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Rúa-Figueroa Fernández de Larrinoa Í, Carreira PE, Brito García N, Díaz Del Campo Fontecha P, Pego Reigosa JM, Gómez Puerta JA, Ortega-Castro R, Tejera Segura B, Aguado García JM, Torre-Cisneros J, Valencia-Martín JL, Pereda CA, Nishishinya-Aquino MB, Otón Sánchez MT, Silva Fernández L, Maese Manzano J, Chamizo Carmona E, Correyero Plaza M. Recommendations for prevention of infection in systemic autoimmune rheumatic diseases. REUMATOLOGIA CLINICA 2022; 18:317-330. [PMID: 34607782 DOI: 10.1016/j.reumae.2021.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/11/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To develop recommendations for the prevention of infection in adult patients with systemic autoimmune rheumatic diseases (SARD). METHODS Clinical research questions relevant to the objective of the document were identified by a panel of experts selected based on their experience in the field. Systematic reviews of the available evidence were conducted, and evidence was graded according to the Scottish Intercollegiate Guidelines Network criteria. Specific recommendations were made. RESULTS Five questions were selected, referring to prevention of infection by Pneumocystis jirovecii with trimethoprim/sulfamethoxazole, primary and secondary prophylactic measures against hepatitis B virus, vaccination against human papillomavirus, vaccination against Streptococcus pneumoniae and vaccination against influenza virus, making a total of 18 recommendations, structured by question, based on the evidence found for the different SARD and/or expert consensus. CONCLUSIONS There is enough evidence on the safety and efficacy of vaccinations and other prophylactic measures against the microorganisms reviewed in this document to specifically recommend them for patients with SARD.
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Affiliation(s)
| | - Patricia E Carreira
- Servicio de Reumatología, Hospital Universitario 12 de octubre, Madrid, Spain
| | - Noé Brito García
- Unidad de Investigación, Sociedad Española de Reumatología, Madrid, Spain.
| | | | - José María Pego Reigosa
- Servicio de Reumatología, Complexo Hospitalario Universitario de Vigo, Grupo IRIDIS-VIGO (Investigation in Rheumatology and Immune-Mediated Diseases), Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, Spain
| | | | - Rafaela Ortega-Castro
- Unidad de Gestión Clínica de Reumatologia, Hospital Universitario Reina Sofía, Universidad de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
| | | | - José María Aguado García
- Unidad de Enfermedades Infecciosas, Hospital Universitario 12 de Octubre. Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Universidad Complutense Madrid, Madrid, Spain
| | - Julián Torre-Cisneros
- Servicio de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica (IMIBIC), Departamento de Ciencias Médicas y Quirúrgicas, Universidad de Córdoba, Córdoba, Spain
| | - José L Valencia-Martín
- Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Izuka S, Yamashita H, Takahashi Y, Kaneko H. Adverse drug reactions to trimethoprim-sulfamethoxazole in systemic lupus erythematosus. Lupus 2021; 30:1679-1683. [PMID: 34304628 DOI: 10.1177/09612033211033985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Trimethoprim-sulfamethoxazole (TMP-SMX), a prophylactic agent against pneumocystis pneumonia (PCP), can cause adverse drug reactions (ADRs), particularly in patients with systemic lupus erythematosus (SLE). However, the risk factors for ADRs remain unclear. Thus, we sought to examine the prevalence of TMP-SMX-related ADRs in patients with SLE and identify specific risk factors for ADR development in these patients. METHODS We retrospectively reviewed data from patients with connective tissue disease (CTD) who were administered TMP-SMX as a PCP prophylactic. The prevalence of ADRs was compared between patients with SLE and those with other CTDs. Univariate and multivariate analyses were conducted to identify risk factors for ADRs in patients with SLE. RESULTS Of the 424 patients with CTD included in our study (SLE, n = 162; other CTDs, n = 262), 22 with SLE (13.6%) developed ADRs, and this rate was significantly higher than that observed in patients with non-SLE CTDs (n = 18 [6.9%], p = 0.033). In patients with SLE, univariate analyses revealed direct associations of ADRs with anti-Sm (p < 0.001), anti-RNP (p = 0.02), and anti-Ro/SS-A antibodies (p = 0.042). Multivariate analysis identified a significant association between anti-Sm antibody levels and the development of ADRs (adjusted odds ratio 5.27, 95% confidence interval 1.80-15.40, p = 0.002). CONCLUSIONS Patients with SLE who are prophylactically administered TMP-SMX are at high risk of ADRs. Among these patients, those who display a positive anti-Sm antibody should be carefully monitored for ADRs.
