The Role of Statin Therapy in Sepsis

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).

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.

Association between Preoperative Statin Therapy and Postoperative Infectious Complications in Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-analysis

Infectious complications of cardiac surgery are often severe and life threatening. Statins having both immunomodulatory and anti-inflammatory effects were intuitively thought to influence the development of postsurgical infections. We sought to systematically examine whether any association exists between statin use and risk of infectious complications in patients undergoing cardiac surgery. We searched Ovid MEDLINE, Ovid EMBASE, Thomson Scientific Web of Science, and Elsevier Scopus from inception through February 2011 for comparative studies examining the association between statin use and risk of postoperative infections in patients undergoing cardiac surgery. We contacted a study's author for missing information. We conducted a random-effects meta-analysis of individual studies' odds ratios (adjusted for potential confounders). We identified 6 cohort studies for inclusion, 3 of which were conducted in Canada and 3 of which were conducted in the United States. Four were single-center studies, and 2 were population based. Exposure ascertainment was based on a review of admission medication list or prescription databases. Infectious outcomes were heterogeneous and included surgical site infections within 30 days, serious infections (sepsis), or any other postoperative infection. Statin use in the preoperative period was associated with a trend toward reduction in the incidence of postoperative infections in patients who underwent cardiac surgery (odds ratio, 0.81 [95% confidence interval, 0.64–1.01]; P = .06; I2 = 75%). Heterogeneity was explained by country effect. Studies performed in Canada showed weaker associations than studies performed in the United States. This difference could not be attributed to study quality alone. We did not find good evidence to support an association between statin use and postoperative infectious complications. However, the trend toward statistical significance for this association indicates that further investigation is warranted.

Resveratrol alleviates endotoxin-induced myocardial toxicity via the Nrf2 transcription factor

Background/Aims

Septic cardiomyopathy is a severe condition that remains a challenge for clinical management. This study investigated whether the natural polyphenolic compound resveratrol could be used as a prophylactic treatment to alleviate sepsis-related myocardial injury; the underlying molecular mechanisms were deciphered by both in vitro and in vivo experiments.

Methods

A mouse model of endotoxin-induced cardiomyopathy was developed by intraperitoneal injection of LPS, and resveratrol was administered prophylatically to the animals. Serum LDH and CK activities were measured to detect myocardial injury, and echocardiography was performed to monitor cardiac structure and function. Various cytokines/chemokines and the Nrf2 antioxidant defense system were examined in the heart tissue. The effects of resveratrol on LPS-induced Nrf2 activation, ROS generation, and apoptotic cell death were further investigated in cultured primary human cardiomyocytes. An Nrf2 specific siRNA was used to define its role in resveratrol-mediated cardiomyocyte protective effect.

Results

Resveratrol pretreatment significantly attenuated LPS-induced myocardial injury in mice, which was associated with suppressed proinflammatory cytokine production and enhanced Nrf2 activation in the heart. In cultured primary human cardiomyocytes, resveratrol activated Nrf2, inhibited LPS-induced ROS generation, and effectively protected the cells from LPS-induced apoptotic cell death. Knockdown of Nrf2 abrogated resveratrol-mediated protection of the cells from LPS-induced cell death.

Conclusion

Resveratrol effectively alleviates endotoxin-induced cardiac toxicity through mechanisms that involve the Nrf2 antioxidant defense pathway. Our data suggest that resveratrol might be developed as a useful prophylactic management for septic cardiomyopathy.

High-density lipoprotein: a novel marker for risk of in-hospital infection in acute ischemic stroke patients?

BACKGROUND

Several studies have shown that high-density lipoprotein (HDL) cholesterol provides protection against bacterial infections. Our aim was to investigate the influence of HDL cholesterol levels on the risk of developing in-hospital infectious complications after an acute ischemic stroke (IS) as well as the possible effect of prestroke statin treatment on this association.

METHODS AND RESULTS

Observational study that included consecutive IS patients during a 5-year period (2006-2010). We analyzed vascular risk factors, prestroke treatments (including statins), laboratory data (including HDL cholesterol levels), stroke severity, and the development of infectious complications (pneumonia, urinary tract infection and sepsis). A multivariate analysis that included HDL cholesterol levels, prior statin treatment and the interaction between both variables was performed to identify those factors associated with the presence of infectious complications. A total of 1,385 patients were included, 130 of whom (9.4%) developed in-hospital infections. The receiver operating characteristic curve showed the predictive value of HDL cholesterol with an area under the curve of 0.597 (95% CI, 0.526-0.668; p = 0.006) and pointed to 38.5 mg/dl of HDL cholesterol (65.5% sensitivity and 53.4% specificity) as the optimal cutoff level for developing infectious complications during hospitalization. An HDL cholesterol level ≥38.5 mg/dl was an independent predictive factor for lower risk of infection (OR 0.308; 95% CI 0.119-0.795), whereas prestroke statin treatment was not associated with the development of infection.

CONCLUSIONS

An HDL cholesterol level ≥38.5 mg/dl was independently associated with lower risk for developing infectious complications in acute IS patients. Statins do not influence this association.

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.

Effect of preinjury statin use on mortality and septic shock in elderly burn patients

BACKGROUND

Premorbid statin use has been associated with decreased mortality in septic and trauma patients. This has been ascribed to the pleiotropic, anti-inflammatory effects of HMG-CoA reductase inhibitors. This association has not been investigated in burn victims.

METHODS

A retrospective review of 223 consecutive patients, aged 55 years and older admitted to Vanderbilt University Regional Burn Center from January 2006 to December 2008, was performed. Multivariate regression analysis determined odds ratios of death and sepsis by statin use, adjusting for cardiovascular comorbidities.

