Prosthetic joint infection after total hip or knee arthroplasty in rheumatoid arthritis patients treated with nonbiologic and biologic disease-modifying antirheumatic drugs

Abstract

The aim of this study was to identify risk factors for acute surgical-site infection (SSI) after total joint arthroplasty in rheumatoid arthritis (RA) patients treated with nonbiologic and biologic disease-modifying antirheumatic drugs (DMARDs). We performed a retrospective study of all consecutive total hip (THA) and total knee (TKA) arthroplasties performed during a 5-year period (THA 81; TKA 339). Multivariate logistic regression analysis was performed to identify SSI risk factors. Of the patients undergoing THA or TKA, 24 cases (5.7%) developed a superficial incisional SSI requiring the use of antibiotics and three cases (0.7%) developed an organ/space SSI necessitating surgical treatment to remove the artificial joint prosthesis. Multivariate logistic regression analysis revealed that the use of biologic DMARDs [P = 0.0007, odds ratio (OR) = 5.69; 95% confidence interval (CI) 2.07-15.61] and longer RA duration (P = 0.0003, OR = 1.09; 95% CI 1.04-1.14) were the only significant risk factors for acute SSI. Furthermore, an analysis that individually evaluated major agents (n > 10) adjusted for disease duration indicated that tumor necrosis factor alpha blockers increased the risk of SSI (infliximab P = 0.001, OR = 9.80, 95% CI 2.41-39.82; etanercept P = 0.0003, OR = 9.16, 95% CI 2.77-30.25). We found that the use of infliximab or etanercept and longer disease duration were associated with an increased risk of acute SSI in RA patients. Prospective studies are thus needed to determine the safety of biologic DMARDs in the perioperative period.

Moderating effects of immunosuppressive medications and risk factors for post-operative joint infection following total joint arthroplasty in patients with rheumatoid arthritis or osteoarthritis

“…[19, 20] Our study conflicts with prior research reporting that patients taking biologic DMARDs within 2 to 4 weeks of surgery were 5.7 times more likely to develop an infection. [20] Of interest, persons in the this same study who had increased RA disease duration were also more likely to develop an infection. [20] We found there was not a significant different between cases and control on the use of TNF-α inhibitors as a class, and this was bolstered with the case-control comparison of percentage using adalimumab specifically.…”

“…These findings support prior studies suggesting there is not an increased infection risk when using immunosuppressive medications (DMARDs) prior to surgery. [19, 20] Our study conflicts with prior research reporting that patients taking biologic DMARDs within 2 to 4 weeks of surgery were 5.7 times more likely to develop an infection. [20] Of interest, persons in the this same study who had increased RA disease duration were also more likely to develop an infection.…”

“…Prior research on this topic is largely based on studies of rheumatoid arthritis (RA) patients. [8,19,20] Research suggests use of traditional disease modifying antirheumatic drugs (DMARDs), a nonbiologic class of immunosuppressive medications used to treat RA, prior to surgery does not increase infection risk. [20] In contrast, steroid use has been found to increase risks of infection and hospital readmission.…”

“…[8,19,20] Research suggests use of traditional disease modifying antirheumatic drugs (DMARDs), a nonbiologic class of immunosuppressive medications used to treat RA, prior to surgery does not increase infection risk. [20] In contrast, steroid use has been found to increase risks of infection and hospital readmission. [19,21] There are conflicting findings on TNF inhibitor use (biologic medications used to treat RA) and infection risk.…”

“…[19,21] There are conflicting findings on TNF inhibitor use (biologic medications used to treat RA) and infection risk. [20-26]…”