 (3869 receiving statins and 2384 not receiving statins) was conducted. Primary outcome was the development of any postoperative infection (composite of deep-sternal wound infection, leg harvest-site infection, pneumonia, or sepsis) after CABG. Secondary outcome was the association between pre-operative statin use and individual incidence of each aforementioned infection. Logistic regression analyses were performed.

RESULTS

Incidence of any postoperative infection in patients who received statins pre-operatively was 6.5% compared to 8.3% in patients who did not receive statins. Pre-operative statin therapy was associated with a significant reduction in the primary outcome (odds ratio (OR) 0.74, 95% confidence interval (CI) 0.60-0.90) in adjusted models. Among individual secondary outcomes, pre-operative statin therapy was associated with a reduced incidence of sternal wound infections (2.5% vs. 3.2%, OR 0.6, 95% CI 0.5-0.8) and leg harvest site infections (0.6% vs. 1.3%, OR 0.46, 95% CI 0.2-0.8). Pre-operative statin therapy was not associated with a reduced incidence of pneumonia or sepsis.

CONCLUSION

Pre-operative statin use is associated with a decrease in overall incidence of post-operative infections after CABG. We propose immunomodulatory effects of statins leading to a dampening of inflammatory cascade as the cause of our findings.

Reduced risk of poststroke pneumonia in thrombolyzed stroke patients with continued statin treatment

BACKGROUND

Pneumonia is a frequent complication after stroke with strong impact on clinical outcome. Statins have pleiotropic immunmodulatory properties and were recently shown to exert beneficial effects on the development and clinical course of pneumonia.

AIMS

We aimed to investigate whether statin use is associated with a reduced risk of poststroke pneumonia in acute ischemic stroke patients treated with tissue plasminogen activator within 4·5hours.

METHODS

Data was extracted from a local register including all consecutive stroke patients who received thrombolysis at our institution. Prior statin use was identified retrospectively from clinical records and had to be continued after hospital admission. Poststroke pneumonia was diagnosed according to standardized criteria of US Centers for Disease Control and Prevention. Mortality and functional outcome at three-months were further assessed.

RESULTS

Overall, 481 ischemic stroke patients were analyzed. Continued statin use was documented in 17% of the patients. Frequency of pneumonia was 11%. Patients with statin use were less likely to develop poststroke pneumonia (5% vs. 13%, P = 0·04). After multivariable adjustment for known risk factors for poststroke pneumonia (age, stroke severity, dysphagia, male sex and diabetes), statin treatment was negatively associated with pneumonia (OR 0·31; 95% CI 0·10-0·94). Occurrence of pneumonia independently predicted three-month mortality and functional outcome.

CONCLUSIONS

Use of statins in acute ischemic stroke patients who receive thrombolysis might reduce the risk of poststroke pneumonia. Further studies are warranted to validate this finding.

The impact of statin use on pneumonia risk and outcome: a combined population-based case-control and cohort study

Introduction

The impact of statin use on pneumonia risk and outcome remains unclear. We therefore examined this risk in a population-based case-control study and did a 5-year update of our previous 30-day mortality analyses.

Methods

We identified 70,953 adults with a first-time hospitalization for pneumonia between 1997 and 2009 in Northern Denmark. Ten age- and sex-matched population controls were selected for each pneumonia patient. To control for potential confounders, we retrieved individual-level data on other medications, comorbidities, recent surgery, socioeconomic indicators, influenza vaccination, and other markers of frailty or health awareness from medical databases. We followed all pneumonia patients for 30 days after hospital admission.

Results

A total of 7,223 pneumonia cases (10.2%) and 64 523 controls (9.1%) were statin users before admission, corresponding to an age- and sex-matched odds ratio (OR) of 1.17 (95% confidence interval [CI]: 1.14-1.21). After controlling for higher comorbidity and a wide range of other potential confounders, the adjusted OR for pneumonia associated with current statin use dropped to 0.80 (95% CI: 0.77-0.83). Previous statin use was not associated with decreased pneumonia risk (adjusted OR = 0.97, 95% CI: 0.91-1.02). Decreased risk remained significant after further adjustment for frailty and health awareness markers.

The prevalence of statin use among Danish pneumonia patients increased from 1% in 1997 to 24% in 2009. Thirty-day mortality following pneumonia hospitalization was 11.3% among statin users versus 15.1% among nonusers. This corresponded to a 27% reduced mortality rate (adjusted hazard ratio = 0.73, 95% CI: 0.67-0.79), corroborating our earlier findings.

Conclusions

Current statin use was associated with both a decreased risk of hospitalization for pneumonia and lower 30-day mortality following pneumonia.