Serious Infection Rates Among Children With Systemic Lupus Erythematosus Enrolled in Medicaid

Abstract

Objective To investigate the nationwide prevalence and incidence of serious infections among children with systemic lupus erythematosus (SLE) enrolled in Medicaid, the U.S. health insurance program for low-income patients. Methods From Medicaid claims (2000–2006) we identified children 5 to <18 years old with SLE (≥3 ICD-9 codes of 710.0, each >30 days apart) and lupus nephritis (LN; ≥2 ICD-9 codes for kidney disease on/after SLE codes). From hospital discharge diagnoses, we identified infection subtypes (bacterial, fungal, viral). We calculated incidence rates (IR) per 100 person-years (PY), mortality rates, and hazard ratios adjusted for sociodemographic factors, medications, and preventive care. Results Among 3,500 children with SLE identified, 1,053 serious infections occurred over 10,108 person-years; the IR was 10.42/100 PY (95% CI 9.80, 11.07) among all those with SLE and 17.65/100 PY (95% CI 16.29, 19.09) among those with LN. Bacterial infections were most common (87%; of which 39% were bacterial pneumonias). In adjusted models, African Americans and Native Americans had higher rates of infections compared with white children, and those with comorbidities or receiving corticosteroids had higher infection rates than those without. Males had lower rates of serious infections compared to females. The 30-day post-discharge mortality rate was 4.4%. Conclusions Overall, hospitalized infections were very common in children with SLE, with bacterial pneumonia being the most common infection. Highest infection risks were among African and Native American children, those with LN, comorbidities, and those taking corticosteroids.

Phenome-wide association study identifies marked increased in burden of comorbidities in African Americans with systemic lupus erythematosus

“…African Americans were more than 3.5 times more likely to have pneumonia and twice as likely to have bacteremia and sepsis. Our study agrees with two studies using the Medicaid administrative database that identified an increased risk of serious infections in African Americans compared to Caucasians with SLE, with the most common being bacteremia, pneumonia, and cellulitis [26, 27]. Our study builds upon these studies by including both inpatient and outpatient infections and offering a longer follow up of 9 years compared to the mean follow up of the studies of 2.5 years.…”

“…This increased risk of infection in SLE is likely due to immunosuppressant medications, the disease itself, or an interaction between these factors [46–48]. Two recent studies using the US Medicaid database investigated infection rates among different SLE patients but did not compare patients with SLE to matched controls [26, 27]. Our study establishes an increased risk of infection in African Americans with SLE compared to matched controls.…”

“…Data on these comorbidities may not be collected in traditional cohort studies, while administrative database studies may not adequately capture SLE-related data. Further, administrative databases can have a fairly short duration of follow up [26, 27]. In contrast, our EHR has follow up over several decades with subjects with SLE having on average 9 years of follow up [20].…”

Survival in adults and children with systemic lupus erythematosus: a systematic review and Bayesian meta-analysis of studies from 1950 to 2016

“…Infections were a major cause of death among paediatric patients in high-income countries. Serious infections are common among paediatric patients 45. Interventions to increase vaccination in children could further improve survival 46…”

Serious Infections in Childhood‐Onset Systemic Lupus Erythematosus: Using Administrative Claims Data to Investigate Disease Outcomes

“…In this issue of Arthritis Care & Research , the authors of “Serious Infection Rates Among Children With Systemic Lupus Erythematosus Enrolled in Medicaid” provide much needed information about this important outcome using a valuable data source . Infection is a common source of morbidity and mortality in adults with systemic lupus erythematosus (SLE), as these authors and other authors have previously demonstrated .…”