Update on Perioperative Infections

Up to 58% of RA patients will undergo some sort of orthopedic procedure in their lifetime (J Rheum 2002). RA patients undergoing orthopedic procedures are at an increased risk of complications and infections.

Many RA patients are taking DMARDs or biologics (75-84%) and corticosteroids (80%). However, the perioperative use of DMARDs and biologics is very inconsistent. Furthermore, perioperative recommendations on medication use vary among organizations. The challenge is balancing the risk of perioperative disease flare and infection risk.

We know little about perioperative flare including the rate of flare and the impact of flare on arthroplasty outcomes, physical therapy, or RA disease status. We do, however, have an enormous amount of data about prosthetic joint infections with current rates of 2.5% for knees and 2% for hips. Studies have shown a clear increased risk of prosthetic joint infections in patients with RA. This is further supported by studies reporting high readmission rates for RA patients within 90 days - 10% due to joint infection and 10% due to sepsis.

Here's the update on perioperative use of various medications in RA patients:

Corticosteroids: Have a very strong association with infection. In the perioperative period there are no differences in hemodynamics with "stress-dose" steroids. Given this, the best approach is to limit perioperative steroid doses, i.e., give the lowest dose on the day of surgery.
Methotrexate: Appears safe and not associated with an increased risk of infection or wound complications.
Leflunomide: Has contradicting reports. One study showed and increased risk whereas no difference was shown in another study.
HCQ: Retrospective studies suggest it is safe with no increase in infections or other complications.
Anti-TNF agents: There are no randomized trials available. A systematic review of 8 observational studies and 3 case control studies compared 2681 RA patients with a recent TNFi exposure against 4310 RA patients with no exposure to TNFi at time of surgery (Poster #2369). Patients exposed to TNFi had an odds ratio of 2.47 for surgical site infections. The authors concluded that: (a) anti-TNF agents increase the risk of perioperative infection, (b) the time to discontinue and re-start TNFi is not clear, (c) the role of disease severity cannot be excluded, and (d) the role of other disease factors must be taken into consideration.
Tocilizumab, Rituximab, and Abatacept: All have limited experience.
Tofacitinib: There is currently no data available.