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Affiliation(s)
- Shinji Izuka
- Division of Rheumatic Diseases, 13805National Center for Global Health and Medicine, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Hiroyuki Yamashita
- Division of Rheumatic Diseases, 13805National Center for Global Health and Medicine, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Yuko Takahashi
- Division of Rheumatic Diseases, 13805National Center for Global Health and Medicine, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Hiroshi Kaneko
- Division of Rheumatic Diseases, 13805National Center for Global Health and Medicine, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
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Rúa-Figueroa Fernández de Larrinoa Í, Carreira PE, Brito García N, Díaz Del Campo Fontecha P, Pego Reigosa JM, Gómez Puerta JA, Ortega-Castro R, Tejera Segura B, Aguado García JM, Torre-Cisneros J, Valencia-Martín JL, Pereda CA, Nishishinya-Aquino MB, Otón Sánchez MT, Silva Fernández L, Maese Manzano J, Chamizo Carmona E, Correyero Plaza M. Recommendations for prevention of infection in systemic autoimmune rheumatic diseases. REUMATOLOGIA CLINICA 2021; 18:S1699-258X(21)00124-8. [PMID: 34176767 DOI: 10.1016/j.reuma.2021.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/08/2021] [Accepted: 04/11/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To develop recommendations for the prevention of infection in adult patients with systemic autoimmune rheumatic diseases (SARD). METHODS Clinical research questions relevant to the objective of the document were identified by a panel of experts selected based on their experience in the field. Systematic reviews of the available evidence were conducted, and evidence was graded according to the Scottish Intercollegiate Guidelines Network criteria. Specific recommendations were made. RESULTS Five questions were selected, referring to prevention of infection by Pneumocystis jirovecii with trimethoprim/sulfamethoxazole, primary and secondary prophylactic measures against hepatitis B virus, vaccination against human papillomavirus, vaccination against Streptococcus pneumoniae and vaccination against influenza virus, making a total of 18 recommendations, structured by question, based on the evidence found for the different SARD and/or expert consensus. CONCLUSIONS There is enough evidence on the safety and efficacy of vaccinations and other prophylactic measures against the microorganisms reviewed in this document to specifically recommend them for patients with SARD.
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Affiliation(s)
| | - Patricia E Carreira
- Servicio de Reumatología, Hospital Universitario 12 de octubre, Madrid, España
| | - Noé Brito García
- Unidad de Investigación, Sociedad Española de Reumatología, Madrid, España.
| | | | - José María Pego Reigosa
- Servicio de Reumatología, Complexo Hospitalario Universitario de Vigo, Grupo IRIDIS-VIGO (Investigation in Rheumatology and Immune-Mediated Diseases), Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, España
| | - José Alfredo Gómez Puerta
- Servicio de Reumatología, Complexo Hospitalario Universitario de Vigo, Grupo IRIDIS-VIGO (Investigation in Rheumatology and Immune-Mediated Diseases), Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, España; Servicio de Reumatología, Hospital Clínic de Barcelona, Barcelona, España
| | - Rafaela Ortega-Castro
- Unidad de Gestión Clínica de Reumatologia, Hospital Universitario Reina Sofía, Universidad de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, España
| | | | - José María Aguado García
- Unidad de Enfermedades Infecciosas, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, España
| | - Julián Torre-Cisneros
- Servicio de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica (IMIBIC), Departamento de Ciencias Médicas y Quirúrgicas, Universidad de Córdoba, Córdoba, España
| | - José L Valencia-Martín
- Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario Ramón y Cajal, Madrid, España
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Oku K, Hamijoyo L, Kasitanon N, Li MT, Navarra S, Morand E, Tanaka Y, Mok CC. Prevention of infective complications in systemic lupus erythematosus: A systematic literature review for the APLAR consensus statements. Int J Rheum Dis 2021; 24:880-895. [PMID: 33999518 DOI: 10.1111/1756-185x.14125] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 04/18/2021] [Indexed: 12/28/2022]
Abstract
Systemic lupus erythematosus (SLE) is a more common autoimmune rheumatic disease in the Asia-Pacific region. The prognosis of SLE remains unsatisfactory in some Asian countries because of delayed diagnosis, limited access to medications, increased complications and issues of tolerability and adherence to treatment. The Asia-Pacific League of Associations for Rheumatology SLE special interest group has recently published a set of consensus recommendations on the management of SLE for specialists, family physicians, specialty nurses, and other healthcare professionals in the Asia-Pacific region. This article reports a systematic literature review of the infective complications of SLE in Asia and evidence for prevention of these infections by pre-emptive antimicrobial therapy and vaccination.
