Statins and outcomes in patients with pneumonia: not only healthy user bias.
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Bias↗
Biomedical subjects
Marcos I Restrepo
Publications and source records attributed to Marcos I Restrepo.
Impact of a lung transplantation donor-management protocol on lung donation and recipient outcomes.
RATIONALE: One of the limitations associated with lung transplantation is the lack of available organs. OBJECTIVE: To determine whether a lung donor-management protocol could increase the number of lungs for transplantation without affecting the survival rates of the recipients. METHODS: We implemented the San Antonio Lung Transplant protocol for managing potential lung donors according to modifications of standard criteria for donor selection and strategies for donor management. We then compared information gathered during a 4-yr period, during which the protocol was used with information gathered during a 4-yr period before protocol implementation. Primary outcome measures were the procurement rate of lungs and the 30-d and 1-yr survival rates of recipients. MAIN RESULTS: We reviewed data from 711 potential lung donors. The mean rate of lung procurement was significantly higher (p < 0.0001) during the protocol period (25.5%) than during the pre-protocol period (11.5%), with an estimated risk ratio of 2.2 in favor of the protocol period. More patients received transplants during the protocol period (n = 121) than during the pre-protocol period (n = 53; p < 0.0001). Of 98 actual lung donors during the protocol period, 53 (54%) had initially been considered poor donors; these donors provided 64 (53%) of the 121 lung transplants. The type of donor was not associated with significant differences in recipients' 30-d and 1-yr survival rates or any clinical measures of adequate graft function. CONCLUSIONS: The protocol was associated with a significant increase in the number of lung donors and transplant procedures without compromising pulmonary function, length of stay, or survival of the recipients.
Adult↗
Reply to Bodi et al.
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Anti-Bacterial Agents↗
Impact of guideline-concordant empiric antibiotic therapy in community-acquired pneumonia.
PURPOSE: We evaluated the impact of guideline-concordant empiric antibiotic therapy on time to clinical stability, time to switch therapy, length of hospital stay, and mortality among patients with community-acquired pneumonia. METHODS: This is a retrospective cohort study of all adult community-acquired pneumonia patients managed at 5 community hospitals from November 1, 1999 to April 30, 2000. Patients were stratified into guideline-concordant and discordant groups as defined by the 2001 American Thoracic Society and the 2003 Infectious Diseases Society of America guidelines. Time to clinical stability, time to switch therapy, length of hospital stay, and in-hospital mortality were evaluated in per-protocol and intention-to-treat stepwise regression models that included the outcome as the dependent variable, guideline-concordant antibiotic therapy as the independent variable, and Pneumonia Severity Index score as a covariate. RESULTS: Of the 631 evaluable patients, 357 (57%) received guideline-concordant empiric antibiotic therapy. Groups were similar with respect to age, sex, comorbidities, severity of illness, and processes of care. Guideline-concordant antibiotic therapy was associated with a significant decrease in time to switch therapy (P < or =.01), length of hospital stay (P < or =.01), and in-hospital mortality (P=.04) for both per-protocol and intention-to-treat analyses. In addition, guideline-concordant antibiotic therapy was associated with a significant decrease in time to clinical stability for intention-to-treat analysis only (P=.03). CONCLUSIONS: Among hospitalized community-acquired patients, guideline-concordant antibiotic therapy is associated with improved in-hospital survival and shorter time to clinical stability, time to switch therapy, and length of hospital stay.
Aged↗
Antibiotic therapy and 48-hour mortality for patients with pneumonia.
PURPOSE: Although numerous articles have demonstrated that recommended empiric antimicrobial regimens are associated with decreased mortality at 30 days, there is controversy over whether appropriate antibiotic selection has a beneficial impact on mortality within the first 48 to 96 hours after admission. Our aim was to determine whether the use of guideline-concordant antibiotic therapy is associated with decreased mortality within the first 48 hours after admission for patients with pneumonia. METHODS: A retrospective cohort study was conducted at two tertiary teaching hospitals in San Antonio, Texas. A propensity score was used to balance the covariates associated with the use of guideline-concordant antimicrobial therapy. A multivariable logistic regression model was used to assess the association between mortality within 48 hours and the use of guideline-concordant antibiotic therapy, after adjusting for potential confounders including the propensity score. RESULTS: Information was obtained on 787 patients with community-acquired pneumonia. The median age was 60 years, 79% were male, and 20% were initially admitted to the intensive care unit. At presentation 52% of subjects were low risk, 34% were moderate risk, and 14% were high risk. Within the first 48 hours, 20 patients died. After adjustment for potential confounders, the use of guideline-concordant antimicrobial therapy (odds ratio 0.37, 95% confidence interval, 0.14-0.95) was significantly associated with decreased mortality at 48 hours after admission. CONCLUSION: Using initial empiric guideline-concordant antimicrobial therapy is associated with decreased mortality at 48 hours. Further research needs to investigate methods to ensure that patients with community-acquired pneumonia are treated with appropriate antimicrobial therapies.
