Anti-Tumour Necrosis Factor Therapy for Inflammatory Bowel Diseases Do Not Impact Serious Infections after Arthroplasty

Abstract

Background and Aims:There is a paucity of data on the safety of joint replacement surgery in patients with inflammatory bowel disease [IBD], including those on tumour necrosis factor-alpha inhibitors [anti-TNF]. We explored the risk of serious infections in this population. Methods: A retrospective case-control study [2006][2007][2008][2009][2010][2011][2012][2013][2014] was performed using the MarketScan Database. All patients aged 18-64 years with an International Classification of Diseases code for IBD and an IBD-specific medication, with ≥ 6 months of enrollment prior to hip, knee or shoulder replacement surgery, were included. Ten non-IBD controls were frequency-matched to each case on length of enrollment, year and the joint replaced. Primary outcome was serious infection [composite of joint infection, surgical site infection, pneumonia, sepsis] within 90 days of the operation. Cox proportional hazards models were used to assess the association of IBD and IBD medications with serious infection. Results: More patients with IBD [N = 1455] had serious infections than controls [3.2% vs 2.3%, p = 0.04], but not after controlling for comorbidities (hazard ratio [HR], 1.3; 95% confidence interval [CI], 0.95-1.76). Among IBD patients, corticosteroids were associated with increased risk of serious infection [HR, 4.6; 95% CI,; p < 0.01] while anti-TNFs were not. Opioids were also associated with increased risk of infection [HR, 1.5; 95% CI, 1.2-1.8; p < 0.01]. Conclusions: After controlling for comorbidities, IBD patients were not at increased risk of serious infection following joint replacement. Corticosteroids, but not anti-TNFs or immunomodulators, were associated with increased risk of serious infections in IBD patients.

Controversies in Perioperative Antimicrobial Prophylaxis

“…44 It is likely that ongoing treatment of inflammatory bowel disease with anti-tumor necrosis factor agents does not increase the frequency of surgical site infection after abdominal or large joint surgery. 45,46 However, one large study did demonstrate a 50% increase in organ space infections and anastomotic leaks in immunosuppressed Crohn's disease patients after elective colectomy. 47 In this study the immunosuppressive regimen included corticosteroids, which confounds the result.…”

Inflammatory Bowel Diseases Increase the Risk of Periprosthetic Joint Infection

“…Some patients may have received immunosuppressive treatment during or close to this perioperative window. A recent study exonerated the administration of immunomodulatory therapy in patients with IBD as the causative factor for infections 20 . The primary end point was occurrence of PJI at 2 years postoperatively.…”

“…Despite a higher complication rate, 1 study did not detect a higher rate of infection in patients with IBD undergoing total joint arthroplasty 19 . The use of immunomodulatory therapy in patients with IBD has also been investigated, and 1 study suggested that it may not be the causative factor for infections 20 .…”

Highlights from the literature: inflammatory bowel disease

“…Using the MarketScan Database in the USA, a retrospective case–control study of patients with IBD 18–64 years of age undergoing hip, knee or shoulder replacement surgery was conducted 3. After controlling for comorbidities, patients with IBD were not at increased risk of serious infection following joint replacement.…”