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Abstract
Background According to RELESSER (Spanish Society of Rheumatology Lupus Registry) data, bacteremia is the main cause of death by infection in systemic lupus erythematosus (SLE). However, the available information about this severe infection in SLE patients remains scarce.
Methods Retrospective, nested case-control study of SLE patients (ACR-97 criteria) with at least one bacteremic episode and random controls from RELESSER Registry. Descriptive, bivariate and multivariate analysis (logistic regression)
Results 114 bacteremic episodes in 83 patients were recorded. Incidence rate: 2,7/ 1,000 patient-years (n total: 3658). At the time of the bacteremia: median age: 40.5 (8–90) years, 88.6% female, disease duration: 9.7 (IR16.7), median SELENA-SLEDAI: 4 (IR8), 66% with severe flare (SFI criteria), active nephritis: 16.7%, median SLICC/ACR DI: 3 (IR4), any comorbidity: 64% (McCabe-Jackson criteria: 28.1% rapidly or ultimately fatal), more frequently renal failure (15.8%) or diabetes (11.4%). SLE treatment at the time of bacteraemia: 88.6% corticosteroids (68,6%>10mg/day), 57% immunosuppressors (mycophenolate 17.5% and cyclophosphamide 12.3%), 27% antimalarials. 44.7% suffered invasive procedures, more frequently intravascular catheter (24.6%). The bacteremia was nosocomial in 35.1% and the source was more frequently urinary (27.2%). 64% developed systemic inflammatory response syndrome and 35% needed intensive care unit admission, with multiorganic failure in 22.8%. The most frequent microorganism was E.coli (29.8%) followed by Staphylococcus aureus (16.7%) (22% methicillin-resistant) and Salmonella spp. (10.5%). 16% of the gram-negative enteric bacilli were extended-spectrum b-lactamase positive. 17.5% were multidrug resistant. 68,4% started the antibiotherapy before blood culture results, resulting finally active in susceptibility testing in 56 cases (71.8%), indicating an appropriate empirical antibiotic therapy in 49%. The bacteremia-related mortality was 14%. The risk of death was higher in patients with severe sepsis (Pitt index >8) (OR: 13 (IC95%: 3.71–45.17). The bacteremia was recurrent in 26.3%. Associations with bacteremia in bivariate analysis (114 bacteremias vs 688 controls) are shown in Table 1. Antimalarials were protective. In the multivariate analysis (adjusted for disease duration), only elevated creatinine (OR 1.31 (95% CI 1.01–1.70), p=0.045), diabetes (OR 6.01 (95% CI 2.26–15.95), p=0.000), cancer (OR 5.32 (95% CI 2.23–12.70), p=0.000), immunosuppressors (OR 6.35 (95% CI 3.42–11.77), p=0.000), cyclophosphamide (OR 9.37 (95% CI 5.12–17.14), p=0.000) and SLICC/ACR DI (OR 1.65 (95% CI 1.31–2.09), p=0.000) remained statistically significant.
Conclusions Bacteremia occurred mostly in active SLE, frequently in the context of a severe flare. Gram negative bacilli predominated, with high rate of multidrug resistance. The empiric treatment was inappropriate in a half of the cases. The recurrence and mortality were high. Immunosuppressors use, comorbidity and damage were all associated to bacteraemia.
Disclosure of Interest None declared