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Affiliation(s)
- Kenji Oku
- Department of Rheumatology, Endocrinology and Nephrology Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Laniyati Hamijoyo
- Rheumatology Division, Department of Internal Medicine, Padjadjaran University, Bandung, Indonesia
| | - Nuntana Kasitanon
- Division of Rheumatology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Meng Tao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
| | - Sandra Navarra
- Section of Rheumatology, University of Santo Tomas Hospital, Manila, Philippines
| | - Eric Morand
- Centre for Inflammatory Diseases, Monash University School of Clinical Sciences, Monash Medical Centre, Melbourne, Vic., Australia
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Chi Chiu Mok
- Division of Rheumatology, Department of Medicine, Tuen Mun Hospital, Hong Kong, Hong Kong
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Is cotrimoxazole prophylaxis against Pneumocystis jirovecii pneumonia needed in patients with systemic autoimmune rheumatic diseases requiring immunosuppressive therapies? Rheumatol Int 2021; 41:1419-1427. [PMID: 33656582 DOI: 10.1007/s00296-021-04808-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Abstract
The incidence of Pneumocystis jirovecii pneumonia (PJP) has increased over recent years in patients with systemic autoimmune rheumatic diseases (SARD). PJP prognosis is poor in those receiving immunosuppressive therapy and glucocorticoids in particular. Despite the effectiveness of cotrimoxazole against PJP, the risk of adverse effects remains significant, and no consensus has emerged regarding the need for PJP prophylaxis in SARD patients undergoing immunosuppressor therapies.Objective: To evaluate the efficacy and safety of cotrimoxazole prophylaxis against PJP in SARD adult patients receiving immunosuppressive therapies. Methods: We performed a systematic review, consulting MEDLINE, EMBASE, and Cochrane Library databases up to April 2020. Outcomes covered prevention of PJP, other infections, morbidity, mortality, and safety. The information obtained was summarized with a narrative review and results were tabulated. Of the 318 identified references, 8 were included. Two were randomized controlled trials and six observational studies. The quality of studies was moderate or low. Despite disparities in the cotrimoxazole prophylaxis regimens described, results were consistent in terms of efficacy, particularly with glucocorticoid doses > 20 mg/day. However, cotrimoxazole 400 mg/80 mg/day, prescribed three times/ week, or 200 mg/40 mg/day or in dose escalation, exhibited similar positive performances. Conversely, cotrimoxazole 400 mg/80 mg/day showed higher incidences of withdrawals and adverse effects. Cotrimoxazole prophylaxis against PJP exhibited efficacy in SARD, mainly in patients taking glucocorticoids ≥ 20 mg/day. All cotrimoxazole regimens exposed seemed equally efficacious, although, higher quality trials are needed. Adverse effects were observed 2 months after initiation, particularly with the 400 mg/80 mg/day regimen. Conversely, escalation dosing or 200 mg/40 mg/day regimens appeared better tolerated.
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Braga BP, Prieto-González S, Hernández-Rodríguez J. Pneumocystis jirovecii pneumonia prophylaxis in immunocompromised patients with systemic autoimmune diseases. Med Clin (Barc) 2019; 152:502-507. [PMID: 30853123 DOI: 10.1016/j.medcli.2019.01.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 02/07/2023]
Abstract
Pneumocystis jirovecii (P. jirovecii) causes a potentially fatal pneumonia in immunocompromised individuals (Pneumocystis pneumonia or PcP), particularly in HIV-infected patients and those treated with immunosuppressive drugs, such as transplant patients and those with systemic autoimmune diseases. P. jirovecii colonization can be found in almost a third of patients with systemic autoimmune diseases. Although the incidence of PcP in such patients is usually low, mortality is quite high, ranging between 30% and 50% in the majority of autoimmune diseases. PcP development is almost always observed in patients not receiving prophylaxis for the infection. Despite the above, there are no clinical guidelines established for PcP prophylaxis in patients with autoimmune diseases treated with glucocorticoids, cytotoxic drugs, or more recently, biological agents. The objective of this review is to analyze the available data on the incidence of PcP and the effect of PcP prophylaxis in patients with autoimmune diseases that may be useful in clinical practice.
