All Title Author
Keywords Abstract

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

DOI: 10.1155/2012/369565

Full-Text   Cite this paper   Add to My Lib


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


[1]  J. F. Marques Neto, E. T. Gon?alves, L. Langen, et al., “Estudo multicêntrico da prevalência da artrite reumatóide do adulto em amostras da popula??o brasileira,” Revista Brasileira de Reumatologia, vol. 33, no. 5, pp. 169–173, 2002.
[2]  D. A. Pappas and J. T. Giles, “Do antitumor necrosis factor agents increase the risk of postoperative orthopedic infections?” Current Opinion in Rheumatology, vol. 20, no. 4, pp. 450–456, 2008.
[3]  “Registro Brasileiro de Monitoriza??o de Terapias Biológicas em Doen?as Reumáticas BIOBADABRASIL. Biobadamerica,”
[4]  J. R. Curtis, A. Jain, J. Askling et al., “A comparison of patient characteristics and outcomes in selected european and U.S. rheumatoid arthritis registries,” Seminars in Arthritis and Rheumatism, vol. 40, no. 1, pp. 2–14.e1, 2010.
[5]  A. E. Thompson, S. W. Rieder, and J. E. Pope, “TNF therapy and the risk of serious infection and malignancy in patients with early rheumatoid arthritis: a meta-analysis of randomized controlled trials,” Arthritis and Rheumatism, vol. 63, no. 6, pp. 1479–1485, 2011.
[6]  J. P. Leombruno, T. R. Einarson, and E. C. Keystone, “The safety of anti-tumour necrosis factor treatments in rheumatoid arthritis: meta and exposure-adjusted pooled analyses of serious adverse events,” Annals of the Rheumatic Diseases, vol. 68, no. 7, pp. 1136–1145, 2009.
[7]  D. M. Grennan, J. Gray, J. Loudon, and S. Fear, “Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery,” Annals of the Rheumatic Diseases, vol. 60, no. 3, pp. 214–217, 2001.
[8]  K. G. Saag, G. G. Teng, N. M. Patkar et al., “American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis,” Arthritis & Rheumatism, vol. 59, no. 6, pp. 762–784, 2008.
[9]  J. Ledingham and C. Deighton, “Update on the British Society for Rheumatology guidelines for prescribing TNF-α blockers in adults with rheumatoid arthritis (update of previous guidelines of April 2001),” Rheumatology, vol. 44, no. 2, pp. 157–163, 2005.
[10]  R. Koike, T. Takeuchi, K. Eguchi, and N. Miyasaka, “Update on the Japanese guidelines for the use of infliximab and etanercept in rheumatoid arthritis,” Modern Rheumatology, vol. 17, no. 6, pp. 451–458, 2007.
[11]  E. J?msen, H. Huhtala, T. Puolakka, and T. Moilanen, “Risk factors for infection after knee arthroplasty. A register-based analysis of 43,149 cases,” Journal of Bone and Joint Surgery, vol. 91, no. 1, pp. 38–47, 2009.
[12]  K. L. Ong, S. M. Kurtz, E. Lau, K. J. Bozic, D. J. Berry, and J. Parvizi, “Prosthetic joint infection risk after total hip arthroplasty in the medicare population,” Journal of Arthroplasty, vol. 24, no. 6, pp. 105–109, 2009.
[13]  S. Ridgeway, J. Wilson, A. Charlet, G. Katafos, A. Pearson, and R. Coello, “Infection of the surgical site after arthroplasty of the hip,” Journal of Bone and Joint Surgery, vol. 87, no. 6, pp. 844–850, 2005.
[14]  K. Saleh, M. Olson, S. Resig et al., “Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program,” Journal of Orthopaedic Research, vol. 20, no. 3, pp. 506–515, 2002.
[15]  D. M. Urquhart, F. S. Hanna, S. L. Brennan et al., “Incidence and risk factors for deep surgical site infection after primary total hip arthroplasty: a systematic review,” Journal of Arthroplasty, vol. 25, no. 8, pp. 1216–1222, 2010.
[16]  Defini??o dos critérios nacionais de infec??es relacionadas à assistência à saúde: preven??o de infec??es do sítio cirúrgico (ISC). Agência Nacional de Vigilancia Sanitária
[17]  F. C. Arnett, S. M. Edworthy, D. A. Bloch et al., “The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis,” Arthritis and Rheumatism, vol. 31, no. 3, pp. 315–324, 1988.
[18]  G. A. Wells, B. Shea, D. O'Connell, et al., The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-analyses, Ottawa Hospital Research Institute, Ottawa, Canada, 2010.
[19]  A. A. den Broeder, M. C. Creemers, J. Fransen et al., “Risk factors for surgical site infections and other complications in elective surgery in patients with rheumatoid arthritis with special attention for anti-tumor necrosis factor: a large retrospective study,” Journal of Rheumatology, vol. 34, no. 4, pp. 689–695, 2007.
[20]  K. Kawakami, K. Ikari, K. Kawamura, et al., “Complications and features after joint surgery in rheumatoid arthritis patients treated with tumour necrosis factor-α blockers: perioperative interruption of tumour necrosis factor-α blockers decreases complications?” Rheumatology, vol. 49, no. 2, pp. 341–347, 2010.
[21]  S. Momohara, K. Kawakami, T. Iwamoto et al., “Prosthetic joint infection after total hip or knee arthroplasty in rheumatoid arthritis patients treated with nonbiologic and biologic disease-modifying antirheumatic drugs,” Modern Rheumatology, vol. 21, no. 5, pp. 469–475, 2011.


comments powered by Disqus

Contact Us


微信:OALib Journal