Incidence and risk factors of infection in a single cohort of 110 adults with systemic lupus erythematosus

Analysis of 5-year hospitalization data of patients with systemic lupus erythematosus: Damage is a risk factor for frequent and longer stays

OBJECTIVE

The annual hospitalization rate of patients with systemic lupus erythematosus (SLE) is approximately 10%, and hospitalizations are responsible for most of the healthcare expenses. Herein, we analyzed 5-year hospitalization data of SLE patients and determined factors leading to hospitalization.

METHODS

Clinical, laboratory, and hospitalization data of SLE patients admitted to our rheumatology clinic in 2015-2020 were retrieved from our SLE database and analyzed. SLICC SLE damage index (SDI) and disease activity at admission (SLEDAI-2K) were determined.

RESULTS

Among 161 hospitalized patients, 86% were females. Total rheumatologic hospitalization number was 298, and 38% of the patients were hospitalized more than once (1.85 ± 1.56). The mean hospitalization duration covering all stays for each patient was 25 ± 26.5 days. Active disease, infection, and damage-related complications were first three causes of hospitalization. Compared to patients hospitalized for active disease or damage, patients hospitalized for infection had a significantly higher number of readmissions (p < .05) and their total hospital stay was longer (p < .01).The frequency of patients with damage and the mean SDI score was significantly lower in the active disease group (68%, 1.93 ± 2.05) than hospitalizations for infection (90%, 2.68 ± 1.63) and damage-related causes (96%, 3.04 ± 1.65) (p < .05). The mean SDI score and duration (r = 0.551, p < .001) and the number of hospitalizations (r = 0.393, p < .001) were positively correlated. The mean disease activity scores of patients hospitalized for active disease, infection, and damage-related reasons were 11.03 ± 6.08, 3.21 ± 2.80, and 2.96 ± 3.32, respectively (p < .001). Renal active disease was the most common (44%), followed by hematological (34.8%), articular (21.7%), and mucocutaneous (21%) activity.Ten percent of the patients all of whom had damage were admitted to intensive care unit (ICU). Total hospitalization duration, mean SDI, antiphospholipid syndrome, lupus anticoagulant, thrombocytopenia, serositis, pulmonary hypertension, history of alveolar hemorrhage, and cardiac valve involvement were associated with ICU admission (p < .05 for all).

CONCLUSION

Disease activity, infections, and damage are the leading causes of hospitalization in SLE patients. Damage prolongs hospital stay and increases hospitalization rate and ICU need. Tight control of disease activity with rational use of immunosuppressive treatment is important to reduce damage and hospitalizations.

Disease activity is associated with changes in the innate immune function in patients with systemic lupus erythematosus

OBJECTIVE

To address the relationship between systemic lupus erythematosus (SLE) disease activity and the functional parameters of the innate immunity.

METHODS

We evaluated a cohort of 26 adult SLE patients and 10 sex and age-paired healthy donors. When the patients had a disease flare (baseline) and when they achieve clinical response (follow-up), we assessed the systemic lupus erythematosus disease activity index 2 K (SLEDAI 2 K) and the following parameters with flow cytometry and confocal microscopy: monocyte subsets, their expression of TLR2, phagocytic monocytes and neutrophils using the pHrodo Red E. coli BioParticles, the respiratory burst with 123-dihydrorhodamine in neutrophils, and the spontaneous and lipopolysaccharide (LPS)-induced production of neutrophil extracellular traps (NETs). We used the Wilcoxon test to compare the paired medians with interquartile range (IQR) and the Mann-Whitney U test for independent medians. To assess the effect of prednisone and SLEDAI 2 K on the mentioned parameters, we applied a generalized mixed linear model.

RESULTS

Twenty-three patients (88.4%) were women. The SLEDAI 2 K was higher at baseline 8 (6-14) in comparison to that at follow-up (6 (4-8), P = 0.028). At baseline, SLE patients had a decreased percentage of intermediate monocytes, a higher expression of TLR2 in total monocytes, increased phagocytosis in monocytes and neutrophils, a decreased respiratory burst intensity, and an increased production of NETs. In the mix model, the SLEDAI 2 K was the main factor influencing these functional innate immune parameters.

CONCLUSION

Disease activity regulates the innate immune function in SLE which may contribute to the clinical features and infection predisposition. Key points • This is the first cohort study addressing the effect of disease activity and prednisone use on the innate immune function of lupus patients. • Our results show that the disease activity is a key regulator of the respiratory burst, phagocytosis, and the production of neutrophil extracellular traps. • Also, we observed a differential proportion of monocyte subsets according to SLE disease activity. • We consider that our manuscript contributes to the evidence addressing the intrinsic immune abnormalities of patients with SLE regardless of the use of immunosuppressants and set the bases for new research work considering the disease activity as an element to decide the prescription and duration of antibiotic prophylaxis in SLE patients, which is of interest to all rheumatologists.

Protective effect of hydroxychloroquine on infections in patients with systemic lupus erythematosus: an observational study using the LUNA registry

Objectives

Infection is a leading cause of death in patients with systemic lupus erythematosus (SLE). Alt hough hydroxychloroquine (HCQ) has been reported to inhibit infection, evidence from Asian populations remains insufficient. We investigated this effect in Japanese SLE patients.

Methods

Data from the Lupus Registry of Nationwide Institutions were used in this study. The patients were ≥20 years old and met the American College of Rheumatology (ACR) classification criteria revised in 1997. We defined "severe infections" as those requiring hospitalization. We analyzed the HCQ's effect on infection suppression using a generalized estimating equation (GEE) logistic regression model as the primary endpoint and performed a survival analysis for the duration until the first severe infection.

Results

Data from 925 patients were used (median age, 45 [interquartile range 35-57] years; female, 88.1%). GEE analysis revealed that severe infections were significantly associated with glucocorticoid dose (odds ratio [OR] 1.968 [95% confidence interval, 1.379-2.810], p<0.001), immunosuppressants (OR 1.561 [1.025-2.380], p=0.038), and baseline age (OR 1.043 [1.027-1.060], p<0.001). HCQ tended to suppress severe infections, although not significantly (OR 0.590 [0.329-1.058], p=0.077). Survival time analysis revealed a lower incidence of severe infections in the HCQ group than in the non-HCQ group (p<0.001). In a Cox proportional hazards model, baseline age (hazard ratio [HR] 1.029 [1.009-1.050], p=0.005) and HCQ (HR 0.322 [0.142-0.728], p=0.006) were significantly related to incidence.

Conclusion

HCQ may help extend the time until the occurrence of infection complications and tends to decrease infection rates.

Traditional Chinese medicine use is associated with lower risk of pneumonia in patients with systemic lupus erythematosus: a population-based retrospective cohort study

Objectives: To investigate the association between traditional Chinese medicine (TCM) therapy and the risk of pneumonia in patients with systemic lupus erythematosus (SLE). Methods: This population-based control study analyzed the data retrieved from the National Health Insurance Research database in Taiwan. From a cohort of 2 million records of the 2000-2018 period, 9,714 newly diagnosed patients with SLE were initially included. 532 patients with pneumonia and 532 patients without pneumonia were matched 1:1 based on age, sex, and year of SLE diagnosis using propensity score matching. The use of TCM therapy was considered from the SLE diagnosis date to the index date and the cumulative days of TCM therapy were used to calculate the dose effect. Conditional logistic regression was used to investigate the risk of pneumonia infection. Furthermore, to explore the severity of pneumonia in SLE, sensitivity analyses were performed after stratification using the parameters of emergency room visit, admission time, and antibiotic use. Results: TCM therapy for >60 days could significantly reduce the risk of pneumonia in patients with SLE (95% CI = 0.46-0.91; p = 0.012). Stratified analysis showed that TCM use also reduced the risk of pneumonia in younger and female patients with SLE by 34% and 35%, respectively. TCM for >60 days significantly reduced the risk of pneumonia in the follow-up periods of >2, >3, >7, and >8 years. In addition, the exposure of TCM for >60 days reduced the risk of pneumonia in patients with SLE who were treated with antibiotics for moderate or severe pneumonia. Finally, the study found that using formulae to tonify the kidney for more than 90 days and formulae to activate blood circulation for less than 30 days could significantly reduce the risk of pneumonia infection in patients with SLE. Conclusion: TCM use is associated with a lower risk of pneumonia among patients with SLE.

