PARIS — Methicillin-resistant Staphylococcus aureus infections have been reported for the first time in patients with rheumatoid arthritis being treated with tumor necrosis factor inhibitors.
In a poster presented at the annual European Congress of Rheumatology, Dr. Jack Lichtenstein noted that he had observed that several of his patients receiving tumor necrosis factor (TNF) inhibitors developed severe methicillin-resistant S. aureus (MRSA) infections, so he undertook a review of medical records of all patients in his clinical practice being treated with these drugs between August 2003 and July 2006 to determine the overall incidence and severity of these infections.
Among 430 patients receiving infliximab, etanercept, or adalimumab, 15 developed MRSA infections, had to stop TNF inhibitor therapy and received intravenous antibiotics, reported Dr. Lichtenstein, a rheumatologist in group practice in Annapolis, Md.
In addition, 12 patients required hospitalization.
Concomitant immunosuppressive treatment included prednisone in 12 patients and methotrexate in 6. Clinical presentations included cellulitis in six, osteomyelitis in three, sinusitis in two, and septic arthritis, mastitis, pneumonia, and Fournier's gangrene with sepsis in one each.
More than half of the infections occurred within the first 6 months of treatment, but four developed after more than a year of therapy. Six were seen in patients on infliximab, five in those on etanercept, and four in those on adalimumab.
Another 10 patients developed methicillin-sensitive S. aureus (MSSA) infections, 5 of which were cellulitis, 4 of which were septic arthritis, and 1 osteomyelitis. Seven of these required hospitalization and nine were given intravenous antibiotics.
Other bacterial infections seen in anti-TNF-treated patients included gram-negative bacterial cellulitis in four, severe Clostridium difficile infections in three, and tuberculosis with fatal pneumonia, Mycobacterium marinum joint infection, and Nocardia pneumonia in one each.
Other infections for which no bacterial agent was cultured included cellulitis in nine, pneumonia in six, and diverticulitis in two.
MRSA and MSSA infections were more common than were other bacterial infections in this group of anti-TNF-treated patients, according to Dr. Lichtenstein, who noted that MRSA infections may have a protracted course and may not respond to available treatments.
Attempts to restart TNF inhibitors after control of the MRSA infections led to recurrent infection in seven patients, and only two patients were able to resume TNF inhibitor therapy after the infection was controlled.
Dr. Lichtenstein wrote that he would no longer continue the use of TNF inhibitors in patients with MRSA or MSSA infections.
About one-third of Americans are carriers of MSSA and 0.8% carry MRSA, and infections with these organisms are expected to be common in immunocompromised patients such as these.
This study was wholly funded by the investigators and had no pharmaceutical, institutional, or financial support.
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BonnieT
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The trouble is that we know that some people get very seriously ill on Rheum. meds, but not taking them isn't a good option either. Thinking devil and deep blue sea.
Yes, that works thanks. And yes something presented at the european congress will be reputable.
However, I think you have drawn slightly the wrong conclusion. The issue he is highlighting is that anti-TNF treatments increase risks of getting MRSA. And points out this is most likely in first 6 months of treatment which is not actually news as it's well known that biologics increase your risk of infection especially in first 6 months. So his new bit is to add MRSA to the list of possible infections.
As for Methotrexate, it is really just a statement of fact that 6 of the patients were also on Methotrexate. It has a far, far smaller immnosuppressive effect than anti-TNFs. And nowhere in this or any other research I've read is MTX alone linked to MRSA.
He does also point out how relatively common MRSA is whether or not you take anti-TNFs, so not surprising that it's an issue with biologics.
Which reminds me to go and wash my hands again....
You must be an admin. Thank you for putting this in intelligible, and calming, words for me. Two of my friends had MRSA within the last six months. I hadn’t seen them, so I know it’s not contact. 15 years ago a close relative acquired it and has used hibiclens for washing ever since. He told me to use it on my arm. I did. My arm is much better today but the original dime sized red mark with small white center is still very visible. As it’s only day two on antibiotics, I’m hoping it will improve more by tomorrow. Thank you again, helixhelix.
