Severe infections in systemic lupus erythematosus: disease pattern and predictors of infection-related mortality

Abstract

Infection is a major cause of morbidity and mortality among patients with systemic lupus erythematosus (SLE). To describe the pattern of serious infections in patients with SLE and to identify the predictors of infection-related mortality among SLE patients with serious infections, we prospectively studied all SLE patients who were hospitalized with infections in Sarawak General Hospital during 2011-2015. Demographic data, clinical features, and outcomes were collected. Cox regression analysis was carried out to determine the independent predictors of infection-related mortality. There were a total of 125 patients with 187 episodes of serious infections. Our patients were of multiethnic origins with female predominance (89.6%). Their mean age was 33.4 ± 14.2 years. The patients had a mean disease duration of 66.8 ± 74.0 months. The most common site of infection was pulmonary (37.9%), followed by septicemia (22.5%). Gram-negative organisms (38.2%) were the predominant isolates within the cohort. There were 21 deaths (11.2%) during the study period. Independent predictors of infection-related mortality among our cohort of SLE patients were flare of SLE (HR 3.98, CI 1.30-12.21) and the presence of bacteremia (HR 2.54, CI 0.98-6.59). Hydroxychloroquine was protective of mortality from serious infections (HR 9.26, CI 3.40-25.64). Pneumonia and Gram-negative organisms were the predominant pattern of infection in our SLE cohort. The presence of flare of SLE and bacteremia were independent prognostic predictors of infection-related mortality, whereas hydroxychloroquine was protective of infection-related mortality among SLE patients with serious infections.

Mortality prediction in systemic lupus erythematosus patients with pulmonary infection

“…Infection complications are known to be a major cause of mortality in SLE, although the 5‐year survival rate in SLE has dramatically increased recently due to earlier diagnosis and treatment . A recent meta‐analysis reported the standardized mortality risk due to infections in SLE to be five times greater than in the general population …”

“…Given the clinical importance of infection in SLE, previous investigations have assessed demographic and clinical risk factors for infection, including age, race, disease activity or duration, immunosuppressive therapy, high anti‐double‐stranded DNA (anti‐dsDNA) titers，low complement levels, nephritis and leucopenia. However, the results of these studies have been inconsistent, perhaps because of infection and methodological differences …”

“…Also, the majority of studies have concentrated on risk factors for infection in SLE patients . There are only a handful of studies that have addressed the risk factors for mortality due to serious infections such as pulmonary infection (PI) in SLE patients.…”

“…The respiratory tracts are the most commonly affected and pulmonary involvement often leads to poor prognosis . Among SLE patients with PI, those prone to faster deterioration are more likely to benefit from active therapeutic interventions.…”

Acute respiratory involvement in Colombian patients with systemic lupus erythematosus undergoing chest computed tomography

“…Patients with SLE are predisposed to ARI such as pleural effusion, pneumonia, lupus pneumonitis, pulmonary hemorrhage and pulmonary thromboembolism . ARI in lupus has been associated with increased mortality and prolonged hospital length of stay.…”