Effect of statins on total cholesterol concentrations, cardiovascular morbidity, and all-cause mortality in chronic obstructive pulmonary disease: a population-based cohort study.

BACKGROUND: The benefit of statin use on total cholesterol (TC) concentration has not been studied previously in patients with chronic obstructive pulmonary disease (COPD). OBJECTIVE: Our study aimed to evaluate statin-associated TC-concentration reduction and subsequent risk for cardiovascular (CV) morbidity and mortality in COPD. METHODS: We performed a population-based cohort study using a record-linkage database in Tayside, Scotland. A total of 1017 COPD patients who had at least 2 separate TC measurements between 1993 and 2007 were studied. They were categorized into statin-exposed and statin-unexposed groups according to their statin use status during follow-up. Main outcomes were TC-concentration change from baseline, CV events, and all-cause mortality during follow-up. Multivariate Cox regression models with a time-dependent variable for statins were used to assess risk for outcomes. RESULTS: Statin-associated TC concentrations decreased by 0.86 mmol/L (16%) in patients treated for primary prevention (PP) (n = 1274) and 0.52 mmol/L (11%) in patients treated for secondary prevention (SP) (n = 443), from 5.30 mmol/L and 4.68 mmol/L at baseline, respectively. TC concentrations also declined by 2% in patients free from established CV disease and by 5% in patients with established CV disease in the statin-unexposed groups. A risk reduction of recurrent CV events with statins was observed (adjusted hazard ratio [HR] = 0.35; 95% CI, 0.15-0.87), but not for PP (adjusted HR = 0.84; 95% CI, 0.37-1.89). Statins reduced CV mortality (adjusted HR = 0.32; 95% CI, 0.13-0.77) in SP but not PP. There were statistically significant reductions in all-cause mortality in both PP (adjusted HR = 0.61; 95% CI, 0.43-0.85) and SP (adjusted HR = 0.58; 95% CI, 0.35-0.97). CONCLUSIONS: In patients with COPD, statins were protective from CV events and CV mortality in SP but not PP, and statins improved all-cause mortality in both PP and SP.

Proposed changes to management of lower respiratory tract infections in response to the Clostridium difficile epidemic.

Clostridium difficile infection (CDI) remains a major healthcare problem associated with antibiotic use in hospitals. Recent years have seen a dramatic increase in the incidence of CDI in the UK and internationally. Lower respiratory tract infections (LRTIs) are the leading indication for antibiotic prescription in hospitals and are therefore a critical battleground in the fight against inappropriate antibiotic use and healthcare-associated infections. This article reviews the evidence for interventions to reduce CDI in hospitalized patients with LRTIs. Reducing prescriptions of cephalosporins and fluoroquinolones in favour of penicillin-based regimens and increased use of tetracyclines have been proposed. Expanding outpatient management of LRTIs and reducing length of hospital stay will limit patient exposure to the healthcare environment in which C. difficile is most easily acquired. Intravenous (iv) broad-spectrum antibiotics are often prescribed when narrower spectrum, oral antimicrobials would be equally effective and, in a proportion of patients, antibiotic therapy is used unnecessarily. Shorter antibiotic regimes may be as effective as prolonged therapy and reduce antibiotic-related complications. Early switch from iv to oral therapy allows simpler antibiotic regimens and facilitates early discharge from hospital. Simple improvements in the management of LRTIs have the potential to reduce the incidence of healthcare-associated infections.

A predictive model of hospitalisation and death from chronic obstructive pulmonary disease.

RATIONALE: A recent study showed that doctors are excessively pessimistic about the prognosis in patients with COPD and suggested that a simple tool to predict outcome is needed. METHODS: In a prospective observational study, 3343 patients with an FEV1<80% of the predicted value and FEV1/FVC<70% were selected from a clinical network of patients screened for COPD in Tayside, Scotland. Data were collected during annual visits on demography, spirometry, smoking history, medical research council (MRC) dyspnoea scale, body mass index (BMI) and other variables. The main outcome measures were hospitalisations and death secondary to COPD. A proportional hazard model was used to identify significant risk factors. RESULTS: Increasing age, low BMI, worsening MRC dyspnoea score, decreased FEV1, and prior respiratory or cardiovascular admission hospitalisation were predictors of poor outcome. Influenza vaccination was protective. CONCLUSION: We have developed a model that estimates the risk of respiratory hospitalisation and death in patients with COPD.

Pneumococcal bacteraemia: clinical and microbiological epidemiology in Dundee, Scotland.

OBJECTIVE: To report the incidence of drug resistant Streptococcus pneumoniae isolated from blood culture in Dundee, Scotland. We shall also review the clinical and laboratory findings in these cases. METHODS: A retrospective review was undertaken of all cases of S. pneumoniae bacteraemia identified in our local area during a three year period from August 1st, 1997 to July 31st, 2000 (107 cases.) Data was obtained from patient medical records, blood culture reports and results of Stoke's disk testing. Many organisms were also sent to the Scottish Meningococcus and Pneumococcus Reference Laboratory for serogrouping and determination of the minimum inhibitory concentration of common antibiotics. RESULTS: Annual incidence of bacteraemia was approximately 15.9-17.8 per 100000 population. Mortality was 33% (34 and 30% for those with pneumonia or meningitis, respectively). No relationship was seen between patient age and overall mortality. Factors relating to increased mortality were a high respiratory rate (p=0.01), high blood urea level (p=0.05) and the presence of confusion (p<0.01) on admission to hospital. The incidence of penicillin resistant S. pneumoniae was 7%, all of these isolates having low level resistance. Macrolide resistance was 8%. Neither were found to be increasing over the three year period. The most common serogroups were 23 (18%) and 14 (12%). CONCLUSIONS: The incidence of penicillin resistant S. pneumoniae isolated from blood culture in Dundee, Scotland, is similar to the UK average and did not appear to be rising between 1997 and 2000.