Increased Staphylococcus aureus Nasal Carriage Rates in Rheumatoid Arthritis Patients on Biologic Therapy

Published:January 17, 2019DOI:https://doi.org/10.1016/j.arth.2019.01.025

      Abstract

      Background

      Rheumatoid arthritis patients are at increased risk for periprosthetic joint infection after arthroplasty. The reason is multifactorial. Nasal colonization with Staphylococcus aureus is a modifiable risk factor; carriage rates in RA patients are unknown. The goal of this study is to determine the S aureus nasal carriage rates of RA patients on biologics, RA patients on traditional disease-modifying anti-rheumatic drugs (DMARDs), and osteoarthritis.

      Methods

      Consecutive patients with RA on biologics (±DMARDs), RA on non-biologic DMARDs, or OA were prospectively enrolled from April 2017 to May 2018. One hundred twenty-three patients were determined necessary per group to show a difference in carriage rates. Patients underwent a nasal swab and answered questions to identify additional risk factors. S aureus positive swabs were further categorized using spa typing. Logistic regression evaluated the association with S aureus colonization between the groups after controlling for known risk factors.

      Results

      RA patients on biologics, 70% of whom were on DMARDs, had statistically significant increase in S aureus colonization (37%) compared to RA on DMARDs alone (24%), or OA (20%) (P = .01 overall). After controlling for glucocorticoids, antibiotic use, recent hospitalization, and diabetes, RA on biologics had a significant increased risk of S aureus nasal colonization (Odds ratio 1.80, 95% confidence interval 1.00-3.22, P = .047).

      Conclusion

      S aureus colonization risk was increased for RA on biologics compared to RA not on biologics and OA. Nasal S aureus carriage increases the risk of surgical site infection; this modifiable risk factor should be addressed prior to total joint arthroplasty for this higher risk patient group.

