2022 EULAR Recommendations for Prophylaxis of Infections in Patients With Rheumatic Diseases

The European Alliance of Associations for Rheumatology (EULAR) recently developed recommendations for the screening and prophylaxis of chronic and opportunistic infections in patients with autoimmune inflammatory rheumatic diseases (AIIRD). The full recommendation were published in the Annals of the Rheumatic Diseases.

Patients with AIIRD are more susceptible to opportunistic and chronic infections, especially when receiving immunosuppressive or immunomodulatory agents. Currently, there are no unified guidelines for screening and prophylaxis of various infections, AIIRD, treatments, and other factors, such as age and comorbidities.

Therefore, the EULAR established a taskforce to develop recommendations to inform rheumatologists and health care providers in clinical practice for patients with AIIRD.

Following EULAR standard operating procedures, a steering group identified relevant research questions and performed a scoping review. The taskforce, which included 22 people, reviewed the information collected, refined the research questions, and selected the pathogens to include in a subsequent systematic literature review. A second virtual taskforce meeting was held to formulate overarching principles and recommendations based on the literature review and expert opinion. A 3-round process of voting and rewording was used to finalize the overarching principles and recommendations.

Consensus was defined as at least 75% in round 1, at least 67% in round 2, and 50% in round 3. Level of evidence and grade of recommendation were added to each statement after the meeting. An anonymous online survey of the taskforce was used to obtain level of agreement, which ranged from 0 (no agreement) to 10 (full agreement).

Overarching Principles

1. Shared decision-making: The risk for infections should be discussed with patients before and periodically during treatment with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), biologic DMARDs (bDMARDs), targeted synthetic DMARDs (tsDMARDs), immunosuppressants, and glucocorticoids. Health care providers should educate patients so they know how to identify infections early and when to seek prompt medical care.
2. Multidisciplinary care: Rheumatologists, who lead the care of patients with AIIRDs, should collaborate with other specialists to prevent and manage chronic and opportunistic infections in patients receiving antirheumatic drugs. Consulting with infectious disease specialists, pulmonologists, hepatologists, and gastroenterologists may be important because tuberculosis (TB) and hepatitis are common in patients with AIIRD.
3. Individualized approach: Providers should consider individual factors, such as age, comorbidities, medications, travel, and smoking, in the decision for screening and prophylaxis of chronic and opportunistic infections.
4. National/regional differences: Guidance for screening and prophylaxis varies across countries and regions based on the prevalence of pathogens and availability of treatments. Health care providers should consider national and regional recommendations when caring for patients with AIIRD.

Points to Consider

1. Screening for TB is recommended for patients before starting bDMARDs and tsDMARDS. Clinicians must consider TB screening before starting csDMARDs, immunosuppressants, and glucocorticoids (according to dose and duration), especially for patients with TB risk factors, such as alcohol abuse, smoking, and living with someone with TB.
2. Screening for latent TB should follow national or international guidelines and should generally include a chest x-ray and interferon-gamma release assay (IGRA) vs a tuberculin skin test, when possible. Clinicians must consider periodic rescreening if risk factors exist or develop over time.
3. National and international guidelines for TB treatment vary widely and should guide choice and timing of therapy. When selecting treatments, potential interactions between drugs used to treat AIIRD and TB must be accounted for.
4. All patients must be screened for hepatitis B virus (HBV) prior to treatment with csDMARDs, bDMARDs, tsDMARDs, immunosuppressants, and glucocorticoids (according to dose and duration). Patients who carry HBV or have resolved HBV may be at risk for HBV reactivation and should be referred to a hepatologist for possible prophylaxis.
5. Patients may be screened for hepatitis C virus (HCV) prior to starting csDMARDs, bDMARDs, tsDMARDs, immunosuppressants, and glucocorticoids (according to dose and duration). Depending on cost-effectiveness and geographical variations, HCV is recommended for patients with HCV risk factors or abnormal liver function tests, such as alanine aminotransferase.
6. HIV screening is recommended prior to bDMARD treatment and should be considered before csDMARDs, tsDMARDs, immunosuppressants, and glucocorticoids (according to dose and duration).
7. Patients who are not immune to varicella zoster virus (VZV), as determined by a detailed medical history, should be informed about the importance of postexposure prophylaxis following contact with VZV.
8. Consider prophylaxis against Pneumocystis jirovecii pneumonia (PCP) in patients receiving high-dose glucocorticoids, especially when combined with immunosuppressants.

Based on knowledge gaps identified during the collection of evidence and development of recommendations, the taskforce developed areas where additional research is needed. The research agenda includes general questions about chronic and opportunistic and infections as well as pathogen-specific questions.

The taskforce concluded, “This is the first set of EULAR recommendations addressing the need for guidance about screening and prophylaxis in people living with AIIRD. Variations relating to treatment, geographical and other differences were taken into account. We believe that these recommendations will be a useful aid for decision making for people living in many countries and working in different healthcare systems.”