The association of systemic lupus erythematosus with short-term mortality in sepsis: a population-level analysis

Systemic lupus erythematosus (SLE) is associated with higher risks of sepsis and sepsis-related mortality compared to the general population. However, the prognostic impact of SLE in sepsis is uncertain. We used statewide data to identify hospitalizations aged ≥18 years in Texas with sepsis, with and without SLE during 2014-2017. Multilevel logistic regression with propensity adjustment (primary model), propensity score matching, and multivariable logistic regression without propensity adjustment were used to estimate the association of SLE with short-term mortality (defined as in-hospital mortality or discharge to hospice) among sepsis hospitalizations. Among 283,025 sepsis hospitalizations, 2933 (1.0%) had SLE. Compared to sepsis hospitalizations without SLE, those with SLE were younger (aged ≥65 years, 25.0% vs 57.0%) and had higher burden of comorbidities (mean Deyo comorbidity index 3.0 vs 2.6). Short-term mortality of sepsis hospitalizations with and without SLE was 22.9% vs 31.3%. SLE remained associated with lower short-term mortality on the secondary models, but not on the primary one (adjusted odds ratio: 0.905; 95% confidence interval: 0.817-1.001). When in-hospital mortality was used as secondary outcome, SLE was associated with mortality only on propensity score matching. The increased sepsis-related mortality in SLE is driven by higher risk of sepsis, but not by higher case fatality among septic patients. SLE may be associated with lower risk of mortality among septic patients, but further studies are needed due to heterogeneity of the prognostic associations across models.

Severe infections in patients with systemic lupus erythematosus from Tunisia: Prevalence and risk factors

Since the improvement in management and the reduction of mortality caused by the disease activity, infections have represented the main cause of morbidity and mortality in systemic lupus erythematosus patients. We aimed to determine the prevalence and identify risk factors of severe infections in systemic lupus erythematosus patients. We conducted a retrospective study on 93 Tunisian lupus patients followed between 2010 and 2019. The mean age of the disease was 33.63 ± 13.76 years. Fifty-two patients had 118 infections and 16% of the infections were serious. The bivariate analysis revealed a positive correlation between the total cumulative doses of corticosteroids and the number of serious infections (p = 0.009). The multivariate study has shown that the number of flares (p = 0.03), pulmonary manifestations (p = 0.01), pleuritis (p = 0.001), and the total cumulative dose of corticosteroids (p = 0.04) were independent risk factors of severe infections (p < 0.001). The use of antimalarials exerted a protective effect from severe infection [OR = 0.19 (95% CI 0.03-0.9)] p < 0.03.

Meta-analysis of clinical risk factors of patients with systemic lupus erythematosus complicated with invasive fungal infection

BACKGROUND

To systematically evaluate the clinical risk factors of patients with systemic lupus erythematosus (SLE) complicated with invasive fungal infection (IFI) among patients.

METHODS

A meta-analysis was performed of all the literatures germane to estimate the clinical risk factors of patients with SLE complicated with IFI from published clinical trials from 1990 to April 2022. Mean differences, odds ratio and 95% confidence intervals were calculated, and the meta-analysis was conducted with Stata 12.0 software (StataCorp, College Station, TX).

RESULTS

A total of 14 clinical research involving 1129 patients were included. The results of meta-analysis demonstrated that immunosuppressant, glucocorticoids, systemic lupus erythematosus disease activity index score, antibiotic were risk factors associated with IFI in SLE patients. However, age, sex, course of disease, leukopenia, lymphopenia, C- reactive protein and hypoproteinemia were not the risk factors associated with IFI in patients with SLE.

CONCLUSION

Our results indicate that immunosuppressant, glucocorticoids, systemic lupus erythematosus disease activity index score, antibiotic were risk factors for IFI in SLE patients. However, high quality of multicenter, large sample size-controlled trials are needed to validate the result.

Predictors of infection requiring hospitalization in patients with systemic lupus erythematosus: a time-to-event analysis

OBJECTIVES

To evaluate the predictors of serious infection in patients with systemic lupus erythematosus (SLE).

METHODS

Serious infections were identified in SLE patients in a prospectively-followed single centre cohort. Associations of serious infection with disease-related variables and medication use were analysed using Cox and related regression models.

RESULTS

346 patients were followed for a mean (SD) of 6.6 (3.7) years. 86 episodes of serious infection were observed, with an incidence rate of 3.8 episodes per 100 person-years. Patients who had serious infection had higher baseline SLE Damage Index (SDI) and Charlston Comorbidity Index (CCI); they were also more likely to have high disease activity status (HDAS), and higher disease activity in multiple clinical domains, higher flare rates, higher time-adjusted prednisolone dose exposure, and less time in lupus low disease activity state (LLDAS). Patients who have received cyclophosphamide, rituximab and mycophenolate were more likely to have experienced serious infection. After multivariable adjustment in Cox regression analysis, cyclophosphamide, higher SDI score, and higher disease activity were associated with an increased hazard of first serious infection. History of previous serious infection conferred the highest risk. Lymphopenia was also a modest but statistically significant predictor of serious infection.

CONCLUSION

History of previous serious infection was the strongest predictor of serious infection in our SLE cohort. This study also suggests that clinical factors such as damage accrual, disease activity, and choice of immunosuppressant, can each have an independent risk in predicting serious infection particularly the first episode.

Major infections in newly diagnosed systemic lupus erythematosus: an inception cohort study

Objective

To evaluate the risk of major infections and the relationship between major infections and mortality in patients with newly diagnosed SLE.

Methods

A newly diagnosed (<3 months) hospitalised Systemic Lupus Inception Cohort (hSLIC) in our centre during 1 January 2013 and 1 November 2020 was established. All patients were followed up for at least 1 year or until death. Patient baseline characteristics were collected. Major infection events were recorded during follow-up, which were defined as microbiological/clinical-based diagnosis treated with intravenous antimicrobials. The cohort was further divided into a training set and a testing set. Independent predictors of major infections were identified using multivariable logistic regression analysis. Kaplan-Meier survival analyses were conducted.

Results

Among the 494 patients enrolled in the hSLIC cohort, there were 69 documented episodes of major infections during the first year of follow-up in 67 (14%) patients. The major infection events predominantly occurred within the first 4 months since enrolment (94%, 65/69) and were associated with all-cause mortality. After adjustments for glucocorticoid and immunosuppressant exposure, a prediction model based on SLE Disease Activity Index >10, peripheral lymphocyte count <0.8×10⁹/L and serum creatinine >104 µmol/L was established to identify patients at low risk (3%–5%) or high risk (37%–39%) of major infections within the first 4 months.

Conclusions

Newly onset active SLE is susceptible to major infections, which is probably due to underlying profound immune disturbance. Identifying high-risk patients using an appropriate prediction tool might lead to better tailored management and better outcome.

Clinical course, chest computed tomography severity score and outcome of coronavirus disease 2019 (COVID-19) in patients with rheumatic diseases

Aim of the work

To assess the clinical manifestations, imaging findings and outcomes of corona virus disease 2019 (COVID-19) in patients with rheumatic diseases.