      Keywords

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      References

        • Ravi B.
        • Croxford R.
        • Hollands S.
        • Paterson J.M.
        • Bogoch E.
        • Kreder H.
        • et al.
        Increased risk of complications following total joint arthroplasty in patients with rheumatoid arthritis.
        Arthritis Rheumatol. 2014; 66: 254-263
        • Schrama J.C.
        • Espehaug B.
        • Hallan G.
        • Engesaeter L.B.
        • Furnes O.
        • Havelin L.I.
        • et al.
        Risk of revision for infection in primary total hip and knee arthroplasty in patients with rheumatoid arthritis compared with osteoarthritis: a prospective, population-based study on 108,786 hip and knee joint arthroplasties from the Norwegian Arthroplasty Register.
        Arthritis Care Res (Hoboken). 2010; 62: 473-479
        • Liu Z.
        • Norman G.
        • Iheozor-Ejiofor Z.
        • Wong J.K.
        • Crosbie E.J.
        • Wilson P.
        Nasal decontamination for the prevention of surgical site infection in Staphylococcus aureus carriers.
        Cochrane Database Syst Rev. 2017; 5: CD012462
        • Kluytmans J.A.
        • Mouton J.W.
        • Ijzerman E.P.
        • Vandenbroucke-Grauls C.M.
        • Maat A.W.
        • Wagenvoort J.H.
        • et al.
        Nasal carriage of Staphylococcus aureus as a major risk factor for wound infections after cardiac surgery.
        J Infect Dis. 1995; 171: 216-219
        • Gorwitz R.J.
        • Kruszon-Moran D.
        • McAllister S.K.
        • McQuillan G.
        • McDougal L.K.
        • Fosheim G.E.
        • et al.
        Changes in the prevalence of nasal colonization with Staphylococcus aureus in the United States, 2001-2004.
        J Infect Dis. 2008; 197: 1226-1234
        • Bassetti S.
        • Wasmer S.
        • Hasler P.
        • Vogt T.
        • Nogarth D.
        • Frei R.
        • et al.
        Staphylococcus aureus in patients with rheumatoid arthritis under conventional and anti-tumor necrosis factor-alpha treatment.
        J Rheumatol. 2005; 32: 2125-2129
        • Albert G.
        • Ricse M.
        • Narvaez J.
        • Rodriguez-Moreno J.
        • Nolla J.M.
        • Dominguez-Luzon M.
        • et al.
        Prevalence of nasal colonization with Staphylococcus aureus in patients with rheumatoid arthritis.
        Curr Rheumatol Rev. 2018; 14: 78-83
        • Varley C.D.
        • Deodhar A.A.
        • Ehst B.D.
        • Bakke A.
        • Blauvelt A.
        • Vega R.
        • et al.
        Persistence of Staphylococcus aureus colonization among individuals with immune-mediated inflammatory diseases treated with TNF-alpha inhibitor therapy.
        Rheumatology (Oxford). 2014; 53: 332-337
        • Radner H.
        • Neogi T.
        • Smolen J.S.
        • Aletaha D.
        Performance of the 2010 ACR/EULAR classification criteria for rheumatoid arthritis: a systematic literature review.
        Ann Rheum Dis. 2014; 73: 114-123
        • Arnett F.C.
        • Edworthy S.M.
        • Bloch D.A.
        • McShane D.J.
        • Fries J.F.
        • Cooper N.S.
        • et al.
        The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis.
        Arthritis Rheum. 1988; 31: 315-324
        • Herold B.C.
        • Immergluck L.C.
        • Maranan M.C.
        • Lauderdale D.S.
        • Gaskin R.E.
        • Boyle-Vavra S.
        • et al.
        Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing risk.
        JAMA. 1998; 279: 593-598
        • Shopsin B.
        • Gomez M.
        • Montgomery S.O.
        • Smith D.H.
        • Waddington M.
        • Dodge D.E.
        • et al.
        Evaluation of protein A gene polymorphic region DNA sequencing for typing of Staphylococcus aureus strains.
        J Clin Microbiol. 1999; 37: 3556-3563
        • Harmsen D.
        • Claus H.
        • Witte W.
        • Rothganger J.
        • Claus H.
        • Turnwald D.
        • et al.
        Typing of methicillin-resistant Staphylococcus aureus in a university hospital setting by using novel software for spa repeat determination and database management.
        J Clin Microbiol. 2003; 41: 5442-5448
        • Miko B.A.
        • Hafer C.A.
        • Lee C.J.
        • Sullivan S.B.
        • Hackel M.A.
        • Johnson B.M.
        • et al.
        Molecular characterization of methicillin-susceptible Staphylococcus aureus clinical isolates in the United States, 2004 to 2010.
        J Clin Microbiol. 2013; 51: 874-879
        • Doran M.F.
        • Crowson C.S.
        • Pond G.R.
        • O’Fallon W.M.
        • Gabriel S.E.
        Frequency of infection in patients with rheumatoid arthritis compared with controls: a population-based study.
        Arthritis Rheum. 2002; 46: 2287-2293
        • von Eiff C.
        • Becker K.
        • Machka K.
        • Stammer H.
        • Peters G.
        Nasal carriage as a source of Staphylococcus aureus bacteremia. Study group.
        N Engl J Med. 2001; 344: 11-16
        • van Rijen M.
        • Bonten M.
        • Wenzel R.
        • Kluytmans J.
        Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers.
        Cochrane Database Syst Rev. 2008; : CD006216
        • Galloway J.B.
        • Mercer L.K.
        • Moseley A.
        • Dixon W.G.
        • Ustianowski A.P.
        • Helbert M.
        • et al.
        Risk of skin and soft tissue infections (including shingles) in patients exposed to anti-tumour necrosis factor therapy: results from the British Society for Rheumatology Biologics Register.
        Ann Rheum Dis. 2013; 72: 229-234
        • Galloway J.B.
        • Hyrich K.L.
        • Mercer L.K.
        • Dixon W.G.
        • Ustianowski A.P.
        • Helbert M.
        • et al.
        Risk of septic arthritis in patients with rheumatoid arthritis and the effect of anti-TNF therapy: results from the British Society for Rheumatology Biologics Register.
        Ann Rheum Dis. 2011; 70: 1810-1814
        • Singh J.A.
        • Cameron C.
        • Noorbaloochi S.
        • Cullis T.
        • Tucker M.
        • Christensen R.
        • et al.
        Risk of serious infection in biological treatment of patients with rheumatoid arthritis: a systematic review and meta-analysis.
        Lancet. 2015; 386: 258-265
        • Goodman S.M.
        • Bykerk V.P.
        • DiCarlo E.
        • Cummings R.W.
        • Donlin L.T.
        • Orange D.E.
        • et al.
        Flares in patients with rheumatoid arthritis after total hip and total knee arthroplasty: rates, characteristics, and risk factors.
        J Rheumatol. 2018; 45: 604-611
        • George M.D.
        • Baker J.F.
        • Hsu J.Y.
        • Wu Q.
        • Xie F.
        • Chen L.
        • et al.
        Perioperative timing of infliximab and the risk of serious infection after elective hip and knee arthroplasty.
        Arthritis Care Res (Hoboken). 2017; 69: 1845-1854
        • Johnson B.K.
        • Goodman S.M.
        • Alexiades M.M.
        • Figgie M.P.
        • Demmer R.T.
        • Mandl L.A.
        Patterns and associated risk of perioperative use of anti-tumor necrosis factor in patients with rheumatoid arthritis undergoing total knee replacement.
        J Rheumatol. 2013; 40: 617-623
        • Goodman S.M.
        • Menon I.
        • Christos P.J.
        • Smethurst R.
        • Bykerk V.P.
        Management of perioperative tumour necrosis factor alpha inhibitors in rheumatoid arthritis patients undergoing arthroplasty: a systematic review and meta-analysis.
        Rheumatology (Oxford). 2016; 55: 573-582
        • Au K.
        • Reed G.
        • Curtis J.R.
        • Kremer J.M.
        • Greenberg J.D.
        • Strand V.
        • et al.
        High disease activity is associated with an increased risk of infection in patients with rheumatoid arthritis.
        Ann Rheum Dis. 2011; 70: 785-791
        • Antri K.
        • Akkou M.
        • Bouchiat C.
        • Bes M.
        • Martins-Simoes P.
        • Dauwalder O.
        • et al.
        High levels of Staphylococcus aureus and MRSA carriage in healthy population of Algiers revealed by additional enrichment and multisite screening.
        Eur J Clin Microbiol Infect Dis. 2018; 37: 1521-1529
        • Brown J.
        • Li C.S.
        • Giordani M.
        • Shahlaie K.
        • Klineberg E.O.
        • Tripet-Diel J.R.
        • et al.
        Swabbing surgical sites does not improve the detection of Staphylococcus aureus carriage in high-risk surgical patients.
        Surg Infect (Larchmt). 2015; 16: 523-525
        • Young B.C.
        • Votintseva A.A.
        • Foster D.
        • Godwin H.
        • Miller R.R.
        • Anson L.W.
        • et al.
        Multi-site and nasal swabbing for carriage of Staphylococcus aureus: what does a single nose swab predict?.
        J Hosp Infect. 2017; 96: 232-237
        • Williams D.M.
        • Miller A.O.
        • Henry M.W.
        • Westrich G.H.
        • Ghomrawi H.M.K.
        Cost-effectiveness of Staphylococcus aureus decolonization strategies in high-risk total joint arthroplasty patients.
        J Arthroplasty. 2017; 32: S91-S96