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Influence of anti-TNF patient warning regarding avoidance of high risk foods on rates of listeria and salmonella infections in the UK
  1. Rebecca Davies,
  2. William G Dixon,
  3. Kath D Watson,
  4. Mark Lunt,
  5. BSRBR Control Centre Consortium,
  6. Deborah P M Symmons,
  7. Kimme L Hyrich,
  8. on behalf of the BSRBR
  1. Arthritis Research UK Epidemiology Unit, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
  1. Correspondence to Dr Kimme Hyrich, Arthritis Research UK Epidemiology Unit, The University of Manchester, Manchester Academic Health Science Centre, Oxford Road, Manchester M13 9PT, UK; Kimme.hyrich{at}

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Tumour necrosis factor (TNF) plays a pivotal role in the control of bacterial intracellular infection.1 The introduction of anti-TNF therapy to treat rheumatoid arthritis (RA) prompted the investigation of infection rates within these patients.2 Following an early signal of an increased risk of tuberculosis in anti-TNF treated patients,3 there have been many reports suggesting an increased risk of other intracellular bacterial infections, including listeria and salmonella.4 ,5 Indeed, the BSR Biologics Register (BSRBR) has reported an increase of such infections within anti-TNF treated patients compared with patients treated with non-biologic disease-modifying antirheumatic drugs.6 In response to these findings, patient information leaflets for anti-TNF agents (etanercept (ETN), infliximab (INF), adalimumab (ADA)) were modified in the UK in January 2006 advising patients to avoid high risk foods, such as raw eggs and poultry, which are associated with an increased risk of these infections.7–9 Given the addition of this advice, we investigated the rate of bacterial intracellular infection, before and after these guidelines were introduced, in RA patients treated with anti-TNF therapy within the BSRBR.10

A total of 11 723 patients with RA starting their first anti-TNF on enrolment in the BSRBR were included. This comprised 9376 patients starting therapy …

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  • Contributors RD, WGD, KLH: Study concept and design; BSRBR Control Centre Consortium: acquisition of data; RD, WGD, ML, KDW, DPMS, KLH: analysis and interpretation of data; RD, WGD, KLH: drafting of manuscript. All authors contributed to critical revision of the manuscript for important intellectual content and approved the article for publication.

  • Collaborators *BSRBR Control Centre Consortium. The BSRBR Control Centre Consortium consists of the following institutions (all in the UK): Antrim Area Hospital, Antrim (Dr Nicola Maiden), Cannock Chase Hospital, Cannock Chase (Dr Tom Price), Christchurch Hospital, Christchurch (Dr Neil Hopkinson), Royal Derby Hospital, Derby (Dr Sheila O'Reilly), Dewsbury and District Hospital, Dewsbury (Dr Lesley Hordon), Freeman Hospital, Newcastle-upon-Tyne (Dr Ian Griffiths), Gartnavel General Hospital, Glasgow (Dr Duncan Porter), Glasgow Royal Infirmary, Glasgow (Prof Hilary Capell), Haywood Hospital, Stoke-on-Trent (Dr Andy Hassell), Hope Hospital, Salford (Dr Romela Benitha), King's College Hospital, London (Dr Ernest Choy), Kings Mill Centre, Sutton-In Ashfield (Dr David Walsh), Leeds General Infirmary, Leeds (Prof Paul Emery), Macclesfield District General Hospital, Macclesfield (Dr Susan Knight), Manchester Royal Infirmary, Manchester (Prof Ian Bruce), Musgrave Park Hospital, Belfast (Dr Allister Taggart), Norfolk and Norwich University Hospital, Norwich (Prof David Scott), Poole General Hospital, Poole (Dr Paul Thompson), Queen Alexandra Hospital, Portsmouth (Dr Fiona McCrae), Royal Glamorgan Hospital, Glamorgan (Dr Rhian Goodfellow), Russells Hall Hospital, Dudley (Prof George Kitas), Selly Oak Hospital, Selly Oak (Dr Ronald Jubb), St Helens Hospital, St Helens (Dr Rikki Abernethy), Weston General Hospital, Weston-super-Mare (Dr Shane Clarke/Dr Sandra Green), Withington Hospital, Manchester (Dr Paul Sanders), Withybush General Hospital, Haverfordwest (Dr Amanda Coulson), North Manchester General Hospital (Dr Bev Harrison), Royal Lancaster Infirmary (Dr Marwan Bukhari) and The Royal Oldham Hospital (Dr Peter Klimiuk).

  • Funding This study was funded by the British Society for Rheumatology (BSR). The BSR commissioned the Biologics Register (BSRBR) as a UK wide national project to investigate the safety of biologic agents in routine medical practice. DPMS and KH are principal investigators on the BSRBR. BSR receives restricted income from UK pharmaceutical companies, presently Abbott Laboratories, Swedish Orphan Biovitrum, Merck, Pfizer, UCB and Roche. This income finances a wholly separate contract between the BSR and the University of Manchester. The principal investigators and their team have full academic freedom and are able to work independently of pharmaceutical industry influence. All decisions concerning analyses, interpretation and publication are made autonomously of any industrial contribution. Members of the Manchester team, BSR trustees, committee members and staff complete an annual declaration in relation to conflicts of interest.

  • Competing interests None.

  • Patient consent Obtained.

  • Data sharing statement Information on data is available at

  • Ethics approval The study was approved by the North-West Multicentre Research Ethics Committee. Patient consent was obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.