I know several people who have had it. It is awful. Hope your Mum is doing well.
Umm..I think once you have had a nasty experience you are bound to be much more aware of the hazards. I think its a really difficult balance between taking precautions and getting on with your life. i hope you can stay infection free from now on!
Thank you BonnieT, In your original mail I understood you were afraid of taking mtx. It has not been shown that this puts you in a special risk catagory whereas there are in fact other studies as well on biologics connected with same issues as in the article. As HH said it's not an easy choice but taking the risk is perhaps a better alternative.
For my whole life, as taught to me by my mother, wash the wound, pour peroxide over it (it usually Bubbles a bit and sometimes stings a bit), then apply antibiotic cream and a bandage. Clean again the same next day. On third day, or sooner if it gets worse, get to doctor. If it’s better, clean and bandaid only during the day. No bandage that night. Should be really good next day. Bandage only as protection.
That people on immune suppressants are more prone to MRSA, or any other infection, comes at no surprise to me. In fact I've taken it for granted for a long time.....
A few years ago I was hospitalised with septic arthritis. The orthopaedic consultant at the time blamed enbrel, which I'd been taking for approx 4 months, for making it easier for the bug from a recent UTI I'd had to access my bloodstream and advised me not to take it again. I was also on methotrexate but he seemed less concerned about that.
On a more positive note, and not a moment too soon if you ask me, I recently heard on the news that one or more of the drug companies have been working on a new antibiotic, which they claim will be effective against currently resistant bacteria. Not sure of the details, but from what I could gather...they reckon this new antibiotic can disguise itself as some sort of molecule or whatever that the nasty bacteria cannot resist attacking, and when they do they get destroyed by the antibiotic. A sort of wooden horse of troy analogy if you like. Results so far are very promising and the medical professional speaking gave a time period of 6 months to two years for it to come into use.
Hospitals have antibiotics now for MRSA which they hold back on prescribing ie GP’s can’t prescribe them, so that we don’t make the same mistake again with overuse and bacteria becoming resistant. They can be given by hospitals only. I’m just getting over MRSA now, this is 12 months after the initial infection and I’m not yet on biologics. I’ve been waiting and waiting for this baricitinib but they want the rash on my legs to clear up completely first. I’m heartily sick of the routine I’ve spent the whole year doing. Bathing my legs in Hibiscrub, shower using Dermol, then rubbing cicaplast into the area of the spots - well, they’re ulcers really. After a few weeks or if I’m lucky months, the infection gets the upper hand and it’s back on erythromycin as Fluclox has become useless now too. I’m having more success with toothpaste than anything else. At least it acts as an astringent and dries them out.
I'm sorry to hear that, 12 months is a long long time but at least you seem to be over the worst of it. I presume the rash on your legs is related to the MRSA ?
It took about 6 months for me to recover, if you can call it recover, from the septic arthritis in my hip and that was bad enough. They had to operate to clean out the infection then blanket bomb it for 5 or 6 days with a cocktail of those strong antibiotics they keep on the top shelf. Was then discharged with a carrier bag full of potent oral antibiotics. So potent was one type that it made me so ill I ended up back in hospital for a couple more days.....oh the fun of it all!
I'm only on a low dose of baricitinib but it is helping my RA. Is there a specific reason why you are going on that and not some other med?
Thanks Bonnie, it hasn't been much fun since I stopped taking immune suppressants following the septic arthritis episode. That said, I'm feeling much better since starting baricitinib, and though not as good as I was pre-septic arthritis days, if the baricitinib keeps doing its job and I don't get any worse then I'm ok with that.
I’m being started on that because it’s a new drug my specialist nurse likes. They’ve only had it at the hospital for about a year.
The rash on my legs - the folliculitis - is MRSA, yes. I think it’s all gone now, but traces of past spots will be visible for at least a year if it follows previous patterns.
There are only a few meds that my rheumy thought suitable for me, and we narrowed them down to azathioprine an baricitinib. She preferred the latter as did an immunologist she referred me to for tests, and to hear his opinion.
