Patients with autoimmune disease are at increased risk not only for opportunistic infections such as Pneumocystis jiroveci pneumonia (PJP), but also for more common infections such as influenza and bacterial pneumonias. A session on Sunday, Vaccines & PJP Prophylaxis: Protecting Our Patients, focused on the risks and benefits of vaccinations for common infectious diseases as well as strategies to risk-stratify patients for PJP and recommend appropriate therapy.
Leonard Calabrese, DO, Professor of Medicine and RJ Fasenmyer Chair of Clinical Immunology at the Cleveland Clinic Lerner College of Medicine, opened the session with a discussion of common infections, such as influenza, and the importance of creating an individualized vaccination schedule for the immunocompromised patient.
“With regards to the flu vaccine, we know that autoimmune disease patients have a higher risk of contracting influenza than the general population, and we know that vaccination to influenza is protective both serologically and clinically,” Dr. Calabrese said. “For the killed vaccine, ACR-EULAR guidelines recommend getting the vaccine two weeks prior to immunosuppression, especially for rituximab. For the live vaccine, ideally two to four weeks before immunosuppression, and it may be considered with caution in patients with autoimmune inflammatory rheumatic diseases.”
Importantly, he noted, recent studies have suggested that methotrexate suppresses immunogenicity of flu vaccine by 10%-20%, and some recommendations are now suggesting that methotrexate should be withheld for two doses following seasonal flu vaccination.
“Patients with rheumatic disease have increased infection morbidity and mortality, along with risk factors such as age, various comorbidities, cytopenias, and extra-articular disease immunosuppression,” Dr. Calabrese said. “Vaccination is the best mode of infection prevention, and it also reduces severity and prevents complications. Yet, vaccine uptake remains low in the United States and other countries and well below the WHO target of 75% for influenza.”
Robin Avery, MD, Professor of Medicine in the Division of Infectious Diseases at Johns Hopkins University, followed with a discussion on the risks, benefits and effectiveness of PJP prophylaxis.
“PJP is a potentially devastating lung infection which primarily affects immunocompromised patients,” Dr. Avery said. “It was one of the most common opportunistic infections seen during the HIV era, prior to the advent of effective antiretroviral therapy, but now is seen mainly in non-HIV immunocompromised patients, in whom it carries a 35%-45% mortality risk.”
Prophylaxis with agents such as trimethoprim-sulfamethoxazole is recommended in consensus guidelines for certain patients with transplants or cancer, she said, but noted that there is still controversy in the field of rheumatology as to which patients with rheumatologic diagnoses are at higher risk, warranting prophylaxis.
“A risk-stratified approach is warranted for decision-making on Pneumocystis prophylaxis in rheumatology,” Dr. Avery said. “There is agreement on the general shape of such an approach, but the finer details remain to be decided. Ideally, a committee would review and formally grade the evidence and develop a rigorous consensus guideline, based on available data on underlying disease, immunosuppressive agents, laboratory results, regional factors, and other risk factors.”