Timing of Infliximab Infusion Prior to Surgery and Post-Operative Infections

surgeon reaching for tools on operating table
surgeon reaching for tools on operating table
Withholding TNF inhibitors before surgery has been recommended due to concern for post-operative infection.

Among patients with rheumatoid arthritis (RA) treated with infliximab, there is no association between the timing of the  tumor necrosis factor inhibitor (TNFI) infusion prior to surgery and the risk for post-operative infections or mortality, according to study results published in Rheumatology.

TNFI are very effective medications against RA and several other immune-mediated conditions. However, the risk for serious infections is a major concern. There are recommendations from professional societies to withhold TNFI prior to surgical interventions, but with considerable variations.

The aim of the current study was to investigate the risk for infections and mortality after coronary artery bypass grafting (CABG) surgery, aortic or lower extremity major surgery, in patients treated with infliximab, according to the timing of the infusion relative to surgery.

The retrospective cohort study included patients with RA from the US Medicare claims data from 2007 to 2015, who underwent CABG, aortic or vascular surgery, or bowel resection, and who were treated with infliximab in the 90 days prior to surgery. Researchers examined the occurrence of various infections (pneumonia, urinary tract infections, surgical site infections, and sepsis) in the 30 days after surgery.

The study included 712 (mean age 72.4 years, 50.8% women) patients who underwent CABG, 244 (mean age 74.2 years, 67.6% women) patients after vascular surgery, and 862 (mean age 74.0 years, 79.8% women) patients after bowel resection. The median time from infliximab infusion to surgery was 36 or 37 days in each cohort.

Among patients with CABG, urinary tract infection was the most common post-operative infection (97 patients, 13.6%), followed by pneumonia (74 patients, 10.4%). Among those after vascular surgery or bowel resection, the most common post-operative infection was surgical site infection (25 patients, 10.2%; and 163 patients, 18.9%, respectively). Mortality was highest among patients after bowel resection (86 patients, 9.9%), followed by vascular surgery (17 patients, 6.9%) and CABG (25 patients, 3.5%).

There was no association between the timing of infliximab infusion prior to surgery and the risk for post-operative infections or mortality. There was no subgroup among which infliximab infusion close to surgery was associated with increased risk for infection or mortality.

The study had several limitations, including only examining infliximab in patients with RA, no data on other outcomes, and using data from claims data rather than medical record data.

“Risks of post-operative infections were not higher among patients who received infliximab close to surgery compared with those who received infliximab remotely, suggesting that withholding infliximab prior to major surgery may not reduce infection risks,” concluded the researchers.


Ward MM, Dasgupta A. Pre-operative withholding of infliximab and the risk of infections after major surgery in patients with rheumatoid arthritis. Rheumatology (Oxford). Published online Jul 25, 2020. doi:10.1093/rheumatology/keaa291