Хронические и оппортунистические инфекции у больных иммуновоспалительными ревматическими заболеваниями: вопросы скрининга и профилактики (по материалам рекомендаций EULAR)

На современном этапе развития ревматологии большое внимание уделяется проблеме коморбидных инфекций, оказывающих значимое влияние на морбидность и летальность, особенно при иммуновоспалительных ревматических заболеваниях (ИВРЗ). Активное внедрение в клиническую практику инновационных препаратов, действие которых направлено на специфические компоненты патогенеза ИВРЗ, привело к нарастанию риска развития инфекций разнообразной природы и локализации, в т. ч. хронических и оппортунистических (ХОИ). В настоящей статье проанализированы рекомендации по скринингу и профилактике ХОИ у взрослых пациентов с ИВРЗ, предложенные в ноябре 2022 г. экспертами Европейского альянса ревматологических ассоциаций (EULAR, European Alliance of Associations for Rheumatology). Отмечается, что эти рекомендации следует рассматривать через призму национальных руководств, учитывающих региональные факторы риска, особенности течения, диагностики, терапии и профилактики ХОИ. При этом абсолютно оправданным представляется периодический пересмотр скрининговых и превентивных процедур по мере накопления новых научных данных. Несмотря на важность мультидисциплинарного подхода и необходимость тесного сотрудничества с врачами других специальностей, рабочая группа EULAR подчеркивает центральную роль ревматолога в ведении пациентов с ХОИ, возникающими на фоне ИВРЗ и связанными с проводимой противоревматической терапией.

1. Fragoulis GE, Nikiphorou E, Dey M, Zhao SS, Courvoisier DS, Arnaud L, et al. 2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis. 2022 Nov 3:ard-2022-223335. doi: 10.1136/ard-2022-223335

2. Winthrop KL, Park SH, Gul A, Cardiel MH, Gomez-Reino JJ, Tanaka Y, et al. Tuberculosis and other opportunistic infections in tofacitinib-treated patients with rheumatoid arthritis. Ann Rheum Dis. 2016;75(6):1133-1138. doi: 10.1136/annrheumdis-2015-207319

3. Long W, Cai F, Wang X, Zheng N, Wu R. High risk of activation of latent tuberculosis infection in rheumatic disease patients. Infect Dis (Lond). 2020;52(2):80-86. doi: 10.1080/23744235.2019.1682187

4. Brode SK, Jamieson FB, Ng R, Campitelli MA, Kwong JC, Paterson JM, et al. Increased risk of mycobacterial infections associated with anti-rheumatic medications. Thorax. 2015;70(7):677-682. doi: 10.1136/thoraxjnl-2014-206470

5. Jick SS, Lieberman ES, Rahman MU, Choi HK. Glucocorticoid use, other associated factors, and the risk of tuberculosis. Arthritis Rheum. 2006;55(1): 19-26. doi: 10.1002/art.21705

6. Prevention CfDCa, National Center for HIV/AIDS VH, STD, and TB Prevention, Elimination DoT. Latent tuberculosis infection: A guide for primary health 2020. Publication N 22-0468. URL: https://www.cdc.gov/tb/publications/ltbi/default.htm (Accessed: 30th November 2022).

7. Xiao X, Da G, Xie X, Liu X, Zhang L, Zhou B, et al. Tuberculosis in patients with systemic lupus erythematosus – A 37-year longitudinal survey-based study. J Intern Med. 2021;290(1):101-115. doi: 10.1111/joim.13218

8. Balbi GGM, Machado-Ribeiro F, Marques CDL, Signorelli F, Levy RA. The interplay between tuberculosis and systemic lupus erythematosus. Curr Opin Rheumatol. 2018;30(4):395-402. doi: 10.1097/BOR.0000000000000493

9. Ruan Q, Zhang S, Ai J, Shao L, Zhang W. Screening of latent tuberculosis infection by interferon-γ release assays in rheumatic patients: A systemic review and meta-analysis. Clin Rheumatol. 2016;35(2):417-425. doi: 10.1007/s10067-014-2817-6

10. Sargın G, Şentürk T, Ceylan E, Telli M, Çildağ S, Doğan H. TST, QuantiFERON-TB Gold test and T-SPOT.TB test for detecting latent tuberculosis infection in patients with rheumatic disease prior to anti-TNF therapy. Tuberk Toraks. 2018;66(2):136-143. doi: 10.5578/tt.66444

11. Jiang B, Ding H, Zhou L, Chen X, Chen S, Bao C. Evaluation of interferon-gamma release assay (T-SPOT.TB(™)) for diagnosis of tuberculosis infection in rheumatic disease patients. Int J Rheum Dis. 2016;19(1):38-42. doi: 10.1111/1756-185X.12772

12. Скрининг и мониторинг туберкулезной инфекции у больных, получающих иммуносупрессивные генно-инженерные биологические препараты: методические рекомендации № 133. М.;2018.

