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Statin therapy reduces mortality in patients with bacteraemia

Citations: Kruger P et al. Statin therapy is associated with fewer deaths in patients with bacteraemia. Intensive Care Med 2006; 32:75-79

Lead author's name and email: Peter Kruger, peter_kruger@health.qld.gov.au

 Three-part Clinical Question: In patients with bacteraemia, does continuing statin therapy reduce mortality?

Search Terms: Textwords: HMG Co-A reductase inhibitor, statin, bacteraemia, mortality.

 The Study: A retrospective cohort study.

The Study Patients: 438 patients with bacteraemia and significant clinical infection requiring admission to an acute general hospital in Australia over a four-year period.

Exposure of Interest: Continuing prior statin therapy.

The Outcome: Death attributable to bacteraemia.

Some clears differences existed between the two groups but the exposures and outcomes were objective.  Follow-up was for 28 days only. Whether death was due to bacteraemia or not was determined by medical records evaluation.

The Evidence: 

EBM Questions: 

1.      Do these methods allow accurate testing of the hypothesis? To a degree. This was a retrospective cohort study with clear differences between the two groups; the statin group reflected an older population with more co-existing diseases. However, after controlling for these differences using a multivariate logistic regression models, the apparent mortality benefit persisted. In any case, this older group should have been expected to have a higher mortality rate.

2.      Do the statistical rests correctly test the results to allow differentiation of statistically significant results? Yes.

3.      Are the conclusions valid in light of the results? Yes.

4.      Did results get omitted and why? - 37 of the original 475 patients were excluded (missing records; blood culture positive but no hospital admission; some repeat episodes – first episode only considered). 10 patients treated with statins prior to admission had their therapy stopped. The mortality rate was higher in this group (30% vs. 2% in patients whose therapy was continued). However, this is a small group and they were not included in the formal analysis.

5.      Did they suggest further areas of research? Yes. This study simply shows a link and the underlying mechanisms require further study. There is evidence that statins have an immuno-modulatory and anti-inflammatory effect and have been shown to be of benefit in other patient groups (e.g. high risk elderly patients having major vascular surgery).

6.      Did they make any recommendations based in the study and were they appropriate? No. They made recommendations about further study not clinical practice.

7.      Is the study relevant to my clinical practice? Yes. Many of our patients suffer with sepsis and statins are a commonly used group of drugs.

8.      What level of evidence does the study represent? Level 2^-.

9.      What grade of recommendation can I make on this result alone? Grade D.

10.   What grade of recommendation can I make when this study is considered along with other available evidence? As above – the only other study referenced looking at sepsis and mortality was also a retrospective cohort study.

11.  Should I change my practice because of these results? Possibly. In the absence of definitive evidence, we should be alert to the musculo-skeletal and hepatic complications that can occur with these drugs, particularly in the critically ill. Prescribing guidelines often recommend that statin therapy is stopped in patients with acute illnesses for fear these side effects but this study shows a possible role as adjuvant therapy in sepsis. However, it seems that stopping pre-existing therapy may be even more detrimental.

12.   Should I audit my practice because of these results? See above – further evidence is required before guidelines can be made.

 Appraised by:

N Niranjan, Anaesthetic SpR, Musgrove Park Hospital, Taunton, Somerset TA1 5DA

17 January 2006

Email: niraj.niranjan@btinternet.com

Citation: EBM Critical Appraisals. Scottish Intensive Care Society EBM Group. 2006 & JICS 2006 Vol7(1). Niranjan N. Kruger P et al. Statin therapy is associated with fewer deaths in patients with bacteraemia. Intensive Care Med 2006; 32:75-79

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