Background:Infection remains a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE) and lupus nephritis (LN) treated with systemic immunosuppression (IS).Objectives:We sought to describe the infection profile in patients with LN treated with aggressive immunosuppression (induction and maintenance therapy) and to identify the associated risk factors.Methods:Patients with LN followed in the Nephrology Department of Fundeni Clinical Institute, were retrospectively reviewed for any infection that occurred from initiation of induction therapy. Infections were graded (1-5) according to the Common Terminology Criteria for Adverse Events. Infection site and type of microorganism were also recorded. Univariate and multivariate Cox proportional hazard regression analysis were performed in order to identify independent risk factors for infection.Results:The study cohort comprised 101 patients (86.1% females) with a mean age of 34 ± 14 years. Forty-eight patients (47.5%) had at least one infection with a total 92 episodes of infection occurring during a median follow-up of 17 months (IQR:8.5-52.5 months). The majority of patients (31 of 48) had infections during the first 12 months since IS treatment initiation. The most common site was lung infection (in 24.8% of patients), followed by urinary tract (20.8% of patients) and cutaneous/mucosal infections (11% of patients). Thirty-eight percent of patients had bacterial infections. Nineteen percent of patients had severe infections (grade 3 or higher) with 3.3% of infection-related deaths (3 patients). The most common induction regimen was cyclophosphamide in addition to corticosteroids (48.5%), with 44.6% of patients receiving pulse methylprednisolone and 45.5% of patients receiving more than 30 mg/d of prednisone as the maximum oral dose. In univariate Cox regression analysis, female gender (HR 3.34; 95% CI, 1.03-10.8, p=0.04), pulse methylprednisolone (HR 2.9; 95% CI, 1.6-5.24, p=0.001), high-dose (≥30 mg/day) oral corticosteroids (HR 4.22; 95% CI, 2.21-8.02,p=0.001) and SLEDAI score (HR 1.047; 95% CI, 1.012-1.084, p=0.008) were risk factors for infection. In multivariate Cox regression analysis, female gender (HR 6.35; 95%CI, 1.86-21.64,p=0.003), high-dose oral corticosteroids (HR 4.7; 95% CI, 2.25-9.87, p=0.003) and SLEDAI score (HR 1.046; 95% CI, 1.003-1.09, p=0.034) remained independent predictors of infection risk. Of the risk factors associated with severe infections (grade 3 or higher), in univariate analysis we identified younger age (HR 0.96, 95%CI, 0.92-0.99, p=0.035), neurological involvement (HR 2.59; 95%, 0.86-7.83, p=0.09), pulse methylprednisolone (HR 5.42; 95% CI, 1.79-16.35, p=0.003) and high-dose oral corticosteroids (HR 8.32; 95% CI, 2.4-28.77, p=0.001) as risk factors for infection. After multivariate adjustment, neurological involvement (HR 4.33; 95%, 1.29-14.51, p=0.01) and high-dose oral corticosteroids (HR 7.6; 95% CI, 1.6-35.39, p=0.01) were identified as independent predictors of infection risk.Conclusion:A high-dose oral corticosteroid regimen increased the risk for any infection and for severe infections by 4.7-fold and 7.6-fold, respectively. In addition, female gender and a higher SLEDAI score were identified as risk factors for any infection, while neurological involvement was associated with an increased risk for severe infections.References:[1]Jung JY, Yoon D, Choi Y, Kim HA, Suh CH. Associated clinical factors for serious infections in patients with systemic lupus erythematosus. Sci Rep. 2019;9(1):9704.Disclosure of Interests: :None declared
Integrating high dose inhaled corticosteroids into oral corticosteroids stewardship
