Open Access Research article

Risk factors for total joint arthroplasty infection in patients receiving tumor necrosis factor α-blockers: a case-control study

Mélanie Gilson1*, Laure Gossec1, Xavier Mariette2, Dalenda Gherissi3, Marie-Hélène Guyot4, Jean-Marie Berthelot5, Daniel Wendling6, Christian Michelet7, Pierre Dellamonica8, Florence Tubach9, Maxime Dougados1 and Dominique Salmon3

Author Affiliations

1 Rheumatology B Department, Cochin Hospital, AP-HP, 27 rue du faubourg Saint-Jacques, Paris 75014, France; UPRES-EA 4058, Medicine Faculty, Paris Descartes University, 12 rue de l'Ecole de Médecine, Paris 75006, France

2 Department of Rheumatology, Bicêtre Hospital, AP-HP, 78 rue du Général Leclerc, Le Kremlin-Bicêtre 94270, France; INSERM U802, Paris-Sud University, 63 rue Gabriel Péri, Le Kremlin-Bicêtre 94270, France

3 Infectious Diseases - Internal Medicine Department, Cochin Hospital, AP-HP, 27 rue de faubourg Saint-Jacques, Paris 75014, France

4 Department of Rheumatology, Provo Hospital, 25 rue de Barbieux, Roubaix 59100, France

5 Department of Rheumatology, Hotel Dieu Hospital, 1 place Alexis-Ricordeau, Nantes 44000, France

6 Department of Rheumatology, Minjoz Hospital, 3 boulevard Alexandre Fleming, Besançon 25000, France

7 Department of Infectious Diseases, University Hospital, 2 rue de l'Hôtel-Dieu, Rennes 35000, France

8 Department of Infectious Diseases, University Hospital, 4 avenue Reine Victoria, Nice 06000, France

9 Department of Clinical Epidemiology and Biostatistics, Bichat Hospital, AP-HP, 46 rue Henri Huchard, Paris 75018, France; INSERM U738, Medicine Faculty, Paris 7 Denis Diderot University, 16 rue Henri Huchard, Paris 75018, France

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Arthritis Research & Therapy 2010, 12:R145 doi:10.1186/ar3087

Published: 16 July 2010

Abstract

Introduction

The objective of this study was to assess natural microbial agents, history and risk factors for total joint arthroplasty (TJA) infections in patients receiving tumor necrosis factor (TNF)α-blockers, through the French RATIO registry and a case-control study.

Methods

Cases were TJA infections during TNFα-blocker treatments. Each case was compared to two controls (with TJA and TNFα-blocker therapy, but without TJA infection) matched on age (±15 years), TJA localization, type of rheumatic disorder and disease duration (±15 years). Statistical analyses included univariate and multivariate analyses with conditional logistic regression.

Results

In the 20 cases (18 rheumatoid arthritis), TJA infection concerned principally the knee (n = 12, 60%) and the hip (n = 5, 25%). Staphylococcus was the more frequent microorganism involved (n = 15, 75%). Four patients (20%) were hospitalized in an intensive care unit and two died from infection. Eight cases (40%) versus 5 controls (13%) had undergone primary TJA or TJA revision for the joint subsequently infected during the last year (P = 0.03). Of these procedures, 5 cases versus 1 control were performed without withdrawing TNFα-blockers (P = 0.08). In multivariate analysis, predictors of infection were primary TJA or TJA revision for the joint subsequently infected within the last year (odds ratio, OR = 88.3; 95%CI 1.1-7,071.6; P = 0.04) and increased daily steroid intake (OR = 5.0 per 5 mg/d increase; 1.1-21.6; P = 0.03). Case-control comparisons showed similar distribution between TNFα-blockers (P = 0.70).

Conclusions

In patients receiving TNFα-blockers, TJA infection is rare but potentially severe. Important risk factors are primary TJA or TJA revision within the last year, particularly when TNFα-blockers are not interrupted before surgery, and the daily steroid intake.