Issue 13

Clinical Question

Are inflammatory bowel disease (IBD) patients treated with pre-operative anti-TNFs at increased risk for infectious complications post-operatively?

Editor’s Bottom Line

These two large studies demonstrate that pre-operative therapy with anti-TNF agents does not result in an detectable increase in the post-operative infection rate.

References

George MD, Baker JF, Yenchih Hsu J, et al. Perioperative timing of infliximab and the risk of serious infection after elective hip and knee arthroplasty. Arthritis Care Res. 2017 Jan 27. [Epub ahead of print]. https://www.ncbi.nlm.nih.gov/pubmed/28129484

Zittan E, Milgrom R, Ma GW, et al. Preoperative Anti-tumor necrosis factor therapy in patients with ulcerative colitis is not associated with an increased risk of infectious and noninfectious complications after ileal pouch-anal anastomosis. Inflamm Bowel Dis. 2016 Oct;22(10):2442–7. https://www.ncbi.nlm.nih.gov/pubmed/27607335

Synopsis

George et al.
The patient cohort (rheumatoid arthritis, IBD, psoriasis (PsO), psoriatic arthritis (PsA), and ankylosing spondylitis (AS)) received ≥1 infliximab (IFX) infusions within 6 months prior to elective surgery (primary or revision hip or knee arthroplasty). The cohort was stratified by last dose of IFX prior to the surgery (<4, 4–8, 8–12, 12–16, and ≥16 weeks) with 8–12 weeks regarded as the reference group. Primary outcome was serious infection within 30 days or prosthetic joint infection (PJI) within 1 year of surgery. Pre- and post-operative medical chart reviews were conducted to identify meaningful covariates.

Within the cohort of 4288, there were 475 patients with IBD (11%). For the 270 serious infections or 2.9 per 100 person-years PJI, there was no increase in rates between a stop timing of IFX <4 weeks vs. 8–12 weeks. However, pre-operative glucocorticoid (>10 mg/d) increased the odds ratio for 30 day infection (OR 2.11, 95% CI: 1.3-3.4) and hazard ratio for PJI (HR 2.7, 95% CI: 1.3-5.6).

Zittan et al.
Eligible patients with UC who had ileal pouch-anal anastomosis (IPAA) surgery were stratified based upon pre-surgical anti-TNF exposure into controls (none) or IFX (stratified by timing of last dose pre-operatively: ≤14, 15–30, 31–180, or >180 days). When possible, IFX levels and antibodies were obtained. Primary study endpoints included pelvic abscess and pouch leaks.

The IFX (n=196) and control (n=562) groups had similar rates for abscesses and infections (19.9% vs. 17.1%, P=0.36 and 14.8% vs. 14.1%, P=0.74, respectively) and leaks (3.2% vs. 11.7%, P=0.44). Having >4 IFX infusions in the pre-operative 180 days did not increase rates versus the controls. For the four groups classified by the timing of the last dose of IFX, there were no significant differences relative to controls in patients who underwent a 2-stage IPAA.

Details

George et al.
Study Design: Retrospective observational cohort study
Funding: NIH, Rheumatology Research Foundation Scientist Development Aware, VA Clinical Science Research & Career Development Award
Allocation: n/a
Setting: US Medicare database
Level of Evidence: 2b (Oxford Levels of Evidence)
 
Zittan et al.
Study Design: Retrospective observational cohort study
Funding: Prometheus Laboratories for IFX testing; Gale and Graham Wright Research Chair
Allocation: n/a
Setting: Single centre in Toronto, ON
Level of Evidence: 2b (Oxford Levels of Evidence)

The summary and conclusion in this issue of E-mentoring in IBD pertains to the manuscript(s) being reviewed, and should be considered in the context of what is already known surrounding the topic and incorporated into practice as deemed appropriate by the individual learner.