RESULTS

Of 223 patients, 70 (31.4%) were taking statins before admission. Mean age and mean total body surface area burn were not significantly different by statin use. The odds ratio of inhospital death was 0.17 (95% confidence interval 0.05-0.57; p = 0.004) if on statins. The odds ratio of mortality when stratified by cardiovascular comorbidities did not change. Sepsis developed in 30 patients (13.5%), with an odds ratio in statin users of 0.50 (95% confidence interval 0.20-1.30; p = 0.155).

CONCLUSION

Preinjury statin use was associated with an 83% reduction in the odds of death after thermal injury. The odds of sepsis decreased by 50%, although not statistically significant. Further study is warranted to investigate the potential benefits of statin therapy in the management of burn victims.

Novel potential therapies for septic shock

Sepsis is the systemic inflammatory response syndrome secondary to a local infection. Septic shock, the severe complication of sepsis associated with refractory hypotension, is frequently a near-fatal condition requiring prompt diagnosis and management. Although the recent years have been associated with considerable improvements in the knowledge of the pathophysiology of the disease and remarkable advances have been achieved in sepsis treatment, the morbidity and mortality of this disease are still unacceptably high. In this review, we will briefly discuss the ongoing standard treatment of septic shock and describe novel potential therapies, aiming to improve hemodynamic support and/or control inflammatory response in sepsis. These therapies were associated with benefits in experimental studies and have been tested or are currently under testing in randomized controlled studies with septic patients.

Disruption of CFTR-dependent lipid rafts reduces bacterial levels and corneal disease in a murine model of Pseudomonas aeruginosa keratitis

PURPOSE

Pseudomonas aeruginosa enters corneal epithelial cells in vitro via membrane microdomains or lipid rafts. Bacterial entry, mediated by the cystic fibrosis transmembrane conductance regulator (CFTR), promotes infection and disease. This study was conducted to determine whether P. aeruginosa and CFTR are colocalized to rafts in isogenic corneal cells expressing wild-type (WT) or mutant DeltaF508-CFTR and whether disruption of the rafts both in vitro and in vivo affects the bacterial levels and the course of the disease.

METHODS

Transformed human corneal epithelial cells from a patient homozygous for DeltaF508-CFTR, and the same cells corrected with WT-CFTR, were exposed to six isolates of P. aeruginosa-three invasive and three cytotoxic strains-in the presence of beta-cyclodextrin (CD), which disrupts rafts. Association and cellular uptake of the invasive strains were measured, as was lactate dehydrogenase release induced by the cytotoxic strains. Scratch-injured mouse eyes were infected with the six P. aeruginosa strains, and the effect of prophylactic or therapeutic administration of CD on bacterial levels and disease was evaluated.

RESULTS

P. aeruginosa and CFTR were colocalized with lipid rafts in cells with WT-CFTR, and CD treatment of these cells disrupted bacterial association, internalization, and cytotoxic effects. Cells expressing DeltaF508-CFTR were marginally affected by CD. Prophylactic and therapeutic topical application of CD ameliorated corneal disease and reduced the bacterial count in the eye.

CONCLUSIONS

P. aeruginosa enters human corneal epithelial cells via lipid rafts containing CFTR, and disruption of raft-mediated uptake of this organism by CD protects against disease and reduces bacterial levels in the mouse model of keratitis.

Statins and sepsis

Severe sepsis and septic shock is common and frequently fatal. Over the last few years, the primary treatments demonstrated to improve outcome from several major clinical trials have finally emerged. However, translating these recent therapeutic advances to routine clinical practice has proven controversial, and new approaches of additional strategies are continued to be developed. Given their pleiotropic effects related to many pathophysiological determinants of sepsis, statin therapy could be the next step in the search for adjuvant therapy. A future challenge may be to test both the efficacy and the safety by large randomized controlled clinical trials ascertaining the effects of statins administered at the onset of sepsis and in patients with severe sepsis or septic shock admitted into intensive care units.

Impact of previous statin and angiotensin II receptor blocker use on mortality in patients hospitalized with sepsis

STUDY OBJECTIVE

To examine the effect of previous outpatient use of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) and/or angiotensin II receptor blockers (ARBs) on 30-day mortality in patients hospitalized with sepsis.

DESIGN

Retrospective national cohort study.

DATA SOURCE

Department of Veterans Affairs (VA) national patient care and pharmacy databases.

PATIENTS

A total of 3018 patients who were hospitalized with sepsis in fiscal year 2000, had at least 1 year of previous VA outpatient care, and had at least one active and filled VA prescription within 90 days of admission.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was 30-day mortality. The primary analysis was a multilevel model with hospital as a random effect and control variables that included comorbid conditions, demographics, and other drugs. Among the 3018 patients hospitalized with sepsis, mean age was 74.4 years, 2975 (98.6%) were male, and 811 (26.9%) died within 30 days of admission. Regarding prescription drug use, 480 patients (15.9%) were taking statins and 107 (3.5%) were taking ARBs. After adjusting for potential confounders, statin use (odds ratio [OR] 0.48, 95% confidence interval [CI] 0.36-0.64) and ARB use (OR 0.42, 95% CI 0.24-0.76) were significantly associated with decreased 30-day mortality.

CONCLUSIONS

Use of statins and/or ARBs before admission was associated with decreased mortality in patients hospitalized with sepsis. Further research is needed to determine if these drugs might be started on admission for those with sepsis.

Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest will be abstracted monthly regarding a broad scope of topics.