13. Kang J, Jeong DH, Yoo B, Lee CK, Kim YG, Hong S, et al. The usefulness of routine chest radiograph examinations in patients treated with TNF inhibitors for inflammatory arthritis in South Korea. Respir Med. 2018;143:109-115. doi: 10.1016/j.rmed.2018.09.005

14. Cerda OL, de Los Angeles Correa M, Granel A, Marcos AI, Giraldo C, Rillo O, et al. Tuberculin test conversion in patients with chronic inflammatory arthritis receiving biological therapy. Eur J Rheumatol. 2019;6(1):19-22. doi: 10.5152/eurjrheum.2018.18096

15. Goel N, Torralba K, Downey C, Salto L. Screening for acquired latent tuberculosis in rheumatoid arthritis patients on tumor necrosis factor inhibition therapy in Southern California. Clin Rheumatol. 2020;39(8):2291-2297. doi: 10.1007/s10067-020-04991-y

16. Насонов ЕЛ (ред.). Ревматология. Российские клинические рекомендации. М.:ГЭОТАР-Медиа;2020.

17. Bourré-Tessier J, Arino-Torregrosa M, Choquette D. Increased incidence of liver enzymes abnormalities in patients treated with isoniazid in combination with disease modifying and/or biologic agents. Clin Rheumatol. 2014;33(8): 1049-1053. doi: 10.1007/s10067-014-2528-z

18. Vanhoof J, Landewe S, Van Wijngaerden E, Geusens P. High incidence of hepatotoxicity of isoniazid treatment for tuberculosis chemoprophylaxis in patients with rheumatoid arthritis treated with methotrexate or sulfasalazine and anti-tumour necrosis factor inhibitors. Ann Rheum Dis. 2003;62(12):1241-1242. doi: 10.1136/ard.2002.004598

19. Nam SH, Oh JS, Hong S, Shim TS, Lee CK, Yoo B, et al. Early discontinuation of tofacitinib in patients with rheumatoid arthritis co-treated with rifampin for latent tuberculosis. Joint Bone Spine. 2020;87(5):475-479. doi: 10.1016/j.jbspin.2020.04.010

20. McAllister WA, Thompson PJ, Al-Habet SM, Rogers HJ. Rifampicin reduces effectiveness and bioavailability of prednisolone. Br Med J (Clin Res Ed). 1983;286(6369):923-925. doi: 10.1136/bmj.286.6369.923

21. Myint A, Tong MJ, Beaven SW. Reactivation of hepatitis B virus: A review of clinical guidelines. Clin Liver Dis (Hoboken). 2020;15(4):162-167. doi: 10.1002/cld.883

22. Reddy KR, Beavers KL, Hammond SP, Lim JK, Falck-Ytter YT; American Gastroenterological Association Institute. American Gastroenterological Association Institute guideline on the prevention and treatment of hepatitis B virus reactivation during immunosuppressive drug therapy. Gastroenterology. 2015;148(1):215-219. doi: 10.1053/j.gastro.2014.10.039

23. Koutsianas C, Thomas K, Vassilopoulos D. Reactivation of hepatitis B virus infection in rheumatic diseases: Risk and management considerations. Ther Adv Musculoskelet Dis. 2020;12:1759720X20912646. doi: 10.1177/1759720X20912646

24. Sasadeusz J, Grigg A, Hughes PD, Lee Lim S, Lucas M, McColl G, et al. Screening and prophylaxis to prevent hepatitis B reactivation: Other populations and newer agents. Clin Liver Dis. 2019;23(3):521-534. doi: 10.1016/j.cld.2019.04.012

25. Fukuda W, Hanyu T, Katayama M, Mizuki S, Okada A, Miyata M, et al. Risk stratification and clinical course of hepatitis B virus reactivation in rheumatoid arthritis patients with resolved infection: Final report of a multicenter prospective observational study at Japanese Red Cross Hospital. Arthritis Res Ther. 2019;21(1):255. doi: 10.1186/s13075-019-2053-1

26. Schwaneck EC, Krone M, Kreissl-Kemmer S, Weißbrich B, Weiss J, Tony HP, et al. Management of anti-HBc-positive patients with rheumatic diseases treated with disease-modifying antirheumatic drugs – A single-center analysis of 2054 patients. Clin Rheumatol. 2018;37(11):2963-2970. doi: 10.1007/s10067-018-4295-8

27. Chen MH, Chen MH, Chou CT, Hou MC, Tsai CY, Huang YH. Low but long-lasting risk of reversal of seroconversion in patients with rheumatoid arthritis receiving immunosuppressive therapy. Clin Gastroenterol Hepatol. 2020;18(11):2573-2581.e1. doi: 10.1016/j.cgh.2020.03.039