Adult↗
Incidence, risk factors, and outcome of ventilator-associated pneumonia.
OBJECTIVE: The purpose of this study is to determine the incidence, risk factors, and outcome of ventilator-associated pneumonia (VAP). DESIGN: Prospective cohort. SETTING: Three hundred sixty-one intensive care units (ICUs) from 20 countries. PATIENTS AND PARTICIPANTS: Two thousand eight hundred ninety-seven patients mechanically ventilated for more than 12 hours. MEASUREMENTS AND RESULTS: Baseline demographic data, primary indication for mechanical ventilation, daily ventilator settings, multiple organ failure over the course of mechanical ventilation, and outcome were collected. Ventilator-associated pneumonia was present in 439 patients (15%). Patients with VAP were more likely to have chronic pulmonary obstructive disease, aspiration, sepsis, and acute respiratory distress syndrome. Mortality in patients with VAP was 38%. Factors associated with mortality were severity of illness, limited activity before the onset of mechanical ventilation and development of shock, acute renal failure, and worsening of hypoxemia during the period of mechanical ventilation. Case-control analysis showed no increased mortality in patients with VAP (38.1% vs 37.9%, P = .95) but prolonged duration of mechanical ventilation and ICU stay. CONCLUSION: In a large cohort of mechanically ventilated patients, VAP is more likely in patients with underlying lung disease (acute or chronic). Ventilator-associated pneumonia was associated with a significant increase in ICU length of stay but no increase in mortality.
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The role of new therapies for severe community-acquired pneumonia.
PURPOSE OF REVIEW: Community-acquired pneumonia (CAP) is associated with significant morbidity and mortality and is the most common cause of death from infectious diseases. CAP patients requiring intensive care unit (ICU) admission carry the highest mortality rates. This paper aims to review the current literature regarding epidemiology, risk factors, severity criteria and reasons for admitting the hospitalized patient to the ICU, and the empiric and specific antibiotic therapeutic regimens employed. RECENT FINDINGS: Multiple sets of clinical practice guidelines have been published in the past few years addressing the treatment of CAP. The guidelines all agree that CAP patients admitted to the hospital represent a major concern, and appropriate empiric therapy should be instituted to improve clinical outcomes. SUMMARY: The cost, morbidity and mortality of CAP patients requiring ICU admission remain unacceptably high. These are heterogeneous groups of patients, so it is important to use risk-stratification based on clinical parameters and prediction tools. Appropriate antibiotic therapy is an important component in the management of both groups of patients. In particular, it is essential to administer an appropriate antimicrobial agent from the initiation of therapy, so that the risks of treatment failure and the morbidity of CAP may be minimized.
Anti-Bacterial Agents↗
The impact of empiric antimicrobial therapy with a β-lactam and fluoroquinolone on mortality for patients hospitalized with severe pneumonia.
