2022 EULAR Recommendations on Screening and Prophylaxis for Opportunistic Infections Save

Opportunistic and chronic infections may be rare and are often difficult to diagnose, especially in patients with autoimmune inflammatory rheumatic diseases (AIIRD), that may be immunocompromised. A EULAR task force has established recommendations for screening and prophylaxis against OI. 

An international Task Force (with 22 members, from 15 countries) formulated recommendations, supported by systematic literature review findings.  This resulted in four overarching principles and eight recommendations.

Screening for latent tuberculosis (TB) was recommended for those receiving biologic/targeted synthetic disease-modifying antirheumatic drugs (DMARDs), as well as conventional synthetic DMARDs, glucocorticoids and immunosuppressants. Interferon gamma release assay is preferred over tuberculin skin test (PPD), when possible. While the need for hepatitis B (HBV) antiviral treatment is guided by HBV testing prior to therapy, they recommended that all hepatitis-C-RNA positive patients should be referred for antiviral treatment. Lastly, Pneumocystis jirovecii prophylaxis seems most beneficial in those taking >15–30 mg of prednisolone or equivalent for >2–4 weeks.

Overarching Principles

• The risk of chronic or opportunistic infections should be discussed with all patients with AIIRD prior to treatment with csDMARDs, tsDMARDs, bDMARDs, immunosuppressants and/or glucocorticoids and reassessed periodically.
• Rheumatologists should collaborate with other specialists on infection risk reduction and management.
• Need for screening and prophylaxis (of chronic and opportunistic infections) is based on individual risk factors and should be reassessed periodically
• National guidelines and recommendations, among other country/region-level factors pertaining to endemic infectious diseases, should be considered.

Recommendations

1. Screening for latent tuberculosis (LTBI is recommended in prior to starting bDMARDs or tsDMARDs* (and also considered in those starting csDMARDs, immunosuppressants* and/or glucocorticoids)
2. Screening for LTBI should follow national and/or international guidelines and would typically include a chest X-ray and Interferon-gamma release assay (IGRA) over tuberculin skin test (TST or PPD) where available
3. Choice and timing of LTBI therapy should be guided by national and/or international guidelines. Special attention should be given to interactions with drugs commonly used to treat AIIRD
4. HBV screening should be considered with the following treatments: csDMARDs, bDMARDs, tsDMARDs*, immunosuppressants* and glucocorticoids
5. HCV screening should be considered prior to starting csDMARDs, bDMARDs, tsDMARDs*, immunosuppressants and glucocorticoids* (and also with known risk factors or elevated alanine aminotransferase levels)
6. HIV screening is recommended prior to treatment with bDMARDs and should be considered prior to treatment with csDMARDs, tsDMARDs, immunosuppressants and glucocorticoids 
7.  With Varicella zoster virus (VZV) exposure, post-exposure prophylaxis should be considered in patients starting csDMARDs, bDMARDs, tsDMARDs, immunosuppressants and/or glucocorticoids 
8. PJP prophylaxis should be considered in AIIRD patients on high doses of glucocorticoids, especially in combination with immunosuppressants