Patients and methods

In a three-center study, patients with rheumatic diseases who developed COVID-19 were included. Patients were classified into two groups, i) inflammatory arthritis including rheumatoid arthritis (RA), spondyloarthritis (SpA) and undifferentiated arthritis, ii) connective tissue diseases (CTDs) including systemic lupus erythematosus (SLE), vasculitis and others. COVID-19 outcomes were assessed based on chest computed tomography severity score (CT-ss), the level of care, the number of patients who died and flare of underlying rheumatic disease.

Results

One hundred ninety-six patients with a mean age of 47.9 ± 15.1 years, 73.5% female, were included. Underlying rheumatic diseases were RA (57.7%), SLE and other CTDs (17.9%), SpA (11.2%), vasculitis (11.2%) and undifferentiated arthritis (2%). Myalgia, malaise and fever were the most common clinical manifestations of COVID-19. Pneumonia on computerized tomography (CT), hospitalization, admission in intensive care unit and need to mechanical ventilation were observed in 75.5, 37.2%, 10.7% and 6.6% of patients, respectively. Treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids, diabetes and underlying pulmonary disease were predictors of moderate to severe pneumonia and hospitalization. Fifteen (7.6%) patients died. Flare of underlying rheumatic disease occurred in 16.3% of patients. Flare of disease in patients with CTDs was significantly more than other rheumatic diseases.

Conclusions

In rheumatic patients, treatment with NSAIDs or prednisolone, diabetes and pulmonary disease are risk factors of moderate to high CT-ss and hospitalization during COVID-19.

Brain paracoccidioidomycosis in an immunosuppressed patient with systemic lupus erythematosus

Background:

Brain paracoccidioidomycosis (PCM) or neuroparacoccidioidomycosis (NPCM) is a fungal infection of the central nervous system (CNS) caused by Paracoccidioides brasiliensis, a dimorphic fungus. The CNS involvement is through bloodstream dissemination. The association between NPCM and systemic lupus erythematous (SLE) is rare. However, SLE patients are under risk of opportunistic infections given their immunosuppression status.

Case Description:

The aim of this case report is to present a 37-year-old female with diagnosis of SLE who presented with progressive and persistent headache in the past 4 months accompanied by the right arm weakness with general and neurologic examination unremarkable. The computerized tomography of the head showed left extra-axial parietooccipital focal hypoattenuation with adjacent bone erosion. The brain magnetic resonance imaging reported left parietooccipital subdural collection associated with focal leptomeningeal thickening with restriction to diffusion and peripheral contrast enhancement. The patient underwent a left craniotomy and dura mater biopsy showed noncaseous granulomatosis with multinucleated giant cells with rounded birefringent structures positive for silver stain, consistent with PCM. Management with itraconazole 200 mg daily was started with a total of 12 months of treatment, with patient presenting resolution of headache and right arm weakness.

Conclusion:

The diagnosis of NPCM is challenging and a high degree of suspicious should be considered in patients with persistent headache and immunosuppression.

Infections in systemic autoimmune diseases

INTRODUCTION

Infections are a major cause of morbidity and mortality in patients with systemic autoimmune diseases. The aim of the present study is to describe the frequency of infections in a historical cohort of the SAD polyclinic of the Maciel Hospital, according to the type of disease and treatment received.

MATERIAL AND METHODS

An analytical, retrospective and observational study was conducted in 339 patients with SAD attended at the outpatient clinic in the period from January 1, 2012 to February 28, 2019. Infectious complications were analysed according to treatment and disease.

RESULTS

339 cases, median age 56, mostly female. Most cases presented SLE (30.1%) and RA (23.6%), followed by antiphospholipid syndrome (20.4%) and Sjögren's syndrome (12.1%). Hydroxychloroquine (66%), followed by corticosteroids (55.5%) were the most frequently used treatments. Thirteen point three percent received biological therapies: 46.9% of the cases presented some infectious complication, 95% were non-opportunistic. Respiratory infections were the most frequent (48.6%) followed by urinary infections (31.7%) and skin and soft tissue infections (17.6%). On comparing the infected and non-infected groups, significant differences were found in the following variables: methotrexate, mycophenolate, corticoids, biological therapies, combination of drugs, active disease, RA and cases with overlap. The use of hydroxychloroquine and sulfasalazine was associated with a lower risk of infection in patients with RA.

CONCLUSIONS

Infections are a frequent complication in patients with RA, due to the immune disturbances of the disease itself and prescribed treatments, mainly corticoids and biologicals. The importance of screening and infection prophylaxis before starting treatment is stressed.

Pneumococcal Vaccination Among Lupus Patients: Who Are the Recipients?

PURPOSE

Pneumococcal vaccination (PV) is indicated for the elderly (age ≥65 years) and those with chronic disease or who are immunosuppressed. We aimed to study the rate and predictors of recommendation/receipt of 23 valent pneumococcal polysaccharide vaccine (PPSV23) in immunosuppressed systemic lupus erythematosus (SLE) patients.

METHODS

Data were obtained through self-report questionnaires and medical chart review of 150 SLE patients. Information on rheumatologist recommendation or receipt of PPSV23 in the preceding 5 years was collected if self-reported in a questionnaire or documented in the medical chart. Chart review was also done to collect data on patient demographics, physician characteristics (if patients had a primary care physician and rheumatologist's SLE patient volume), and the disease characteristics of SLE. Comparisons using χ2 or t tests and logistic regression analyses were conducted for predictors of recommendation/receipt of PV.

RESULTS

The mean (SD) age was 47.4 (15.9) years; 90% were women. Sixty-five of 94 eligible patients for PV (based on immunosuppressive medications use or age) had been either recommended or administered PPSV23. On univariate logistic regression analysis, age, duration of disease, current use of hydroxychloroquine or mycophenolate, and rheumatologist's SLE patient volume were significant correlates of recommendation/receipt of PPSV23. However, on multivariate analysis, the only significant predictor was rheumatologist's SLE patient volume after adjusting for the above correlates such that with every 50 patients increase in SLE patient clinic volume, the odds of recommendation/receipt of PPSV23 increased by 2.37 times.

CONCLUSIONS

The volume of lupus patients that rheumatologists see is strongly associated with the likelihood that their SLE patients will have PPSV23 recommended and delivered, suggesting a volume outcome relationship.

High burden of infections in Indian patients with Idiopathic Inflammatory Myopathy: validation of observations from the MyoCite dataset

OBJECTIVE

To determine the prevalence, profile and predictors of infections in an Indian cohort with idiopathic inflammatory myopathies (IIM).

METHODS

We reviewed the records of a retrospective cohort with IIM enrolled from consecutive patients being followed up in the clinic, and these constituted the observation cohort. A newly diagnosed inception cohort with IIM were followed prospectively as the validation cohort for confirmation of observations and comparison with the observation cohort.

RESULTS

Among the 68 patients in the observation cohort (average age 33.4 years, female:male 4.2:1), 37 (54.4%) experienced 54 infections between them; of these 54 infections, 21 (38.8%) were major and recurrent infections and they occurred in 11 patients (16.17%) over 3.08 years. Tuberculosis was the most common infection (12, 22.2%), with a predominance of extrapulmonary forms. Serum protein [odds ratio (OR) 0.44], platelets (0.44) at disease onset and daily steroid dose (1.04) predicted major infections on multivariate analysis. A higher daily dose of steroids at first infection correlated with number of recurrent infections. The infection-free 1-year survival was 73.8%.Of the 70 patients in the validation cohort (average age 35.7 years, female:male 3.7:1), 3 had myositis attributed to an infection. A similar proportion of the cohort experienced infections (22, 33.3%) with similar number of major (10, 45.4%) and recurrent (4, 18%) infections being recorded. The most common infection was community-acquired pneumonia, followed by tuberculosis, with serum albumin (OR 0.25) at disease onset being the only predictor. The one-year infection-free survival rate was 64.7%. Those who had a major infection had increased mortality at 1 year, with a survival rate of 60%, compared with 89.09% in those without.In both cohorts, a daily prednisone dose >6.25 mg predisposed to major infections.

