The Incidence of Hospital Stays due to Infection in Patients with Systemic Lupus Erythematosus at Chonburi Hospital and Associated Factors
Abstract
Background: Systemic lupus erythematosus (SLE) is an autoimmune disease, and its treatment with immunosuppressive agents can increase the risk of infection, leading to hospitalization. Disease activity can also cause hospitalization, but it requires different treatment. In particular, infection is a curable condition. Some symptoms, such as fever, can be caused by both infection and disease activity. Being aware of the incidence of hospital stays due to infection can lead to timely awareness and the administration of empirical antibiotics when appropriate. The aims of this study were to estimate the incidence of hospital stays due to infection in patients with SLE and identify associated factors.
Methods: This was a retrospective cross-sectional study. Patients older than 18 years with diagnosed SLE in the Inpatient Department (IPD) at Chonburi Hospital were recruited from January 1, 2020, to January 1, 2022. Data on patient demographics, the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K), reasons for hospitalization, medication, laboratory results, and discharge status were collected. Fischer's exact test or the Mann-Whitney U test was used to make appropriate comparisons between groups, and binary logistic regression was employed to determine associations.
Result: Among the 250 patients, the mean age was 38.7 years, and 87.6% were female. The incidence of hospital stays due to infection in patients with SLE was 25.6%. The most common cause of hospitalization was a disease flare (35.2%). Patients with hospital stays due to infection had a lower SLEDAI-2K score [Median (IQR), 1 (0, 8) vs. 7 (0, 14), p < 0.01], higher ESR [Median (IQR), 69 (41, 95) vs. 56 (33, 77), p = 0.03], longer hospital stays (more than seven days) [59.4% vs. 36.6% (n=66), p < 0.01], and a higher mortality rate [15.6% vs. 2.7%, p < 0.01] than the other group. This study showed that the following factors are associated with hospital stays due to infection: steroids at a dose of 10 mg/day or higher of prednisolone equivalent dose [adjusted OR 2.51, p = 0.04], Azathioprine [adjusted OR 4.01, p < 0.01], and anti-malarial agents [adjusted OR 0.28, p = 0.01].
Conclusions: The incidence of hospital stays due to infection in patients with SLE was 25.6%. The association between steroids at a dose of 10 mg/day or higher of prednisolone equivalent dose, azathioprine, and anti-malarial agents and hospital stays due to infection exists, but further study is needed to investigate this association more thoroughly.
References
Mok CC, Lau CS. Pathogenesis of systemic lupus erythematosus. J Clin Pathol. 2003;56(7):481-90.
Chaiamnuay P, Darmawan J, Muirden KD, Assawatanabodee P. Epidemiology of rheumatic disease in rural Thailand: a WHO-ILAR COPCORD study. Community Oriented Programme for the Control of Rheumatic Disease. J Rheumatol. 1998;25(7):1382-7.
Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum. 1997;40(9):1725.
Petri M, Orbai AM, Alarcón GS, Gordon C, Merrill JT, Fortin PR, et al. Derivation and validation of the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus. Arthritis Rheum. 2012;64(8):2677-86.
Aringer M, Costenbader K, Daikh D, Brinks R, Mosca M, Ramsey-Goldman R, et al. 2019 European League Against Rheumatism/American College of Rheumatology Classification Criteria for Systemic Lupus Erythematosus. Arthritis Rheumatol. 2019;71(9):1400-12.
Fanouriakis A, Kostopoulou M, Alunno A, Aringer M, Bajema I, Boletis JN, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Annals of the Rheumatic Diseases. 2019;78(6):736.
Chakravarty EF, Bush TM, Manzi S, Clarke AE, Ward MM. Prevalence of adult systemic lupus erythematosus in California and Pennsylvania in 2000: estimates obtained using hospitalization data. Arthritis Rheum. 2007;56(6):2092-4.
Edwards CJ, Lian TY, Badsha H, Teh CL, Arden N, Chng HH. Hospitalization of individuals with systemic lupus erythematosus: characteristics and predictors of outcome. Lupus. 2003;12(9):672-6.
Lee J, Dhillon N, Pope J. All-cause hospitalizations in systemic lupus erythematosus from a large Canadian referral centre. Rheumatology (Oxford). 2013;52(5):905-9.