INTRODUCTION: National clinical practice guidelines have recommended specific empiric antimicrobial regimes for patients with severe community-acquired pneumonia. However, evidence confirming improved mortality with many of these regimes is lacking. Our aim was to determine the association between the empiric use of a β-lactam with fluoroquinolone, compared with other recommended antimicrobial therapies, and mortality in patients hospitalized with severe community-acquired pneumonia. METHODS: A retrospective observational study was conducted at two tertiary teaching hospitals. Eligible subjects were admitted with a diagnosis of community-acquired pneumonia and had a chest X-ray and a discharge ICD-9 diagnosis consistent with this. Subjects were excluded if they received 'comfort measures only' during the admission, had been transferred from another acute care hospital, did not meet criteria for severe pneumonia, or were treated with non-guideline-concordant antibiotics. A multivariable logistic regression model was used to assess the association between 30-day mortality and the use of a β-lactam antibiotic with a fluoroquinolone compared with other guideline-concordant therapies, after adjustment for potential confounders including a propensity score. RESULTS: Data were abstracted on 172 subjects at the two hospitals. The mean age was 63.5 years (SD 15.0). The population was 88% male; 91% were admitted through the emergency department and 62% were admitted to the intensive care unit within the first 24 hours after admission. Mortality was 19.8% at 30 days. After adjustment for potential confounders the use of a β-lactam with a fluoroquinolone (odds ratio 2.71, 95% confidence interval 1.2 to 6.1) was associated with increased mortality. CONCLUSION: The use of initial empiric antimicrobial therapy with a β-lactam and a fluoroquinolone was associated with increased short-term mortality for patients with severe pneumonia in comparison with other guideline-concordant antimicrobial regimes. Further research is needed to determine the range of appropriate empiric antimicrobial therapies for patients with severe community-acquired pneumonia.
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Community-Acquired Pneumonia Recovery in the Elderly (CAPRIE): efficacy and safety of moxifloxacin therapy versus that of levofloxacin therapy.
BACKGROUND: Limited prospective data are available for elderly patients with community-acquired pneumonia (CAP). This study aimed to determine the efficacy and safety of moxifloxacin versus that of levofloxacin for the treatment of CAP in hospitalized elderly patients (age, > or = 65 years). METHODS: We conducted a prospective, double-blind, randomized, controlled trial. Eligible patients were stratified by CAP severity before randomization to receive treatment with either intravenous/oral moxifloxacin (400 mg daily) or intravenous/oral levofloxacin (500 mg daily) for 7-14 days. Clinical response at test-of-cure (the primary efficacy end point was between days 5 and 21 after completion of therapy), and clinical response during therapy (between days 3 and 5 after the start of therapy) and bacteriologic response were secondary end points. RESULTS: The safety population included 394 patients (195 in the moxifloxacin group and 199 in the levofloxacin group). The population eligible for clinical efficacy analysis (i.e., the clinically valid population) included 281 patients (141 in the moxifloxacin group and 140 in the levofloxacin group); 51.3% were male, and the mean age (+/-SD) was 77.4 +/- 7.7 years. Cure rates at test-of-cure for the clinically valid population were 92.9% in the moxifloxacin arm and 87.9% in the levofloxacin arm (95% confidence interval [CI], -1.9 to 11.9; P = .2). Clinical recovery by days 3-5 after the start of treatment was 97.9% in the moxifloxacin arm vs. 90.0% in the levofloxacin arm (95% CI, 1.7-14.1; P = .01). In the moxifloxacin group, cure rates were 92.6% for patients with mild or moderate CAP and 94.7% for patients with severe CAP, compared with cure rates of 88.6% and 84.6%, respectively, in the levofloxacin group (P = not significant). Cure rates in the moxifloxacin arm were 90.0% for patients aged 65-74 years and 94.5% for patients aged > or = 75 years, compared with 85.0% and 90.0%, respectively, in the levofloxacin arm (P = not significant). There were no statistically significant differences between the treatment groups with regard to drug-related adverse events. CONCLUSIONS: Intravenous/oral moxifloxacin therapy was efficacious and safe for hospitalized elderly patients with CAP, achieving > 90% cure in all severity and age subgroups, and was associated with faster clinical recovery than intravenous/oral levofloxacin therapy, with a comparable safety profile.
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Steroid infusion for severe pneumonia: not so fast...
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Community-Acquired Infections↗
The impact of prior outpatient ACE inhibitor use on 30-day mortality for patients hospitalized with community-acquired pneumonia.