CONCLUSION

Major and recurrent infections are common in Indian IIM patients and confer higher risk for future infections and lower survival. Respiratory and atypical bacterial infections such as tuberculosis occur throughout the disease course.

Rapid and precise diagnosis of pneumonia coinfected by Pneumocystis jirovecii and Aspergillus fumigatus assisted by next-generation sequencing in a patient with systemic lupus erythematosus: a case report

Background

Pneumocystis jirovecii and Aspergillus fumigatus, are opportunistic pathogenic fungus that has a major impact on mortality in patients with systemic lupus erythematosus. With the potential to invade multiple organs, early and accurate diagnosis is essential to the survival of SLE patients, establishing an early diagnosis of the infection, especially coinfection by Pneumocystis jirovecii and Aspergillus fumigatus, still remains a great challenge.

Case presentation

In this case, we reported that the application of next -generation sequencing in diagnosing Pneumocystis jirovecii and Aspergillus fumigatus coinfection in a Chinese girl with systemic lupus erythematosus (SLE). Voriconazole was used to treat pulmonary aspergillosis, besides sulfamethoxazole and trimethoprim (SMZ-TMP), and caspofungin acetate to treat Pneumocystis jirovecii infection for 6 days. On Day 10 of admission, her chest radiograph displayed obvious absorption of bilateral lung inflammation though the circumstance of repeated fever had not improved. Unfortunately, the patient discharged from the hospital since the financial burden, and during the follow-up, it was documented the patient died within one week after discharge.

Conclusions

This successful application of the next generation sequencing assisting the rapid diagnosis of Pneumocystis jirovecii and Aspergillus fumigatus coinfection provides a new perspective in the clinical approach against the systematic fungi infections and highlights the potential of this technique in rapid etiological diagnosis.

Predictors of Infection in Children with Systemic Lupus Erythematosus: A Single Center Study in Indonesia

Patients with Systemic Lupus Erythematosus (SLE) are susceptible to infection due to defects in their immune system. Corticosteroids and immunosuppressant drugs used as SLE therapy also contribute to infection. This study aimed is to determine predictors of infection in pediatric patients with SLE. This retrospective cohort study was conducted at Dr. Sardjito Hospital, a referral hospital in Yogyakarta, Indonesia between 2013 and 2019. Logistic regression analysis was performed to identify predictor variables for the occurrence of infection. A total of 109 SLE patients were included in this study. The incidence of infection in children with SLE was 27.5%. The most common types of infection in hospitalized SLE patients were urinary tract infections (41%), skin and soft tissue infections (20.5%), and pneumonia (20.5%). Multivariate regression analysis showed that the use of methylprednisolone pulse dose (RR 3.204; 95% CI 1.234-8.318) was a predictor of infection. Clinician should closely observe SLE patients with predictors for infection.

The risk of COVID-19 in patients with bullous pemphigoid and pemphigus: A population-based cohort study

Background

The burden of COVID-19 in patients with bullous pemphigoid (BP) and pemphigus is yet to be evaluated.

Objective

To assess the risks of COVID-19 and COVID-19-associated hospitalization and mortality in patients with BP and pemphigus and to delineate determinants of severe COVID-19 illness among these patients.

Methods

A population-based cohort study compared COVID-19 and its complications in patients with BP (n = 1845) and pemphigus (n = 1236) with age-, sex-, and ethnicity-matched control subjects.

Results

The risks of COVID-19 (hazard rate [HR], 1.12; 95% confidence interval [CI], 0.72-1.73; P = .691) and COVID-19-associated hospitalization (HR, 1.58; 95% CI, 0.84-2.98; P = .160) was comparable between patients with BP and controls. The risk of COVID-19-associated mortality was higher among patients with BP (HR, 2.82; 95% CI, 1.15-6.92; P = .023). The risk of COVID-19 (HR, 0.81; 95% CI, 0.44-1.49; P = .496), COVID-19-associated hospitalization (HR, 1.41; 95% CI, 0.53-3.76; P = .499), and COVID-19-associated mortality (HR, 1.33; 95% CI, 0.15-11.92; P = .789) was similar in patients with pemphigus and their controls. Systemic corticosteroids and immunosuppressants did not predispose COVID-19-positive BP and pemphigus patients to a more severe illness.

Limitations

Retrospective data collection.

Conclusions

Patients with BP experience increased COVID-19-associated mortality and should be monitored closely. Maintaining systemic corticosteroids and immunosuppressive adjuvant agents during the pandemic is not associated with worse outcomes.

Hospitalized Infections in Lupus: A Nationwide Study of Types of Infections, Time Trends, Health Care Utilization, and In-Hospital Mortality

OBJECTIVE

To examine the time trends in hospitalized infections in patients with systemic lupus erythematosus (SLE), and the factors associated with health care utilization and in-hospital mortality.

METHODS

US National Inpatient Sample data from 1998-2016 were used to examine the epidemiology, time trends, and outcomes of 5 common hospitalized infections in patients with SLE, namely, pneumonia, sepsis/bacteremia, urinary tract infection (UTI), skin and soft tissue infections (SSTIs), and opportunistic infections (OIs). Time trends were compared using the Cochran-Armitage test. Multivariable-adjusted logistic regression models were used to examine the factors associated with health care utilization (hospital stay >3 days, hospital charges above the median, or discharge to a nonhome setting) and in-hospital mortality.

RESULTS

Hospitalization rates per 100,000 claims among SLE patients in 1998-2000 versus in 2015-2016 were as follows: for OIs, 1.13 versus 1.61 (1.2-fold increase); for SSTIs, 4.78 versus 12.2 (2.5-fold increase); for UTI, 1.94 versus 6.12 (3.2-fold increase); for pneumonia, 15.09 versus 17.05 (1.1-fold increase); and for sepsis, 6.31 versus 39.64 (6.3-fold increase). In 2011-2012, sepsis surpassed pneumonia as the most common hospitalized infection in patients with SLE. In multivariable-adjusted models, a diagnosis of sepsis, older age, a Deyo-Charlson common comorbidities score of ≥2, having Medicare or Medicaid insurance, and urban hospital location were significantly associated with increased odds of in-hospital mortality and with all health care utilization outcomes. African American race was significantly associated with increased odds of health care utilization.

CONCLUSION

The results of this study indicate that the rates of hospitalized infections increased over time in patients with SLE, and that pneumonia was surpassed by sepsis as the most common hospitalized infection. In addition, associations of risk factors with poorer outcomes were identified. These findings may help inform patients, providers, and policy makers with regard to the burden of infection in SLE, and could lead to interventions/pathways to improve outcomes.

Bacterial infections in a pediatric cohort of primary and acquired complement deficiencies

BACKGROUND

Acquired complement deficiency can occur in the setting of autoimmune syndromes, such as systemic lupus erythematosus (SLE), with very low or, occasionally, undetectable C3 levels. Based on inherited complement defects, patients with transiently low complement may be at similar risk for serious bacterial infection, but the degree of risk related to C3 level and temporal association is unknown.

METHODS

We performed a retrospective study including pediatric patients with undetectable total complement activity or absent individual complement components measured at our institution from 2002 to 2018. We assessed annual rate of serious bacterial infection (SBI) defined as requiring hospitalization and/or parenteral antibiotics by manual chart review. Among included SLE patients, we assessed the 30-day probability of SBI for given C3 measurements using a logistic regression model to determine risk. Primary complement deficiency was analyzed for SBI rate as comparison. Covariates included age, level of immune suppression and history of lupus nephritis.

RESULTS

Acquired complement deficiency secondary to SLE-related disease [n = 44] was the most common underlying diagnosis associated with depressed complement levels and were compared to a cohort of primary complement deficient patients [n = 18]. SBI per 100 person-years and cohort demographics were described in parallel. Our logistic regression analysis of pediatric patients with SLE showed low C3 level was temporally associated with having an SBI event. Given equivalent immunosuppression, patients with an SBI had lower C3 levels at the beginning of the observation period relative to patients without SBI.