Aldarmaki R, Al Khogali HI, Al Dhanhani AM. Hospitalization in patients with systemic lupus erythematosus at Tawam Hospital, United Arab Emirates (UAE): Rates, causes, and factors associated with length of stay. Lupus. 2021;30(5):845-51.
da Rosa GP, Cervera R, Espinosa G. Causes of Hospitalization in Systemic Lupus Erythematosus: A Narrative Review. Curr Rheumatol Rev. 2021;17(1):29-40.
Elixhauser A, Steiner C. Readmissions to U.S. Hospitals by Diagnosis, 2010. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006.
Prigerson HG, Maciejewski PK. Dartmouth Atlas: putting end-of-life care on the map but missing psychosocial detail. J Support Oncol. 2012;10(1):25-8.
Illescas-Montes R, Corona-Castro CC, Melguizo-Rodríguez L, Ruiz C, Costela-Ruiz VJ. Infectious processes and systemic lupus erythematosus. Immunology. 2019;158(3):153-60.
Jeong SJ, Choi H, Lee HS, Han SH, Chin BS, Baek JH, et al. Incidence and risk factors of infection in a single cohort of 110 adults with systemic lupus erythematosus. Scand J Infect Dis. 2009;41(4):268-74.
Noël V, Lortholary O, Casassus P, Cohen P, Généreau T, André MH, et al. Risk factors and prognostic influence of infection in a single cohort of 87 adults with systemic lupus erythematosus. Ann Rheum Dis. 2001;60(12):1141-4.
Kaien G, Dafna DG, Jiandong S, Murray BU. Hospitalizations in Patients with Systemic Lupus Erythematosus in an Academic Health Science Center. The Journal of Rheumatology. 2017;44(8):1173.
Gladman DD, Ibañez D, Urowitz MB. Systemic lupus erythematosus disease activity index 2000. J Rheumatol. 2002;29(2):288-91.
Koelmeyer R, Nim HT, Nikpour M, Sun YB, Kao A, Guenther O, et al. High disease activity status suggests more severe disease and damage accrual in systemic lupus erythematosus. Lupus Sci Med. 2020;7(1).
Cojocaru M, Cojocaru IM, Silosi I, Vrabie CD. Manifestations of systemic lupus erythematosus. Maedica (Bucur). 2011;6(4):330-6.
Ammirati E, Frigerio M, Adler ED, Basso C, Birnie DH, Brambatti M, et al. Management of Acute Myocarditis and Chronic Inflammatory Cardiomyopathy. Circulation: Heart Failure. 2020;13(11):e007405.
Keane MP, Lynch JP, 3rd. Pleuropulmonary manifestations of systemic lupus erythematosus. Thorax. 2000;55(2):159-66.
Kim JS, Lee KS, Koh EM, Kim SY, Chung MP, Han J. Thoracic involvement of systemic lupus erythematosus: clinical, pathologic, and radiologic findings. J Comput Assist Tomogr. 2000;24(1):9-18.
Torre O, Harari S. Pleural and pulmonary involvement in systemic lupus erythematosus. Presse Med. 2011;40(1 Pt 2):e19-29.
Park MS. Diffuse alveolar hemorrhage. Tuberc Respir Dis (Seoul). 2013;74(4):151-62.
The American College of Rheumatology nomenclature and case definitions for neuropsychiatric lupus syndromes. Arthritis Rheum. 1999;42(4):599-608.
Hill QA, Hill A, Berentsen S. Defining autoimmune hemolytic anemia: a systematic review of the terminology used for diagnosis and treatment. Blood Advances. 2019;3(12):1897-906.
Ju JH, Min JK, Jung CK, Oh SN, Kwok SK, Kang KY, et al. Lupus mesenteric vasculitis can cause acute abdominal pain in patients with SLE. Nat Rev Rheumatol. 2009;5(5):273-81.
de Carvalho JF. Mesenteric vasculitis in a systemic lupus erythematosus patient with a low sledai: an uncommon presentation. Clinics (Sao Paulo). 2010;65(3):337-40.
Chen S, Kauffman C, Steinbach W, Baddley J, Verweij P, Clancy C, et al. Revision and Update of the Consensus Definitions of Invasive Fungal Disease From the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium. Clinical Infectious Diseases. 2019;71.
Buttgereit F, Straub RH, Wehling M, Burmester GR. Glucocorticoids in the treatment of rheumatic diseases: an update on the mechanisms of action. Arthritis Rheum. 2004;50(11):3408-17.
Grijalva CG, Chen L, Delzell E, Baddley JW, Beukelman T, Winthrop KL, et al. Initiation of tumor necrosis factor-α antagonists and the risk of hospitalization for infection in patients with autoimmune diseases. Jama. 2011;306(21):2331-9.