28. Lau CS, Chia F, Dans L, Harrison A, Hsieh TY, Jain R, et al. 2018 update of the APLAR recommendations for treatment of rheumatoid arthritis. Int J Rheum Dis. 2019;22(3):357-375. doi: 10.1111/1756-185X.13513

29. Mok CC. Hepatitis B and C infection in patients undergoing biologic and targeted therapies for rheumatic diseases. Best Pract Res Clin Rheumatol. 2018;32(6):767-780. doi: 10.1016/j.berh.2019.03.008

30. Hwang JP, Lok AS. Management of patients with hepatitis B who require immunosuppressive therapy. Nat Rev Gastroenterol Hepatol. 2014;11(4):209-219. doi: 10.1038/nrgastro.2013.216

31. Chen YM, Chen HH, Huang WN, Chen YH, Hsieh TY, Yang SS, et al. Reactivation of hepatitis B virus infection following rituximab treatment in HBsAg-negative, HBcAb-positive rheumatoid arthritis patients: A long-term, real-world observation. Int J Rheum Dis. 2019;22(6):1145-1151. doi: 10.1111/1756-185X.13582

32. Watanabe T, Fukae J, Fukaya S, Sawamukai N, Isobe M, Matsuhashi M, et al. Incidence and risk factors for reactivation from resolved hepatitis B virus in rheumatoid arthritis patients treated with biological disease-modifying antirheumatic drugs. Int J Rheum Dis. 2019;22(4):574-582. doi: 10.1111/1756-185X.13401

33. Рекомендации EASL 2017 года по лечению гепатита B на русском языке. 2017. URL: https://hcv-forum.ru/viewtopic.php?t=937%20#p4876 (Accessed: 30th November 2022).

34. Terrault NA, Lok ASF, McMahon BJ, Chang KM, Hwang JP, Jonas MM, et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology. 2018;67(4):1560-1599. doi: 10.1002/hep.29800

35. Costa L, Caso F, Atteno M, Giannitti C, Spadaro A, Ramonda R, et al. Long-term safety of anti-TNF-α in PsA patients with concomitant HCV infection: A retrospective observational multicenter study on 15 patients. Clin Rheumatol. 2014;33(2):273-276. doi: 10.1007/s10067-013-2378-0

36. Brunasso AM, Puntoni M, Gulia A, Massone C. Safety of antitumour necrosis factor agents in patients with chronic hepatitis C infection: A systematic review. Rheumatology (Oxford). 2011;50(9):1700-1711. doi: 10.1093/rheumatology/ker190

37. Sebastiani M, Milazzo L, Atzeni F, Vacchi C, Manfredi A, Quartuccio L, et al. Italian consensus recommendations for the management of hepatitis C infection in patients with rheumatoid arthritis. Mod Rheumatol. 2019;29(6):895-902. doi: 10.1080/14397595.2018.1558918

38. Гриднева ГИ, Белов БС. Актуальные вопросы ведения пациентов с ВИЧ-инфекцией и ревматическими заболеваниями. Современная ревматология. 2021;15(6):7-12. doi: 10.14412/1996-7012-2021-6-7-12

39. Cates M, Donati M, Gillet S, Ustianowski A, Galloway J. Managing varicella zoster virus contact and infection in patients on antirheumatic therapy. Rheumatology (Oxford). 2018;57(4):596-605. doi: 10.1093/rheumatology/kex189

40. Winthrop KL, Tanaka Y, Lee EB, Wollenhaupt J, Al Enizi A, Azevedo VF, et al. Prevention and management of herpes zoster in patients with rheumatoid arthritis and psoriatic arthritis: A clinical review. Clin Exp Rheumatol. 2022;40(1):162-172. doi: 10.55563/clinexprheumatol/cpu6r9

41. Honda N, Tagashira Y, Kawai S, Kobayashi T, Yamamoto M, Shimada K, et al. Reduction of Pneumocystis jirovecii pneumonia and bloodstream infections by trimethoprim-sulfamethoxazole prophylaxis in patients with rheumatic diseases. Scand J Rheumatol. 2021;50(5):365-371. doi: 10.1080/03009742.2020.1850854

42. Park JW, Curtis JR, Kim MJ, Lee H, Song YW, Lee EB. Pneumocystis pneumonia in patients with rheumatic diseases receiving prolonged, non-high-dose steroids-clinical implication of primary prophylaxis using trimethoprim-sulfamethoxazole. Arthritis Res Ther. 2019;21(1):207. doi: 10.1186/s13075-019-1996-6

43. Wolfe RM, Peacock JE Jr. Pneumocystis pneumonia and the rheumatologist: Which patients are at risk and how can PCP be prevented? Curr Rheumatol Rep. 2017;19(6):35. doi: 10.1007/s11926-017-0664-6