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Affiliation(s)
- Beatriz P Braga
- Department of Internal Medicine, Hospital do Divino Espírito Santo de Ponta Delgada, São Miguel, Portugal
| | - Sergio Prieto-González
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - José Hernández-Rodríguez
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.
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Pneumocystis Pneumonia and the Rheumatologist: Which Patients Are At Risk and How Can PCP Be Prevented? Curr Rheumatol Rep 2018; 19:35. [PMID: 28488228 DOI: 10.1007/s11926-017-0664-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Immunosuppressive therapy for connective tissue diseases (CTDs) is steadily becoming more intense. The resultant impairment in cell-mediated immunity has been accompanied by an increasing risk for opportunistic infection (OI). Pneumocystis pneumonia (PCP) has been recognized as an OI in patients with CTDs, but specific risk factors and precise indications for PCP prophylaxis remain poorly defined. This review was undertaken to update information on the risk of PCP in patients with CTDs and to examine current guidelines for PCP prophylaxis in this population. RECENT FINDINGS Data on the occurrence of PCP and indications for prophylaxis in patients with CTDs is sparse. Large systematic reviews did not incorporate patients with CTD secondary to the lack of randomized control trials. Upon reviewing guidelines published since 2015, prophylaxis for PCP is recommended only for patients with ANCA-positive vasculitis, specifically granulomatosis with polyangiitis (GPA), who are undergoing intense induction therapy. Evidence-based recommendations for the prophylaxis of PCP in patients with CTDs cannot be provided. There is expert consensus that PCP prophylaxis is warranted in patients with GPA undergoing induction therapy. Prophylaxis should perhaps also be considered for other CTD patients who are receiving similar intense immunosuppressive therapy especially if they are lymphopenic or have a low CD4 count.
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Teichtahl AJ, Morrisroe K, Ciciriello S, Jennens I, Tadros S, Wicks I. Pneumocystis jirovecci pneumonia in connective tissue diseases: Comparison with other immunocompromised patients. Semin Arthritis Rheum 2015; 45:86-90. [PMID: 25708837 DOI: 10.1016/j.semarthrit.2015.01.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 01/17/2015] [Accepted: 01/23/2015] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Pneumocystis jirovecci pneumonia (PJP) is an opportunistic fungal infection occurring in immunocompromised patients, such as those with human immunodeficiency virus (HIV), organ transplantation, malignancies and connective tissue diseases (CTDs). Risk factors for PJP are not well characterised, leading to uncertainty regarding the indications for antimicrobial prophylaxis and monitoring. This study compared differences between patients with and without CTDs who developed PJP. METHODS Retrospective data was collected for all subjects with a positive toludine blue O stain or a positive P. jirovecci PCR and a concurrent respiratory illness that was clinically consistent with PJP between 2002 and 2013 at the Royal Melbourne Hospital, Australia. Sub-groups were assigned according to the underlying disease. Peripheral blood results were retrieved from an in-house pathology database. RESULTS Eleven of 90 subjects (12.2%) diagnosed with PJP had underlying CTDs. The CTDs group was more likely to have been exposed to corticosteroids (100% versus 35.2%, p < 0.001) and other iatrogenic immunosuppression (90.9% versus 24.6%, p < 0.001). After adjusting for age and gender, the CTDs group had greater lymphopaenia (0.17 versus 0.58 × 10(9)/L; p = 0.034) and were older (69.6 versus 50.6 years; p < 0.001) than the non-CTD group. Excluding renal transplant recipients, people with CTDs also had lower eGFR than the non-CTD group (65 versus 80; p = 0.015). CONCLUSIONS CTDs contributed to a significant proportion of total PJP diagnoses. Clinicians treating CTDs must be vigilant for PJP, particularly in older patients with exposure to corticosteroids or other iatrogenic immunosuppression, lymphopaenia and renal impairment; factors which may lower the clinical threshold for initiating prophylaxis.
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Affiliation(s)
- Andrew J Teichtahl
- Department of Rheumatology, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia; Baker IDI Heart and Diabetes Institute, Melbourne 3004, Victoria, Australia
| | - Kathleen Morrisroe
- Department of Rheumatology, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
| | - Sabina Ciciriello
- Department of Rheumatology, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
| | - Ian Jennens
- Victorian Infectious Diseases Services, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
| | - Susan Tadros
- Department of Rheumatology, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
| | - Ian Wicks
- Department of Rheumatology, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia; Inflammation Division, The Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville 3050, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia
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