BACKGROUND: Recent studies suggest that angiotensin-converting enzyme (ACE) inhibitors may have beneficial effects for patients at risk for some types of infections. We examined the effect of prior outpatient use of ACE inhibitors on mortality for patients hospitalized with community-acquired pneumonia. METHODS: A retrospective cohort study conducted at two tertiary teaching hospitals. Eligible subjects were admitted with a diagnosis of, had a chest x-ray consistent with, and had a discharge ICD-9 diagnosis of pneumonia. Subjects were excluded if they were "comfort measures only" or transferred from another acute care hospital. Subjects were considered to be on a medication if they were taking it at the time of presentation. RESULTS: Data was abstracted on 787 subjects at the two hospitals. Mortality was 9.2% at 30-days and 13.6% at 90-days. At presentation 52% of subjects were low risk, 34% were moderate risk, and 14% were high risk. In the multivariable conditional logistic regression analysis, after adjusting for potential confounders, the use of ACE inhibitors at presentation (odds ratio 0.44, 95% confidence interval 0.22-0.89) was significantly associated with 30-day mortality. CONCLUSION: Prior outpatient use of an ACE inhibitor was associated with decreased mortality in patients hospitalized with community-acquired pneumonia despite their use being associated with comorbid illnesses likely to contribute to increased mortality. Confirmatory studies are needed, as well as research to determine the mechanism(s) of this protective effect.
Adult↗
The effect of prior statin use on 30-day mortality for patients hospitalized with community-acquired pneumonia.
BACKGROUND: Recent studies suggest that HMG-CoA reductase inhibitors ("statins") may have beneficial effects for patients at risk for some types of infections. We examined the effect of prior outpatient use of statins on mortality for patients hospitalized with community-acquired pneumonia. METHODS: A retrospective cohort study conducted at two tertiary teaching hospitals. Eligible subjects were admitted with a diagnosis of, had a chest x-ray consistent with, and had a discharge ICD-9 diagnosis of pneumonia. Subjects were excluded if they were "comfort measures only" or transferred from another acute care hospital. Subjects were considered to be on a medication if they were taking it at the time of presentation. RESULTS: Data was abstracted on 787 subjects at the two hospitals. Mortality was 9.2% at 30-days and 13.6% at 90-days. At presentation 52% of subjects were low risk, 34% were moderate risk, and 14% were high risk based on the pneumonia severity index. In the multivariable regression analysis, after adjusting for potential confounders including a propensity score, the use of statins at presentation (odds ratio 0.36, 95% confidence interval 0.14-0.92) was associated with decreased 30-day mortality. DISCUSSION: Prior outpatient statin use was associated with decreased mortality in patients hospitalized with community-acquired pneumonia despite their use being associated with comorbid illnesses likely to contribute to increased mortality. Confirmatory studies are needed, as well as research to determine the mechanism(s) of this protective effect.
Cohort Studies↗
Antimicrobial treatment of community-acquired pneumonia.
Community-acquired pneumonia (CAP) is a clinical diagnosis that has a significant impact on health care management around the world. Early clinical suspicion and prompt empiric antimicrobial therapies are mandatory in patients with CAP. This article provides a review of recent studies and guidelines addressing antimicrobial therapy for hospitalized patients with CAP.
Anti-Bacterial Agents↗
Prognosis factors and outcome of community-acquired pneumonia needing mechanical ventilation.
PURPOSE: To evaluate the variables associated with mortality of patients with community-acquired pneumonia who require mechanical ventilation and to determine the attributable morbidity and intensive care unit (ICU) mortality of community-acquired pneumonia. MATERIAL AND METHODS: Retrospective cohort study carried out in 361 ICUs from 20 countries including 124 patients who required mechanical ventilation on the first day of admission to the hospital due to acute respiratory failure secondary to severe community-acquired pneumonia. To assess the factors associated with outcome, a forward stepwise logistic regression analysis was performed, and to determine the attributable mortality of community-acquired pneumonia, a matched study design was used. RESULTS: We found 3 independent variables significantly associated with death in patients with community-acquired pneumonia requiring mechanical ventilation: simplified acute physiological score greater than 45 (odds ratio, 5.5 [95% confidence interval, 1.7-12.3]), shock (odds ratio, 5.7 [95% confidence interval, 1.7-10.1]), and acute renal failure (odds ratio, 3.0 [95% confidence interval, 1.1-4.0]). There was no statistically significant difference in ICU mortality among patients with or without community-acquired pneumonia (32% vs 35%; P=.59). CONCLUSIONS: Community-acquired pneumonia needing mechanical ventilation is not a disease associated with higher mortality. The main determinants of patient outcome were initial severity of illness and the development of shock and/or acute renal failure.
Cohort Studies↗