Serious infections in Rheumatoid Arthritis and strategies for their prevention: A review and discussion of implications for clinical practice

Introduction: Serious infections (SIs) in rheumatoid arthritis (RA) are common and may be life-threatening or fatal. The goal of this review was to assess the spectrum of SIs in RA, review potential causes for these SIs and to formulate strategies for prevention. Methods: We performed a systematic review that included multiple databases viz. PubMed, Medline, Scopus, and Google Scholar. Search terms used were 'Rheumatoid Arthritis AND infection'. Searches were limited to the title of articles, human subjects and non-juvenile arthritis and to those articles published in English. Results: In total, 3,324 articles, identified through PubMed, Medline, Scopus and Google Scholar repository were found. After removing duplicates, 825 articles remained for further screening from which 141 articles were selected. These were further assessed and 110 were then excluded because 31 articles were case reports, 35 focused on young subjects (<16 years) and 44 studies focused on non-serious infection. Overall, only 31 studies met our selection criteria. Conclusion: SIs are far more common in RA than in the general population. Corticosteroids are associated with an appreciable increase in SI risk. Most commonly used and currently favored synthetic DMARDs confer a small or no risk, biologic DMARDs confer moderate risk in the first year of therapy and then a diminishing risk thereafter, and higher dose biologic or combination biologic therapy should be avoided since the SI risk is unacceptably high. Undetectable Mannose Binding Lectin (MBL) is a major risk factor for SI in RA, comparable to Prednisolone.