Effect of statin therapy on mortality in patients with ventilator-associated pneumonia: a randomized clinical trial.

Abstract

IMPORTANCE:

Observational studies have reported that statin use may be associated with improved outcomes of various infections. Ventilator-associated pneumonia (VAP) is the most common infection in the intensive care unit (ICU) and is associated with substantial mortality.

OBJECTIVE:

To determine whether statin therapy can decrease day-28 mortality in patients with VAP.

DESIGN, SETTING, AND PARTICIPANTS:

Randomized, placebo-controlled, double-blind, parallel-group, multicenter trial performed in 26 intensive care units in France from January 2010 to March 2013. For power to detect an 8% absolute reduction in the day-28 mortality rate, we planned to enroll 1002 patients requiring invasive mechanical ventilation for more than 2 days and having suspected VAP, defined as a modified Clinical Pulmonary Infection Score of 5 or greater. The futility stopping rules were an absolute increase in day-28 mortality of at least 2.7% with simvastatin compared with placebo after enrollment of the first 251 patients.

INTERVENTIONS:

Participants were randomized to receive simvastatin (60 mg) or placebo, started on the same day as antibiotic therapy and given until ICU discharge, death, or day 28, whichever occurred first.

MAIN OUTCOMES AND MEASURES:

Primary outcome was day-28 mortality. Day-14, ICU, and hospital mortality rates were determined, as well as duration of mechanical ventilation and Sequential Organ Failure Assessment (SOFA) scores on days 3, 7, and 14.

RESULTS:

The study was stopped for futility at the first scheduled interim analysis after enrollment of 300 patients, of whom all but 7% in the simvastatin group and 11% in the placebo group were naive to statin therapy at ICU admission. Day-28 mortality was not lower in the simvastatin group (21.2% [95% CI, 15.4% to 28.6%) than in the placebo group (15.2% [95% CI, 10.2% to 22.1%]; P = .10; hazard ratio, 1.45 [95% CI, 0.83 to 2.51]); the between-group difference was 6.0% (95% CI, -3.0% to 14.9%). In statin-naive patients, day-28 mortality was 21.5% (95% CI, 15.4% to 29.1%) with simvastatin and 13.8% (95% CI, 8.8% to 21.0%) with placebo (P = .054) (between-group difference, 7.7% [95%CI, -1.8% to 16.8%). There were no significant differences regarding day-14, ICU, or hospital mortality rates; duration of mechanical ventilation; or changes in SOFA score.

CONCLUSIONS AND RELEVANCE:

In adults with suspected VAP, adjunctive simvastatin therapy compared with placebo did not improve day-28 survival. These findings do not support the use of statins with the goal of improving VAP outcomes.

TRIAL REGISTRATION:

clinicaltrials.gov Identifier: NCT01057758.

• Authors: Laurent Papazian, Antoine Roch, Pierre-Emmanuel Charles, Christine Penot-Ragon, Gilles Perrin, Philippe Roulier, Philippe Goutorbe, Jean-Yves Lefrant, Sandrine Wiramus, Boris Jung, Sébastien Perbet, Romain Hernu, André Nau, Olivier Baldesi, Jerome Allardet-Servent, Karine Baumstarck, Elisabeth Jouve, Myriam Moussa, Sami Hraiech, Christophe Guervilly, Jean-Marie Forel, STATIN-VAP Study Group
• Journal: JAMA (JAMA) Vol. 310 Issue 16 Pg. 1692-700 (Oct 23 2013) ISSN: 1538-3598 [Electronic] United States
• PMID: 24108510 (Publication Type: Journal Article, Multicenter Study, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)

Chemical References

• Anti-Bacterial Agents
• Hydroxymethylglutaryl-CoA Reductase Inhibitors
• Simvastatin

Topics

• Aged
• Anti-Bacterial Agents (therapeutic use)
• Double-Blind Method
• Female
• Humans
• Hydroxymethylglutaryl-CoA Reductase Inhibitors (therapeutic use)
• Intensive Care Units
• Male
• Middle Aged
• Pneumonia, Ventilator-Associated (drug therapy)
• Respiration, Artificial
• Simvastatin (therapeutic use)
• Survival Analysis