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Invasive fungal infections in patients with rheumatoid arthritis: an explorative analysis from the German RABBIT
Alina Purschke1, Vera Zietemann2, Peter Herzer3,4
1Epidemiology and Health Services Research, German Rheumatology Research Center, Berlin, Germany alina.purschke@drfz.de.
Objectives:
To explore characteristics and treatment of patients with rheumatoid arthritis (RA) with invasive fungal infections (IFIs) and to describe infection details and outcome.
Methods:
IFIs reported to the German RABBIT (Rheumatoid Arthritis: Observation of Biologic Therapy) register between May 2001 and December 2023 were analysed using a two-stage approach. First, a detailed case description, including a comparison of cases by infection outcome, was conducted using routine register data and hospital discharge letters. Second, a multivariable time-dependent Cox regression model was fitted to analyse associations with IFI development using routine register data only.
Results:
Among 22 535 patients with RA, 69 IFIs occurred (incidence rate: 0.65/1000 patient-years), with a case fatality of 35% (n=24). Causative pathogens were Pneumocystis jirovecii (35%), Candida spp (33%) and Aspergillus spp (13%).Patients with IFIs were on average 65.4 years old; 54% were female, 80% ever-smokers, 84% glucocorticoid (GC) users and 91% had any infection-risk associated comorbidity at hospitalisation. IFI development was associated with older age (HR 1.36 per 10 years (95% CI 1.05 to 1.76)), male sex (HR 1.92 (95% CI 1.14 to 3.21)), ever-smoking (HR 2.43 (95% CI 1.35 to 4.37)), cardiovascular disease (HR 3.03 (95% CI 1.80 to 5.10)), chronic lung disease (HR 2.09 (95% CI 1.21 to 3.61)), other autoimmune disease (HR 2.11 (95% CI 1.10 to 4.07)), and the use of GCs (HR 1.17 (95% CI 1.11 to 1.22)).
Conclusion:
In patients with RA, IFIs are rare but life-threatening. They occur particularly in patients who are predisposed to infection due to relevant comorbidities, a history of smoking or both. Except for GC use, the overall impact of targeted RA treatment on the risk of IFI appears to be less relevant than that of multimorbidity.
Insights
Invasive fungal infections (IFIs) are rare but life-threatening in rheumatoid arthritis (RA) patients. Risk factors include comorbidities, smoking, and glucocorticoid use, with multimorbidity posing a greater threat than RA treatments.
Area of Science:
- Rheumatology
- Infectious Diseases
- Epidemiology
Background:
- Rheumatoid arthritis (RA) patients are susceptible to invasive fungal infections (IFIs).
- Understanding IFI characteristics and risk factors in RA is crucial for patient management.
- The German RABBIT register provides a valuable data source for studying IFIs in RA.
Purpose of the Study:
- To investigate the characteristics, treatment, and outcomes of RA patients with IFIs.
- To identify risk factors associated with the development of IFIs in RA patients.
- To compare IFI cases based on infection outcomes.
Main Methods:
- Analysis of IFIs reported to the German RABBIT register (May 2001-December 2023).
- Two-stage approach: detailed case description and multivariable Cox regression.
- Inclusion of routine register data and hospital discharge letters for comprehensive analysis.
Main Results:
- 69 IFIs occurred in 22,535 RA patients (0.65/1000 patient-years); case fatality was 35%.
- Common pathogens included Pneumocystis jirovecii (35%), Candida spp. (33%), and Aspergillus spp. (13%).
- IFI risk associated with older age, male sex, smoking, cardiovascular/lung/autoimmune diseases, and glucocorticoid use.
Conclusions:
- IFIs in RA patients are rare but carry a high mortality risk.
- Predisposition to IFIs is linked to comorbidities, smoking history, and glucocorticoid use.
- Multimorbidity appears to be a more significant risk factor for IFIs than RA-targeted treatments, except for glucocorticoids.