CONCLUSION

Pediatric patients with the diagnosis of SLE can develop very low C3 levels that associate with risk of serious bacterial infection comparable to that of patients with primary complement deficiency. Patients prone to severe complement consumption may particularly be at risk.

The risk of hospitalized infection in patients with systemic lupus erythematosus treated with hydroxychloroquine

Objective

To compare the risk of hospitalized infection (HI) between users and non-users of hydroxychloroquine (HCQ) in systemic lupus erythematosus (SLE).

Methods

Using claims data, patients were defined as SLE cases by the following criteria: 1) they had at least one SLE diagnostic code; 2) they had a prescription for specific drugs, including corticosteroids, steroid pulse therapy, and immunosuppressive drugs; and 3) they were at least 16 years old between September 2015 and July 2017 (n = 17,483). The SLE cases with at least one prescription for HCQ were defined as the HCQ group (n = 1,431), while the others were defined as the non-HCQ group. Among the SLE cases, propensity score-matched cases were observed for 1 year (n = 1,095 in each group).

Results

The median age and proportion of female patients in both groups were about 42 years and 88%, respectively. The proportions of cases with HIs were similar (HCQ group, 4.5%; non-HCQ group, 5.6%; p = 0.240, McNemar test). The hazard ratio of the HCQ group for HIs after adjusting for patients’ characteristics was not significant at 0.9 (0.6–1.3).

Conclusion

The use of HCQ was not associated with a risk of HIs in patients with SLE.

Infections in systemic autoimmune diseases

INTRODUCTION

Infections are a major cause of morbidity and mortality in patients with systemic autoimmune diseases. The aim of the present study is to describe the frequency of infections in a historical cohort of the SAD polyclinic of the Maciel Hospital, according to the type of disease and treatment received.

MATERIAL AND METHODS

An analytical, retrospective and observational study was conducted in 339 patients with SAD attended at the outpatient clinic in the period from January 1, 2012 to February 28, 2019. Infectious complications were analysed according to treatment and disease.

RESULTS

339 cases, median age 56, mostly female. Most cases presented SLE (30.1%) and RA (23.6%), followed by antiphospholipid syndrome (20.4%) and Sjögren's syndrome (12.1%). Hydroxychloroquine (66%), followed by corticosteroids (55.5%) were the most frequently used treatments. Thirteen point three percent received biological therapies: 46.9% of the cases presented some infectious complication, 95% were non-opportunistic. Respiratory infections were the most frequent (48.6%) followed by urinary infections (31.7%) and skin and soft tissue infections (17.6%). On comparing the infected and non-infected groups, significant differences were found in the following variables: methotrexate, mycophenolate, corticoids, biological therapies, combination of drugs, active disease, RA and cases with overlap. The use of hydroxychloroquine and sulfasalazine was associated with a lower risk of infection in patients with RA.

CONCLUSIONS

Infections are a frequent complication in patients with RA, due to the immune disturbances of the disease itself and prescribed treatments, mainly corticoids and biologicals. The importance of screening and infection prophylaxis before starting treatment is stressed.

Clinical characteristics and risk factors of infection in patients with systemic lupus erythematosus: A systematic review and meta-analysis of observational studies

OBJECTIVE

Infection is one of the major causes of morbidity and mortality in systemic lupus erythematosus (SLE) patients. We conducted a systematic review and meta-analysis to investigate the clinical characteristics and risk factors of infection in SLE by comparing demographic factors, laboratory data, clinical features, and therapeutic factors between infection and non-infection SLE patients.

METHODS

PubMed, Embase, and Cochrane databases were searched systematically without restricting the language or year (up to September 2019) by using MeSH terms and keywords pertaining to SLE and infection. Three independent reviewers selected all observational studies based on the established inclusion criteria. Odds ratio (OR) and standardized mean difference (SMD) along with 95% confidence intervals (CI) were used and the analyses were carried out by using a random/fixed-effects model. When necessary, different subgroup and sensitivity analyses were conducted. Study quality was assessed by the modified version (nine-star scoring system) of the Newcastle-Ottawa Scale (NOS) and publication bias was evaluated by funnel plots, and Egger's and Begg's tests.

RESULTS

In total, we included 39 studies (3709 infection SLE patients and 10526 non-infection SLE patients) based on the inclusion criteria. Compared with the SLE patients without infection, we found that infected SLE patients had a significantly higher incidence rate of the following: 1) lymphopenia (OR = 2.738 95%CI (1.017-7.376), P = 0.046, I² = 81.4%), 2) thrombocytopenia (OR = 1.61 95%CI (1.4-1.85), P<0.001, I² = 0%), 3) anemia (OR = 2.294 95%CI (1.402-3.755), P = 0.001, I² = 83.0%), 4) hypoproteinemia (OR = 2.336 95%CI (1.408-3.876), P = 0.001, I² = 84.2%), 5) C3 consumed (OR = 1.890 95%CI (1.190-3.002), P = 0.007, I² = 77.4%), 6) diabetes mellitus (OR = 3.890 95%CI (2.450-6.160), P < 0.001, I² = 0%), 7) elevated creatinine (OR = 1.954 95%CI (1.646-2.320), P < 0.001, I² = 0.0%), 8) renal involvement (OR = 2.692 95%CI (2.000-3.623), P < 0.001, I² = 76.0%), 9) serositis (OR = 3.877 95%CI (0.995-15.110), P = 0.051, I² = 79.1%), and 10) use of steroid immunosuppressants (OR = 3.116 95%CI (1.959-4.957), P < 0.001, I² = 77.9%). Furthermore, infected SLE patients had a significantly higher mean dose of prednisone (SMD = 2.088 95%CI (1.196-2.981), P < 0.001, I² = 97.8%). In addition, SLE patients with infection showed a significantly lower incidence of antimalarial drug use (OR = 0.634 95%CI (0.451-0.892), P = 0.009, I² = 56.0%). Infected SLE patients had a significantly higher level of 1) 24-h urinary protein (SMD = 0.560 95%CI (0.300-0.810), P < 0.001, I² = 0%), 2) CRP (SMD = 0.437 95%CI (0.184-0.691), P = 0.001, I² = 68.6%), and 3) SLE Collaborating Clinics damage index (SDI) (SMD = 0.451 95%CI (0.238-0.664), P < 0.001, I² = 0.0%), along with a significantly lower level of albumin (SMD = -0.400 95%CI (-0.610--0.200), P < 0.001, I² = 0.0%). After adjustment for false discovery rate (FDR), lymphopenia and serositis were no longer associated with the occurrence of infection; however, the remaining factors were still associated with infection in SLE. According to the nine-star scoring system of NOS, 71.79% of the studies were considered as high methodological quality (low risk of bias). No significant publication bias, except for renal involvement, was detected from funnel plots or Egger's and Begg's test, while this publication bias of renal involvement did not impact the pooled estimates.

CONCLUSION

We identified many factors including thrombocytopenia, anemia, hypoproteinemia, hypocomplementemia, hypoalbuminemia, higher level of CRP, higher SDI score, renal involvement and diabetes mellitus that were associated with infection in SLE patients. In addition, glucocorticoids (especially high-dose) and immunosuppressants (e.g. cyclophosphamide) rendered SLE patients more susceptible to infection, while antimalarial drug administration (hydroxychloroquine) was a protective factor against infection in SLE patients. SLE patients with the above clinical characteristics and risk factors might be at high risk from infection, which might contribute to the early identification of infection in SLE patients for better prognosis.