44. Park JW, Curtis JR, Moon J, Song YW, Kim S, Lee EB. Prophylactic effect of trimethoprim-sulfamethoxazole for pneumocystis pneumonia in patients with rheumatic diseases exposed to prolonged high-dose glucocorticoids. Ann Rheum Dis. 2018;77(5):644-649. doi: 10.1136/annrheumdis-2017-211796

45. Vela Casasempere P, Ruiz Torregrosa P, García Sevila R. Pneumocystis jirovecii in immunocompromised patients with rheumatic diseases. Reumatol Clin (Engl Ed). 2021;17(5):290-296. doi: 10.1016/j.reuma.2020.02.006

46. Hsu HC, Chang YS, Hou TY, Chen LF, Hu LF, Lin TM, et al. Pneumocystis jirovecii pneumonia in autoimmune rheumatic diseases: A nationwide population-based study. Clin Rheumatol. 2021;40(9):3755-3763. doi: 10.1007/s10067-021-05660-4

47. Mori S, Sugimoto M. Pneumocystis jirovecii pneumonia in rheumatoid arthritis patients: Risks and prophylaxis recommendations. Clin Med Insights Circ Respir Pulm Med. 2015;9(Suppl 1):29-40. doi: 10.4137/CCRPM.S23286

48. Teichmann LL, Woenckhaus M, Vogel C, Salzberger B, Schölmerich J, Fleck M. Fatal pneumocystis pneumonia following rituximab administration for rheumatoid arthritis. Rheumatology (Oxford). 2008;47(8):1256-1257. doi: 10.1093/rheumatology/ken234

49. King C, Harper L, Little M. The complications of vasculitis and its treatment. Best Pract Res Clin Rheumatol. 2018;32(1):125-136. doi: 10.1016/j.berh.2018.07.009

50. Galli M, Antinori S, Atzeni F, Meroni L, Riva A, Scirè C, et al. Recommendations for the management of pulmonary fungal infections in patients with rheumatoid arthritis. Clin Exp Rheumatol. 2017;35(6):1018-1028.

51. Harada T, Kato R, Sueda Y, Funaki Y, Takata M, Okazaki R, et al. The efficacy and safety of reduced-dose sulfamethoxazoletrimethoprim for chemoprophylaxis of pneumocystis pneumonia in patients with rheumatic diseases. Mod Rheumatol. 2021;31(3):629-635. doi: 10.1080/14397595.2020.1812834

52. Utsunomiya M, Dobashi H, Odani T, Saito K, Yokogawa N, Nagasaka K, et al. Optimal regimens of sulfamethoxazoletrimetho prim for chemoprophylaxis of pneumocystis pneumonia in patients with systemic rheumatic diseases: results from a nonblinded, randomized controlled trial. Arthritis Res Ther. 2017;19(1):7. doi: 10.1186/s13075-016-1206-8

53. Suyama Y, Okada M. Can we prescribe TMP/SMX prophylaxis without any concerns equally for all patients with rheumatic disease? Ann Rheum Dis. 2019;78(2):17. doi: 10.1136/annrheumdis-2018-213027

54. Sonomoto K, Tanaka H, Nguyen TM, Yoshinari H, Nakano K, Nakayamada S, et al. Prophylaxis against pneumocystis pneumonia in rheumatoid arthritis patients treated with b/tsDMARDs: Insights from 3787 cases in the FIRST registry. Rheumatology (Oxford). 2022;61(5):1831-1840. doi: 10.1093/rheumatology/keab647

55. Jinno S, Akashi K, Onishi A, Nose Y, Yamashita M, Saegusa J. Comparative effectiveness of trimethoprim-sulfamethoxazole versus atovaquone for the prophylaxis of pneumocystis pneumonia in patients with connective tissue diseases receiving prolonged high-dose glucocorticoids. Rheumatol Int. 2022;42(8):1403-1409. doi: 10.1007/s00296-021-04945-w

56. Kitazawa T, Seo K, Yoshino Y, Asako K, Kikuchi H, Kono H, et al. Efficacies of atovaquone, pentamidine, and trimethoprim/sulfamethoxazole for the prevention of Pneumocystis jirovecii pneumonia in patients with connective tissue diseases. J Infect Chemother. 2019;25(5):351-354. doi: 10.1016/j.jiac.2019.01.005

57. Stamp LK, Hurst M. Is there a role for consensus guidelines for P. jiroveci pneumonia prophylaxis in immunosuppressed patients with rheumatic diseases? J Rheumatol. 2010;37(4):686-688. doi: 10.3899/jrheum.091426

58. Fragoulis GE, Dey M, Zhao S, Schoones J, Courvoisier D, Galloway J, et al. Systematic literature review informing the 2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases. RMD Open. 2022;8(2):e002726. doi: 10.1136/rmdopen-2022-002726