Pre-talk Questions. Infections and Lupus. Pre-talk Questions. Pre-talk Questions. 1) What is the best treatment for a cold?

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1 Infections and Lupus 1) What is the best treatment for a cold? a) Chicken soup b) Zinc losenges c) Echinacea d) Antibiotics (such as azithromycin Z-Pak) Donald Thomas, MD, FACP, FACR, CCD Arthritis and Pain Associates of PG County Greenbelt and Clinton, MD (301) ) If you have Sjogren s syndrome (causing dry mouth) and your tongue is sore and red, what is the likely cause? a) Bacterial infection b) Thrush c) Alcohol abuse d) Inflammation from your lupus 3) Which of the following medicines suppress the immune system? (2 answers) a) CellCept b) Prednisone 2 mg a day c) Plaquenil d) Methotrexate 1

2 4) Which of the following vaccines should lupus patients who are immunosuppressed NOT get? a) Influenza vaccine (flu shot) b) Pneumovax (pneumonia vaccine) c) Tetanus booster shot d) Nasal H1N1 vaccine 5) Which of the following keeps Plaquenil from working? a) Smoking b) Drinking beer c) Staying out of the sun d) Taking it with food 6) You are having some pleurisy and active arthritis from your lupus and it is time to get the flu shot. What should you do? a) Go ahead and get the flu shot b) Wait until your lupus is under better control c) Wait until next year d) Use the nasal spray influenza vaccine 7) Your granddaughter gets her MMR vaccine and you are on an immunosuppressant medicine. What should you do? a) Kiss her and comfort her b) Avoid contact for 2 weeks c) Give her Echinacea d) Have her come over for homemade cookies 2

3 9) What percent of deaths in SLE patients are due to infection? a) 5% b) 15% c) 30% d) 60% 8) If you have lupus, which of the following antibiotics should you say you are allergic to? a) Penicillin b) Azithromycin c) Levaquin d) Sulfa What kills lupus patients? Early after diagnosis (1 st 1-2 years): Active lupus disease (most common cause) Severe infection (2 nd most common cause) Late after diagnosis Severe infection Active lupus disease Cardiovascular disease What kills lupus patients? 30% of all deaths in patients with systemic lupus are due to infection 3

4 What we will cover: What is an infection? Why do lupus patients get infections? Preventing infections Treating infections What is an infection? Definition: Another organism (germ) living in the body Germ gets nourishment from the body Germ multiplies/damages tissues of the body Germs: Quantity + Strength What causes infections: Body s protection: Skin Intestinal tract Respiratory tract Symptoms of infection? Immune system attacks the germs This can cause inflammation Redness Swelling Heat Pain Pus Beneficial organisms Immune system 4

5 What kinds of organisms (germs)? Bacteria Examples: strep throat, most urinary tract infections Treated with common antibacterial antibiotics Penicillin, Septra, Levaquin, etc. Viruses Examples: colds, flu, shingles, HIV, herpes, stomach flu Most have no treatment HIV, herpes, CMV, influenza do have treatments Fungus Examples: thrush, athlete s foot, vaginal yeast infection Protozoal parasites Examples: tapeworm, malaria Infections most common in lupus: Respiratory tract infections Colds Sneezing, dry cough, muscle aches, fever Bronchitis Cough, wheezing, muscle aches, fever Sinusitis Facial pain, facial congestion, fever Pneumonia Cough, sputum production, fever, chest pain Urinary tract infections (UTI) urine frequency, painful urination, urgency to urinate, lower back pain Thrush (candida yeast infection of mouth) White coating in mouth, red tender tongue Thrush Thrush in Sjogren s Syndrome 5

6 Why do lupus patients get infections? Abnormal immune system Immunosuppressant medications Prednisone > 7.5 mg a day Methotrexate Imuran (azathioprine) CellCept (mycophenolate) Cytoxan (cyclophospamide) Biologic medications Enbrel, Humira, Remicade, Simponi, Rituximab Telling the difference between lupus and infection Both cause: Fevers Body aches Fatigue Telling the difference between lupus and infection Increase suspicion for infection: Shaking chills High white blood cell count (if not on prednisone) Absence of lupus affecting multiple parts of body Preventing Infections: Maximize therapies that don t suppress immune system Vaccinations Prophylactic antibiotics 6

7 Preventing Infections: Maximize therapies that don t suppress immune system Decreases the need for immunosuppressant medicines Use sunscreen daily Take Plaquenil daily Do not smoke Proper rest Regular exercise Eat healthy Preventing Infections: Vaccinations Pneumovax Pneumonia = #1 cause of death from infection in lupus Prevents pneumonia from pneumococcus 1 2 times during lifetime Flu shot (influenza vaccine) Kills 20,000 30,000 Americans yearly Majority are immunosuppressed, elderly, and unvaccinated Every fall Never causes the flu H1N1 ( swine flu ) Only need 1 Tetanus/diphtheria booster every 10 years Preventing Infections: Vaccinations (special considerations) Hepatitis B if household member has chronic hepatitis B Meningococcal vaccine if you have had your spleen removed Special Vaccine Considerations: Avoid live vaccines (if on immunosuppressant medicines): MMR (measles, mumps, rubella) OPV (polio) (OK to get eipv) BCG Vaccinia Typhoid Yellow fever Nasal influenza and H1N1 vaccines Shingles (Zostavax) 7

8 Special Vaccine Considerations: If not on immunosuppressant medicine: Consider Zostavax (shingles vaccine) if 60 years old 20% of lupus patients get shingles Causes a severe, painful rash Pain can last for months to years Shingles Special Vaccine Considerations: Do not get any vaccination if: Lupus is significantly active On 40mg a day of prednisone or more Wait until you are on 20mg a day or less Special Vaccine Considerations: If a close contact receives a live virus vaccine and you are immunosuppressed: Avoid contact for 2 weeks Avoid contact for 1 month if they received OPV Close contacts should get the eipv polio vaccine instead of the OPV 8

9 Antibiotics before dental work: To prevent heart valve infection (endocarditis) If you have a heart valve problem Diagnosed with an echocardiogram If you are positive for antiphospholipid antibodies, you are at higher risk for heart valve problems Some rheumatologists ask all of their patients to get antibiotics before dental work Treating infection Call and see your primary care doctor (or go to ER) ASAP if: Have a fever Shaking chills Coughing up sputum Facial pain and fever or drainage Urination pain, frequency, urgency Your doctor may also ask you to call and see your rheumatologist To see if your lupus is active Treating Infection: Shingles Painful rash with little fluid filled bumps Occurs on one side of body Due to chicken pox virus The virus stays in the body and lives inside the nerves after you get chicken pox as a child Can cause chronic nerve damage pain The quicker it is treated, the better it does Treating Infection: Never take sulfonamide (sulfa) antibiotics: Septra Bactrim Trimethoprim-sulfamethoxizole Gantrisin Sulfadiazine List sulfa as an allergy Can cause lupus to flare 9

10 Treating Infection: Always take all of your prescribed antibiotics There should never be any pills left over If you are getting worse: call your PCP ASAP 10