Systemic lupus erythematosus and risk of infection

INTRODUCTION

Systemic lupus erythematosus (SLE) is an autoimmune disorder that affects almost every organ system and it is treated with immunomodulation and immunosuppression. SLE patients have an intrinsically dysfunctional immune system which is exacerbated by disease activity and leaves them vulnerable to infection. Treatment with immunosuppression increases susceptibility to infection, while hydroxychloroquine use decreases this risk. Infectious diseases are a leading cause of hospitalization and death.

AREAS COVERED

This narrative review provides an overview of recent epidemiology and predictors of infections in SLE, delineates the risk of infection by therapeutic agent, and provides suggestions for risk mitigation. Articles were selected from Pubmed searches conducted between September 2019 and January 2020.

EXPERT OPINION

Despite the large burden of infection, effective and safe preventative care such as universal hydroxychloroquine use and vaccination are underutilized. Future efforts should be directed to quality improvement, glucocorticoid reduction, and validation of risk indices that identify patients at the highest risk of infection.

Septicaemia is associated with increased disease activity and mortality in systemic lupus erythematosus: a retrospective analysis from Taiwan

OBJECTIVE

This study aimed to investigate how septicaemia, non-septicaemia infection and the disease itself are associated with disease activity and mortality in inpatients with systemic lupus erythematosus (SLE) in Taiwan.

METHODS

We retrospectively reviewed 1115 patients and enrolled 427 with SLE admitted for lupus flare-ups and co-morbidities. Disease activity and infection type/site were recorded and categorized according to the causes of admission and mortality into three categories, of which two were specified as follows: (a) septicaemia admissions, non-septicaemia admissions; and (b) septicaemia mortality, non-septicaemia infection mortality and non-infection mortality. The relationships between lupus flare-ups and mortality in different groups were analysed using an unpaired t-test, Mann-Whitney U-test and logistic regression.

RESULTS

Septicaemia was the major cause of mortality in SLE inpatients. There were 98 (22.95%) mortality patients among all 427 SLE patients. The septicaemia admissions had higher disease activity (SLE Disease Activity Index 2000 = 13.00 ± 7.98) than the non-septicaemia admissions (9.77 ± 5.72; p < 0.01). The mean current SLEDAI score of the septicaemia mortality group (14.91 ± 8.01) was higher than that of the non-septicaemia infection mortality group (10.05 ± 5.75; p = 0.02), in spite of the similar mean earlier SLEDAI score. The risk of mortality in the septicaemia mortality group due to previous septicaemia admissions was 13.2 times (odds ratio) higher than in the non-septicaemia infection mortality group and 15.6 times higher than in the non-infection mortality group.

CONCLUSION

Septicaemia relates to increased lupus disease activity and is associated with a greater risk of mortality in the SLE patients than other causes of admission. Fewer previous septicaemia admissions decrease the risk of septicaemia mortality.

Factors predictive of serious infections over time in systemic lupus erythematosus patients: data from a multi-ethnic, multi-national, Latin American lupus cohort

Aim

The aim of this study was to identify factors predictive of serious infections over time in patients with systemic lupus erythematosus (SLE).

Methods

A multi-ethnic, multi-national Latin American SLE cohort was studied. Serious infection was defined as one that required hospitalization, occurred during a hospitalization or led to death. Potential predictors included were sociodemographic factors, clinical manifestations (per organ involved, lymphopenia and leukopenia, independently) and previous infections at baseline. Disease activity (SLEDAI), damage (SLICC/ACR Damage Index), non-serious infections, glucocorticoids, antimalarials (users and non-users), and immunosuppressive drugs use; the last six variables were examined as time-dependent covariates. Cox regression models were used to evaluate the predictors of serious infections using a backward elimination procedure. Univariable and multivariable analyses were performed.

Results

Of the 1243 patients included, 1116 (89.8%) were female. The median (interquartile range) age at diagnosis and follow-up time were 27 (20–37) years and 47.8 (17.9–68.6) months, respectively. The incidence rate of serious infections was 3.8 cases per 100 person-years. Antimalarial use (hazard ratio: 0.69; 95% confidence interval (CI): 0.48–0.99; p = 0.0440) was protective, while doses of prednisone >15 and ≤60 mg/day (hazard ratio: 4.18; 95 %CI: 1.69–10.31; p = 0.0019) and >60 mg/day (hazard ratio: 4.71; 95% CI: 1.35–16.49; p = 0.0153), use of methylprednisolone pulses (hazard ratio: 1.53; 95% CI: 1.10–2.13; p = 0.0124), increase in disease activity (hazard ratio: 1.03; 95% CI: 1.01–1.04; p = 0.0016) and damage accrual (hazard ratio: 1.22; 95% CI: 1.11–1.34; p < 0.0001) were predictive factors of serious infections.

Conclusions

Over time, prednisone doses higher than 15 mg/day, use of methylprednisolone pulses, increase in disease activity and damage accrual were predictive of infections, whereas antimalarial use was protective against them in SLE patients.

Associated clinical factors for serious infections in patients with systemic lupus erythematosus

Infection occurs frequently in patients with systemic lupus erythematosus (SLE), and has been a major cause of morbidity and mortality. However, no large-scale comprehensive studies have estimated the effect of clinical characteristics on serious infection in actual clinical practice yet. We investigated the influence of clinical characteristics on serious infections using electronic medical records data. We conducted a nested case-control study. Patients with SLE who developed serious infection which needs hospitalization or intravenous antibiotics (n = 120) were matched to controls (n = 240) who didn't. Odds ratios (OR) and 95% confidence intervals (CIs) for infection associated with clinical features were obtained by conditional logistic regression analyses. The conditional logistic regression analysis with adjustment showed that serositis (OR, 2.76; 95% CI, 1.33-5.74), hematologic involvement (OR, 2.53; 95% CI, 1.32-4.87), and use of higher than the low dose of glucocorticoids (GCs; >7.5 mg/d prednisolone-equivalent) (OR, 2.65; 95% CI, 1.31-5.34) were related to serious infections in SLE. Serositis, hematologic involvement, and use of higher than the low dose of GCs were associated with serious infections in patients with SLE.

The Systemic Lupus Erythematosus Infection Predictive Index (LIPI): A Clinical-Immunological Tool to Predict Infections in Lupus Patients

Among autoimmune diseases, systemic lupus erythematosus (SLE) patients have a unique predisposition to develop infections, which represents one of their main causes of morbidity and mortality. Many infections occur at disease diagnosis in the absence of immunosuppressive therapy, suggesting that the immunological abnormalities in SLE patients might be fundamental for the development of this complication. The aim of this study was to address the main clinical and immunological features associated with the development of infection and to create and validate a compound clinical-immunological infection predictive index in a cohort of SLE patients. We included 55 SLE patients with < 5 years since diagnosis. The clinical and immunological features were evaluated periodically and patients were followed-up during 1 year, searching for the development of infection. Immunophenotyping was performed by multiparametric flow cytometry and neutrophil extracellular traps (NETs) were assessed by confocal microscopy. Eighteen patients (32.7%) presented 19 infectious events, 5 (26.3%) were severe. For the construction of the index, we performed a logistic regression analysis and the cutoff points were determined with ROC curves. Increased numbers of peripheral Th17 cells, B cell lymphopenia, and lower TLR2 expression in monocytes, as well as the use of cyclophosphamide were the major risk factors for the development of infection and thus were included in the index. Besides, patients that developed infection were characterized by increased numbers of low-density granulocytes (LDGs) and higher expression of LL-37 in NETs upon infection. Finally, we validated the index retrospectively in a nested case-control study. A score >1.5 points was able to predict infection in the following year (AUC = 0.97; LR- = 0.001, specificity 100%, P = 0.0003). Our index encompasses novel immunological features able to prospectively predict the risk of infection in SLE patients.

