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Risk Factors for Surgical Site Infections and Other Complications in Elective Surgery in Patients with Rheumatoid Arthritis with Special Attention for Anti-Tumor Necrosis Factor: A Large Retrospective Study
ALFONS A. den BROEDER, MARJONNE C.W. CREEMERS, JAAP FRANSEN, EEFJE de JONG, DIRK-JAN RAM de ROOIJ, ATE WYMENGA, MAARTEN de WAAL-MALEFIJT, and FRANK H.J. van den HOOGEN ABSTRACT. Objective. To identify risk factors for surgical site infection (SSI) in patients with rheumatoid arthritis (RA) with special attention for anti-tumor necrosis factor (anti-TNF) treatment. Methods. All patients with RA who had undergone elective orthopedic surgery since introduction of anti-TNF were included in a retrospective parallel-cohort study with a one-year followup. Primary endpoint was a SSI according to the 1992 Centers for Disease Control and Prevention criteria and/or antibiotic use. Cohort 1 did not use anti-TNF, cohort 2 used anti-TNF but had either stopped (2A) or continued anti-TNF preoperatively (2B), the cutoff point being set at 4 times the half-life time of the drug. Infection rates were compared between cohorts, and logistic regression analysis was performed to examine risk factors. Results. In total, 1219 (768 patients) procedures were included, and crude infection risks were 4.0% (41/1023), 5.8% (6/104), and 8.7% (8/92) in cohorts 1, 2A, and 2B, respectively. Elbow surgery (OR 4.1, 95% CI 1.6–10.1), foot/ankle surgery (OR 3.2, 95% CI 1.6–6.5), and prior skin or wound infection (OR 13.8, 95% CI 5.2–36.7) were associated with increased risk of SSI, whereas duration of surgery (OR 0.42, 95% CI 0.23–0.78) and sulfasalazine use (OR 0.21, 95% CI 0.05–0.89) were associated with decreased risk. Perioperative use of anti-TNF was not significantly associated with an increase in SSI rates (OR 1.5, 95% CI 0.43–5.2). Conclusion. The most important risk factor for SSI is history of SSI or skin infection. Although our study was not powered to detect small differences in infection rates, perioperative continuation of anti-TNF does not seem to be an important risk factor for SSI. (First Release Nov 15 2006; J Rheumatol 2007;34:689–95) Key Indexing Terms:
ANTI-TUMOR NECROSIS FACTOR From the Department of Rheumatology and Orthopaedic Surgery, Sint Maartenskliniek; and Department of Rheumatology and Orthopaedic Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands. A.A. den Broeder, MD, PhD; F.H.J. van den Hoogen, MD, PhD, Sint Maartenskliniek and Radboud University Nijmegen Medical Centre; M.C.W. Creemers, MD, PhD; J. Fransen, PhD; M. de Waal-Malefijt, MD, Department of Rheumatology and Orthopaedic Surgery, Radboud University Nijmegen Medical Centre; E. de Jong; D-J.R.A.M. de Rooij, MD, PhD; A. Wymenga, MD, PhD, Department of Rheumatology and Orthopaedic Surgery, Sint Maartenskliniek. Address reprint requests to Dr. A.A. den Broeder, Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, 6500 GM Nijmegen, The Netherlands. E-mail: a.denbroeder@maartenskliniek.nl Accepted for publication August 23, 2006.
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