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Risk of Orthopedic Surgical Site Infections in Patients with Rheumatoid Arthritis Treated with Antitumor Necrosis Factor Alfa Therapy

DOI: 10.1155/2012/369565

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Abstract:

Introduction. International guidelines recommend interruption of anti-TNF medications in the perioperative period, but there are no randomized trials to support such recommendation. Objectives. To study literature evidence assessing the risk of surgical site infections in orthopedic surgery patients with RA using anti-TNF drugs, compared to untreated patients or those using conventional DMARD. Methods. Systematic review of cohort studies is concerning surgical site infections in orthopedic procedures in patients with RA. Results. Three studies were selected. Only one was considered of high-quality, albeit with low statistical power. The review resulted in inconclusive data, since the best quality study showed no significant differences between groups, while others showed increased risk of infections in patients using anti-TNF medications. Conclusion. It is unclear whether patients with RA using anti-TNF medications are at increased risk of surgical site infections. Randomized controlled trials or new high quality observational studies are needed to clarify the issue. 1. Introduction Rheumatoid arthritis (RA) affects between 0.2 and 1% of brazilian population [1]. Twenty-five percent of RA patients undergo some surgery for the treatment of orthopedic sequelae after 22 years of followup [2]. Currently, most patients with RA are in use of conventional modifying disease activity drugs (DMARD), and some of them are on antagonists of tumor necrosis factor (anti-TNF) medications [3, 4]. Anti-TNF drugs have been used to treat patients with RA who do not get to remission with one or more conventional DMARD. Systematic reviews have shown no increased risk of bacterial infections after treatment with such drugs [5, 6]. There is no consensus in the literature on the use of immunosuppressive drugs in the perioperative period in orthopedic surgery since there are few studies on the topic. A randomized clinical trial showed no increased perioperative infections in patients on methotrexate [7]. There are no clinical trials assessing treatment with anti-TNF medications in this context so far. The guidelines of the American College of Rheumatology (ACR), British Society of Rheumatology, and Japan College of Rheumatology recommend the suspension of anti-TNF medications in the perioperative period [8–10], but this might lead to worsening of disease activity, which could affect the postoperative rehabilitation. In observational studies of patients undergoing hip and knee arthroplasties, several independent risk factors for surgical site infection were found, including RA

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