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In-ICU-acquired infections in flare-up systemic rheumatic disease patients receiving immunosuppressant

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Abstract

Objectives

Systemic rheumatic diseases (SRDs) are a group of inflammatory disorders that can need intensive care unit (ICU) admission during a flare-up, requiring administration of immunosuppressants. We undertook this study to determine the frequency, outcome, and occurrence associated factors of infections in flare-up SRD patients receiving immunosuppressant.

Methods

Monocenter, a retrospective study including SRD patients admitted to ICU for a flare-up requiring immunosuppressant from 2004 to 2019. The primary endpoint was in-ICU-acquired infections.

Results

Ninety-eight patients (female/male ratio: 1.6; mean age at admission: 39.5 ± 17.4 years) were admitted to the ICU for a SRD flare-up, inaugural in 61.2% cases. A specific treatment was given to every patient: corticosteroids 100%, cyclophosphamide 45.9%, plasma exchange 46.9%. Ninety-five infections occurred in 35 (36%) patients mainly pneumonias. The overall in-hospital mortality was 17.3%, and 46% of patients with a nosocomial infection died during their ICU stay. The logistic regression multivariable model retained renal replacement therapy and mechanical ventilation as independent predictors of infection.

Conclusion

In-ICU-acquired infection in SRD flare-up is a frequent event associated with organ failures but not with in-ICU use of immunosuppressants. These data suggest that the fear of infection should not withhold a careful in-ICU use of immunosuppressive drugs.

Key Points

• In-ICU infections are frequent in flare-up systemic rheumatic disease patients.

• Infections are associated with increased mortality.

• Cyclophosphamide given in ICU was not independently associated with infection.

• Severe neutropenia occurred in 27% of patients receiving cyclophosphamide in ICU.

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Data availability

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Abbreviations

CI:

Confidence interval

ECMO:

Extracorporeal membrane oxygenation

ELSO:

Extracorporeal Life Support Organization

ICU:

Intensive care unit

IDSA:

Infection Disease Society of America

IQR:

25th–75th percentile interquartile range

OR:

Odd ratio

SAPS:

Simplified Acute Physiology Score

SOFA:

Sequential Organ-Failure Assessment

SRDs:

Systemic Rheumatic Diseases

VA-ECMO:

Venoarterial ECMO

VV-ECMO:

Venovenous ECMO

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Authors and Affiliations

  1. Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié–Salpêtrière, Institut E3M, 47–83, boulevard de l’Hôpital, 75651, Paris Cedex, France

    Florence Assan, Alexis Mathian, Paul Quentric, Quentin Moyon, Fleur Cohen-Aubart, Julien Haroche, Zahir Amoura & Marc Pineton de Chambrun

  2. Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié–Salpêtrière, Institut de Cardiologie, Paris, France

    Pierre Bay, Guillaume Hekimian, Nicolas Bréchot, Quentin Moyon, Matthieu Schmidt, Charles-Edouard Luyt, Alain Combes & Marc Pineton de Chambrun

  3. Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Inserm, Paris, France

    Paul Quentric & Marc Pineton de Chambrun

  4. INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, F-75013, Paris, France

    Matthieu Schmidt, Charles-Edouard Luyt, Alain Combes & Marc Pineton de Chambrun

Authors
  1. Florence Assan
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  2. Pierre Bay
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  3. Alexis Mathian
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  9. Fleur Cohen-Aubart
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Contributions

- F. A., P. B., M. Pd. C. contributed to study design, data collection, statistical analysis conduction and interpretation, manuscript writing, and final approval.

- A. M., C. E. L., Z. A., A. C. contributed to study design, statistical analysis interpretation, manuscript writing, and final approval.

- All other authors contributed to the data collection.

- M. Pd. C. is the guarantor of this study.

Corresponding author

Correspondence to Marc Pineton de Chambrun.

Ethics declarations

Ethics approval and consent to participate

The database is registered with the “Commission Nationale de l’Informatique et des Libertés” (2217847v0). In accordance with the ethical standards of our hospital’s institutional review board, the Committee for the Protection of Human Subjects, and French law, written informed consent was not needed for demographic, physiological, and hospital-outcome data analyses because this observational study did not modify existing diagnostic or therapeutic strategies; however, patients were informed of their inclusion in the study.

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Not applicable.

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None.

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Supplementary information

ESM 1.

Box-Plot results of neutrophil, lymphocyte, platelet counts and hemoglobin level on induction-day and the lowest in-ICU value after induction with comparison according cyclophosphamide administration. (PDF 431 kb)

ESM 2.

Kaplan-Meier estimated probability of infection-free survival after in-IC immunosuppressive treatments administration in the 98 systemic rheumatic disease patients’ with comparison according the number of organ failure treatments on induction-day. Legend: Organ failure treatments: mechanical ventilation, inotropes or vasopressive drugs, renal replacement therapy, ECMO (venovenous or venoarterial). Group 1: no organ failure treatment. Group 2: one or two organ failure treatments. Group 3: three or four organ failure treatments. (PDF 283 kb)

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Assan, F., Bay, P., Mathian, A. et al. In-ICU-acquired infections in flare-up systemic rheumatic disease patients receiving immunosuppressant. Clin Rheumatol 41, 2845–2854 (2022). https://doi.org/10.1007/s10067-022-06197-w

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  • DOI: https://doi.org/10.1007/s10067-022-06197-w

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