Clinical characteristics and risk factors of infections in patients with systemic lupus erythematosus

To investigate the clinical characteristics of infection in SLE patients and analyze the risk factors of infection. A retrospective analysis method was used and the data were collected from 173 case times of 142 hospitalized patients. We found the incidence rate of infections in SLE was 50.7%. The most common infection sites were lungs, followed by upper respiratory tracts and urinary tracts. The most common pathogens were bacteria, followed by fungi. The infection-associated risk factors were duration of hospitalization, lupus activity state, the use of high-dose corticosteroids and immunosuppressive agents, the low serum level of complements 3 and 4 (C3 and C4), fever, the high level of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), the abnormality of white blood cell (< 4 × 10⁹/L or > 10 × 10⁹/L), and the low level of albumin (P < 0.05 or P < 0.001). The independent risk factors for SLE patients with infection consist of the abnormality of white blood cells, the high level of CRP, the low serum level of C4, and longtime hospitalization. Attention should be paid to the risk factors of infection, and treatment to enhance immunity should be carried out to reduce the chance of infection.

Invasive fungal infections in Colombian patients with systemic lupus erythematosus

Introduction Systemic lupus erythematosus is an autoimmune disease with multi-organ involvement. Complications, such as invasive fungal infections usually occur in patients with a greater severity of the disease. Objective The objective of this study was to determine the prevalence and risk variables associated with invasive fungal infections in a Colombian systemic lupus erythematosus population. Materials and methods A cross-sectional, retrospective study that evaluated patients with systemic lupus erythematosus for six years. The primary outcome was invasive fungal infection. Descriptive, group comparison and bivariate analysis was performed using Stata 12.0 software. Results Two hundred patients were included in this study; 84.5% of the patients were women and the median age was 36 years; 68% of the subjects had haematological complications; 53.3% had nephropathy; 45% had pneumopathy and 28% had pericardial impairment; 7.5% of patients had invasive fungal infections and the most frequently isolated fungus was Candida albicans. Pericardial disease, cyclophosphamide use, high disease activity, elevated ESR, C3 hypocomplementemia, anaemia and lymphopenia had a significant association with invasive fungal infection ( P < 0.05). Conclusions We describe for the first time the prevalence of invasive fungal infection in a Colombian population with systemic lupus erythematosus, which was higher than that reported in other latitudes. In this population the increase in disease activity, the presence of pericardial impairment and laboratory alterations (anaemia, lymphopenia, increased ESR and C3 hypocomplementemia) are associated with a greater possibility of invasive fungal infections. Regarding the use of drugs, unlike other studies, in the Colombian population an association was found only with the previous administration of cyclophosphamide. In addition, patients with invasive fungal infections and systemic lupus erythematosus had a higher prevalence of mortality and hospital readmission compared with patients with systemic lupus erythematosus without invasive fungal infection.

Infection in systemic lupus erythematosus, similarities, and differences with lupus flare

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with diverse manifestations, and its pathogenesis is unclear and complicated. Infection and SLE are similar in that they both cause inf lammatory reactions in the immune system; however, one functions to protect the body, whereas the other is activated to damage the body. Infection is known as one of the common trigger factors for SLE; there are a number of reports on infectious agents that provoke autoimmune response. Several viruses, bacteria, and protozoa were revealed to cause immune dysfunction by molecular mimicry, epitope spreading, and bystander activation. In contrast, certain pathogens were revealed to protect from immune dysregulation. Infection can be threatening to patients with SLE who have a compromised immune system, and it is regarded as one of the common causes of mortality in SLE. A clinical distinction between infection and lupus f lare up is required when patients with SLE present fevers. With a close-up assessment of symptoms and physical examination, C-reactive protein and disease activity markers play a major role in differentiating the different disease conditions. Vaccination is necessary because protection against infection is important in patients with SLE.

Infection in Southern Chinese Patients with Systemic Lupus Erythematosus: Spectrum, Drug Resistance, Outcomes, and Risk Factors

Objective.

To investigate the spectrum, antibiotic-resistant pattern, risk factors, and outcomes of infection in patients hospitalized with systemic lupus erythematosus (SLE).

Methods.

We collected the clinical and microbiological data from hospitalized patients with SLE with infection between June 2005 and June 2015, and then conducted retrospective analyses.

Results.

Among our sample of 3815 hospitalized patients, 1321 (34.6%) were diagnosed with infection. The majority (78.3%) of infection occurred within 5 years of SLE onset. Bacterial infection was predominant (50.6%), followed by viral infection (36.4%) and fungal infection (12.5%). The lungs (33.7%) and upper respiratory tracts (26.3%) were most commonly affected. Gram-negative bacteria (GNB) were predominant over gram-positive bacteria (178 isolates vs 90 isolates). The most frequently isolated bacteria were Escherichia coli (24.6%), followed by Acinetobacter baumannii (13.4%) and coagulase-negative Staphylococcus (13.4%). Multidrug-resistant (MDR) strains were detected in 26.9% of bacterial isolates. The most common fungus was Candida spp. (99 episodes), followed by Aspergillus (24 episodes) and Cryptococcus neoformans (13 episodes). The overall mortality rate for this cohort was 2.2%; 48 patients died of infection. Factors associated with bacterial and viral infection were higher Systemic Lupus Erythematosus Disease Activity Index, renal involvement, thrombocytopenia, accumulated dose of glucocorticoids (GC), and treatment with cyclophosphamide (CYC). Renal involvement, accumulated dose of GC, and treatment with CYC were associated with fungal infection.

Conclusion.

Infection was the leading cause of mortality in patients hospitalized with SLE. There were some notable features of infection in Chinese patients including early onset, higher proportion of respiratory tract involvement, predominance of GNB with emergence of MDR isolates, and a variety of pathogens.

Infections and systemic lupus erythematosus

OBJECTIVE

To determine the incidence of infections in a population of systemic lupus erythematosus individuals and the characteristics of infections regarding original site, as well as to study the possible associations between infections and treatment.

METHODS

An analytical retrospective study using data from medical charts of systemic lupus erythematosus patients from a single university hospital. A total of 144 patients followed up for five years were included. Data collected comprised age of patients and age at onset of lupus, sex and ethnicity, disease duration before the study period, medications, cumulative dose of prednisone, occurrence of infections and their original site.

RESULTS

The most frequent infections were urinary tract infections (correlated to use of prednisone - p<0.0001 and cyclophosphamide - p=0.045), upper airways infections (correlated to use of prednisone - p=0.0004, mycophenolate mofetil - p=0.0005, and cyclosporine - p=0.025), and pneumonia (associated to prednisone - p=0.017).

CONCLUSION

Prednisone was the drug more often associated with presence of infections, pointing to the need for a more judicious management of this drug.

Burden of Serious Infections in Adults With Systemic Lupus Erythematosus: A National Population-Based Study, 1996-2011

OBJECTIVE

To compare rates of hospitalization for serious infections, trends in rates from 1996 to 2011, and in-hospital mortality between patients with systemic lupus erythematosus (SLE) and those without SLE in a national sample.

METHODS

We analyzed hospitalizations for pneumonia, bacteremia/sepsis, urinary tract infections, skin infections, and opportunistic infections among adults in the Nationwide Inpatient Sample. We compared rates of hospitalization yearly among patients with SLE and the general population. We also computed odds ratios (ORs) for in-hospital mortality.

RESULTS

In 1996, the estimated number of hospitalizations for pneumonia in patients with SLE was 4,382, followed by sepsis (2,305), skin infections (1,422), urinary tract infections (643), and opportunistic infections (370). Rates were much higher in patients with SLE than in those without SLE, with age-adjusted relative risks ranging from 5.7 (95% confidence interval [95% CI] 5.5-6.0) for pneumonia to 9.8 (95% CI 9.1-10.7) for urinary tract infection in 1996. Risks increased over time, so that by 2011, all relative risks exceeded 12.0. Overall risk of in-hospital mortality was higher in SLE only for opportunistic infections (adjusted OR 1.52 [95% CI 1.12-2.07]). However, in pneumonia and sepsis, mortality risks were higher in SLE among those who required mechanical ventilation.