I also have a skin condition, which leaves scars mostly on my back, upper chest and face. I've had swabs taken a couple of times, thankfully no nasty bacteria have been found.
Good luck to you, and hope your rash clears up soon so you can get started on the baricitinib.
Thank you 😊 sadly the chance of being prescribed it are lessening as time passes and it seems I need to wait “in limbo” until I’ve at least been seen by dermatology (who are dragging their feet arranging an appointment) or my inflammatory markers go off the scale again. Grrrrr!
So sorry you’re enduring this. But stay strong. About 15 years ago I had a severe bout with what was diagnosed as shingles. I spent six months dragging my leg around as if it were an anchor. In much pain. Four doctors could not come up with help for my open lesions that traveled from my sciatic nerve down my left leg to my foot and toes where they were most prominent. The fifth doctor was a dermatologist. He said he wished I had come to him first he may not have diagnosed shingles but did not say what he thought it might be. He prescribed an ointment called Ultravate which began healing the sores in two days. Took a few weeks to clear it all and I’ve been left with permanent nerve damage and neuropathy which gets worse as I age. I believe the ointment was a steroid the other doctors had never heard of it. I guess it depends on the experiences of the doctors and second and third opinions matter.
I’ve seen a tv documentary about things they are using to fight final stage cancers that are working such as injecting a live measles vaccine or cold virus into person/tumor which has cured the patients. We know so much yet still learn. Amazing what some minds do while mine seems to just sit on my shoulders.
And so many things tried before and forgotten. In the beginning of 1900 there was a doctor who had a terminally ill cancer patient that got a strong bacterial infection in the hospital. The patients temp rose dangerously high. After the temp falling the tumor was gone as well. This doctor, whom you can read about in the history of medicine, started infecting his cancer patients with bacteria, some died, others immunesystems were not able to raise the temp high enough and there were also several that were cured. Then to make the therapy safer he infected his patients with dead bacteria. This method is long forgotten, was never developed further. There used to be a number of " miracle " healings in history where high temperature had always been a part of it.
There was also an analysys of why these miracle healings have decreased. The reason could perhaps be found in the new treatment methods where the muscle has been taken away from the immune-system. Who knows.
Unfortunately it’s a fact that the anti TNFs can cause nasty infections in some people. This is well explained in all the blurb they give you before you start taking them. As Helix said MXT is a baby in these stakes as it’s only a mild immunosuppressive.
I suppose the main worry is the situation with antibiotics now but I hope to goodness they come up with something new soon.
I take Adalimumab and it has transformed my life. There’s no way I want to give it up. I’ve taken it for 6 months and the last 3 months I have felt really well with energy and very little pain. 😁
Antibiotic resistance is a big concern, especially for someone like me who is taking immune suppressants and is prone to infections. It was/is frightening how fast the e.coli type bug that causes my infections became resistant to all of the common antibiotics. If I should get an infection now then I have to bypass my GP and go straight to hospital for IVAs.
After a long abstinence from immune suppressing meds, which has taken its toll on me, I've recently started taking the fairly new drug - baricitinib. The main reason my rheumy chose this is because it leaves the body far quicker than other meds, within a day or two I've been told. So theoretically at least, that should give my immune system more chance of fighting any infection I might get.
Sorry to hear about your resistant infections. It is a worry and the one thing that really scares me about taking these drugs. It would scare me even I wasn’t! Still, hey ho, it’s the usual weighing up the benefits against the possible side effects again. Wish we didn’t have to make these choices. x
Hope I don't sound alarmist as I don't mean to. I'm only experiencing these problems because I have another health condition which makes me prone to infections. I've had RA for 15+ years and never had a single infection until this particular condition reared its ugly head about 5 years ago.
Hi, Downtime! Happy to hear Adalimumab has helped you so much. It gives us hope to find a drug that will help. My breast doc told me that methotrexate was originally developed to help with breast cancer and found that it helped other ills as well. Just a fact I found interesting. Thank you for responding.
Interesting though this article is my attitude is your going to die if you worry about it and your going to die if you don't. I will live my life as best as i can knowing it will get me in the end.xxx
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