Porta S, Danza A, Arias Saavedra M, Carlomagno A, Goizueta MC, Vivero F, et al. Glucocorticoids in Systemic Lupus Erythematosus. Ten Questions and Some Issues. J Clin Med. 2020;9(9).
Antonis F, Myrto K, Jeanette A, Martin A, Laurent A, Sang-Cheol B, et al. EULAR recommendations for the management of systemic lupus erythematosus: 2023 update. Annals of the Rheumatic Diseases. 2023:ard-2023-224762.
Ruangkriengsin D, Phisalprapa P. Causes of prolonged hospitalization among general internal medicine patients of a tertiary care center. J Med Assoc Thai. 2014;97 Suppl 3:S206-15.
Idolor O, Edigin E, Eseaton PO, Trang A, Kichloo A, Shaka H, et al. Systemic lupus erythematous readmissions have reduced: a 9-year longitudinal study of the nationwide readmission database. Clin Rheumatol. 2023;42(2):377-83.
Lin CH, Hung PH, Hu HY, Chen YJ, Guo HR, Hung KY. Infection-related hospitalization and risk of end-stage renal disease in patients with systemic lupus erythematosus: a nationwide population-based study. Nephrol Dial Transplant. 2017;32(10):1683-90.
Littlejohn E, Marder W, Lewis E, Francis S, Jackish J, McCune WJ, et al. The ratio of erythrocyte sedimentation rate to C-reactive protein is useful in distinguishing infection from flare in systemic lupus erythematosus patients presenting with fever. Lupus. 2018;27(7):1123-9.
Al-Rayes H, Al-Swailem R, Arfin M, Sobki S, Rizvi S, Tariq M. Systemic lupus erythematosus and infections: a retrospective study in Saudis. Lupus. 2007;16(9):755-63.
Battaglia M, Garrett-Sinha LA. Bacterial infections in lupus: Roles in promoting immune activation and in pathogenesis of the disease. J Transl Autoimmun. 2021;4:100078.
Tektonidou MG, Wang Z, Dasgupta A, Ward MM. Burden of Serious Infections in Adults With Systemic Lupus Erythematosus: A National Population-Based Study, 1996-2011. Arthritis Care Res (Hoboken). 2015;67(8):1078-85.
Marcos M, Fernández C, Soriano À, Marco F, Martínez JA, Almela M, et al. Epidemiology and clinical outcomes of bloodstream infections among lupus patients. Lupus. 2011;20(9):965-71.
Iñigo R-F, Francisco JL-L, Víctor Del C, María G-I, Esther U, Julián T-C, et al. Bacteremia in Systemic Lupus Erythematosus in Patients from a Spanish Registry: Risk Factors, Clinical and Microbiological Characteristics, and Outcomes. The Journal of Rheumatology. 2020;47(2):234.
Ruiz-Irastorza G, Olivares N, Ruiz-Arruza I, Martinez-Berriotxoa A, Egurbide MV, Aguirre C. Predictors of major infections in systemic lupus erythematosus. Arthritis Res Ther. 2009;11(4):R109.
Huang C-F, Chen P-L, Liu M-F, Lee C-C, Lee N-Y, Chang C-M, et al. Nontyphoidal Salmonella bacteremia in patients with connective tissue diseases. Journal of Microbiology, Immunology and Infection. 2012;45(5):350-5.
Shahram F, Akbarian M, Davatchi F. Salmonella infection in systemic lupus erythematosus. Lupus. 1993;2(1):55-9.
Abramson S, Kramer SB, Radin A, Holzman R. Salmonella bacteremia in systemic lupus erythematosus. Eight-year experience at a municipal hospital. Arthritis & Rheumatism. 1985;28(1):75-9.
Alves F, Rodrigues R, Silva A, Pessoa G, Moura L, Alves J, et al. Macroscopic Anatomy, Histopathology, and Image Diagnosis of Joints and Synovial Cartilages. 2018.
Dorgham DA, Anwar S, Khaled AS. Infection in systemic lupus erythematosus patients. The Egyptian Rheumatologist. 2021;43(2):115-8.
Rolain J-M, Colson P, Raoult D. Recycling of chloroquine and its hydroxyl analogue to face bacterial, fungal and viral infections in the 21st century. International Journal of Antimicrobial Agents. 2007;30(4):297-308.
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