CONCLUSION

Hospitalization rates for serious infections in SLE increased substantially between 1996 and 2011, reaching over 12 times higher than in patients without SLE in 2011. Reasons for this acceleration are unclear. In-hospital mortality was higher among patients with SLE and opportunistic infections and those with pneumonia or sepsis who required mechanical ventilation.

Spectrum of infections and outcome among hospitalized South Africans with systemic lupus erythematosus

Our aim was to determine reasons for admission, the prevalence and spectrum of infections, and the outcomes in a multiethnic cohort of hospitalized systemic lupus erythematosus (SLE) patients in Durban, South Africa. We reviewed the records of hospitalized SLE patients seen over a 79-month period; the demographic data, clinical manifestations, laboratory findings, reasons for admission, nature of infection, and outcome were recorded. Our 167 patients, comprising 59.3% Indians, 33.5% African Blacks, 5.4% Coloreds, and 1.8% Whites, had 327 admissions. Active disease and infections accounted for 218 (66.7%) and 115 (35.2%) admissions respectively, with 58 (17.7%) due to both active disease and infection. Features of active disease were mucocutaneous 33.0%, hematological 30.3%, renal 28.9%, and vasculitis 27.1%. Overall, 83 patients (49.7%) had 155 infections; pneumonia (36.8%), cutaneous sepsis (18.1%), tuberculosis (13.5%), urinary tract infections (12.9%), and septicemia (7.1%) were the most common. The organisms commonly isolated were Staphylococcus aureus 25.4%, Escherichia coli 20.3%, and Klebsiella species and Mycobacterium tuberculosis in 13.6% each. Serositis (odds ratio (OR) = 2.7, p = 0.005) and seizures (OR = 4.8, p = 0.007) were associated with increased risk of infection. Twenty-four (14.4%) patients died from infection and active disease; the patients who died had higher SLEDAI scores (p = 0.02) and longer duration of hospitalization (p = 0.03) but no significant associations on multiple logistic regression analysis. Bacterial infections, including tuberculosis, are common in SLE, and they are a major cause of mortality.

Incidence and risk of infection in egyptian patients with systemic lupus erythematosus

BACKGROUND

Infection in systemic lupus erythematosus (SLE) is common and is one of the leading causes of morbidity and mortality.

OBJECTIVE

To study the risk and occurrence of infection in Egyptian SLE patients and to determine its characteristics.

METHODS

A total of 200 SLE patients were followed up for 1 year at monthly intervals, undergoing clinical and laboratory evaluation. Disease activity was assessed by SLE disease activity measurement (SLAM) score. Infections were diagnosed on basis of clinical findings, medical opinion, positive blood and urine cultures, Gram stain results, and specific serological assays as measurement of CMV and EBV antibodies.

RESULTS

A total of 55% of patients developed infection, 45% had one infection, and the rest had multiple infection episodes. Total number of infections was 233 infections/year, 47.2% were major and 52.8% were minor infections. Urinary tract was the most commonly involved site with bacterial infection being the commonest isolated organism (46.4%), and E. coli the commonest isolated bacteria (14.2%). There were 51 episodes caused by systemic viral infection (CMV in 25, EBV in 22, HCV in 3, and 1 in HBV).

CONCLUSION

There is a high rate of infection among SLE patients. Disease activity, leukopenia, high CRP level, positive anti-dsDNA, consumed C3, and cyclophosphamide therapy are independent risk factors for infection in SLE.

Challenges for lupus management in emerging countries

In emerging countries, systemic lupus erythematosus (SLE) has been associated with several unfavorable outcomes including disease activity, damage accrual, work disability and mortality. Poor socioeconomic status (SES) and lack of access to healthcare, especially in medically underserved communities, may be responsible for many of the observed disparities. Diagnostic delay of SLE or for severe organ damages (renal involvement) have a negative impact on those adverse outcomes in lupus patients who either belong to minority groups or live in emerging countries. Longitudinal and observational prospective studies and registries may help to identify the factors that influence poor SLE outcomes in emerging countries. Infection is an important cause of mortality and morbidity in SLE, particularly in low SES patients and tuberculosis appears to be frequent in SLE patients living in endemic areas (mainly emerging countries). Thus, tuberculosis screening should be systematically performed and prophylaxis discussed for patients from these areas. SLE treatment in the developing world is restricted by the availability and cost of some immunosuppressive drugs. Moreover, poor adherence has been associated to bad outcomes in lupus patients with a higher risk of flares, morbidity, hospitalization, and poor renal prognosis. Low education and the lack of money are identified as the main barrier to improve lupus prognosis. Newer therapeutic agents and new protocols had contributed to improve survival in SLE. The use of corticoid-sparing agents (hydroxychloroquine, methotrexate, azathioprine and mycophenolate mofetif) is one of the most useful strategy; availability of inexpensive generics may help to optimize access to these medications.

Infection risk in systemic lupus erythematosus patients: susceptibility factors and preventive strategies

Infection is one of the leading causes of morbidity and mortality in systemic lupus erythematosus (SLE). Bacterial infections are most frequent, followed by viral and fungal infections. The impaired cellular and humoral immune functions seen in patients with SLE are predisposing conditions, whilst disease activity, prednisone doses over 7.5–10 mg/day, high doses of methylprednisolone or cyclophosphamide are well-recognised risk factors for infection. The first six months after rituximab treatment and the use of more than three courses are also associated with an increased susceptibility for infection. It has not been established whether belimumab, azathioprine and mycophenolate mofetil increase the risk of serious infections. Most vaccines are effective and safe in SLE patients, although vaccination should be avoided during periods of active disease. Live virus vaccines are contraindicated for immunosuppressed patients. Influenza and pneumococcal vaccines are universally recommended. Tuberculosis prophylaxis should be considered in selected cases. Therefore, it is advisable not to exceed doses of 5 mg/day of prednisone in chronic treatment. Methylprednisolone and cyclophosphamide should be used in low-dose regimens. Antimalarials have a well-known protective role against infection, in addition to other beneficial properties, thus, hydroxychloroquine is recommended for all SLE patients where no contraindication exists.

Linking complement and anti-dsDNA antibodies in the pathogenesis of systemic lupus erythematosus

Systemic lupus erythematosus is a severe autoimmune disease that affects multiple organ systems resulting in diverse symptoms and outcomes. It is characterized by antibody production to a variety of self-antigens, but it is specifically associated with those against anti-dsDNA. Anti-dsDNA antibodies are present before the onset of clinical disease and are associated with severe manifestations of lupus such as glomerulonephritis. Their levels fluctuate with changes in disease activity and, in combination with the levels of complement proteins C3 and C4, are strong indicators of disease flare and treatment response in patients with lupus. The decreased complement levels that are noted during flares of lupus activity are believed to be secondary to increased autoantibody production and immune complex formation that results in tissue damage; however, recent data suggest that complement activation can also drive development of these pathogenic autoantibodies. This review will explore the various roles of complement in the development and pathogenesis of anti-dsDNA antibodies.

Diagnosis and management of infectious complications of childhood rheumatic diseases

Progress in the diagnosis and management of pediatric rheumatic disease has improved complications from underlying disease and the survival of children. However, as a consequence, infection has now become one of the leading causes of morbidity and mortality. Differentiating between infections and disease flares in children with rheumatic conditions can often pose diagnostic quandaries. Children with rheumatic diseases are at risk of infection, not only because of the use of immune-modulating medications but also because of underlying immune dysfunction associated with their disease. Although bacterial infections are the most common, any organism can potentially be a causative agent and, at times, more invasive measures of diagnosis, for example bronchoscopy and tissue biopsies may be necessary. Maintaining a high index of suspicion of infection with prompt diagnosis and treatment are important to further improve patient outcomes.