358. Effectiveness of antimicrobial prophylaxis strategies in ANCA vasculitis: a scoping review of current evidence
Creators: name: Jacob Robinson1, 2
Publisher: name: Zenodo
Year: 2022
Subjects: Vasculitis
ANCA
Abstracts
Giant Cell Arthritis
MPA
GPA
EGPA
Takayasu
IgA vasculitis

description: <strong>Objective</strong>: Severe infections associated with use of strong immunosuppressive medication are a leading cause of morbidity and mortality in patients with ANCA vasculitis (AV). Treatment guidelines for AV conditionally recommend prophylaxis against <em>Pneumocystis jirovecii</em> pneumonia (PJP) with trimethoprim/sulfamethoxazole (TMP/SMX), but note the lack of robust, high quality evidence directly adessing prophylaxis strategies in AV patients. We conducted this scoping review to map the extent and type of evidence currently available to inform decisions about infection prophylaxis strategies in AV, in order to identify gaps in knowledge and guide the design of future studies. <strong>Method:</strong> The Preferred Reporting Ite for Systematic Reviews and Meta-Analysis – extension for Scoping Reviews (PRISMA-ScR) guided our approach. We conducted a comprehensive search of six databases, and reference lists of reviews identified through this search, to identify original research studies published in English between January 1,2000 – July 31, 2020. We included studies that reported the effect of any type of antimicrobial infection prophylaxis strategy (compared to no treatment or another prophylaxis strategy) on infection-related outcomes in AV patients being treated with immunosuppressive medication for remission induction or maintenance. Studies were screened in duplicate for inclusion in two stages (abstract and full-text review) by four researchers using a blinded approach. Data was extracted by two reviewers, with differences resolved via consensus in consultation with a third reviewer. <strong>Results:</strong> Nineteen studies met inclusion criteria, including two randomized trials and 17 cohort studies. Sixteen studies were restricted to AV patients only, while three studies included AV patients alongside patients with other for of vasculitis or autoimmune conditions. Most studies included small samples, with seven studies consisting of fewer than 100 patients, and all but two studies with fewer than 200 participants. TMP-SMX was the most commonly assessed prophylactic strategy, and was most often compared to no prophylaxis (8 studies). Eight other studies compared the effect of receiving any prophylaxis with at least one of multiple agents (e.g., TMP-SMX, pentamidine, dapsone, mupirocin, ciloxacin, antifungals, and/or antivirals) to no prophylaxis. Three studies compared use of antiviral agents to no prophylaxis. In the cohort studies, the proportion receiving prophylaxis with the agent(s) studied was highly variable, ranging from 17% to 92%. Studies were also heterogeneous with regard to specific outcomes studied. The most common outcomes included <em>pneumocystis jirovecii</em> pneumonia (PJP), serious infections (e.g., requiring hospitalization or intravenous antibiotics), or any infection; other outcomes included specific types of infections (e.g., cytomegalovirus reactivation, herpes zoster, fungal infections), disease relapse, mortality, adverse ug events, and chronic staphylococcus aureus nasal carriage. Most cohort studies included no or very limited control of potential confounding factors. <strong>Conclusion:</strong> This scoping review suggests widespread variation in use of recommended and alternative infection prophylaxis strategies in AV. Larger, controlled investigations are critically needed to compare the effectiveness of guideline-recommended TMP-SMX prophylaxis and alternative antibacterial, antiviral, and antifungal strategies, particularly with emerging novel immunosuppressive therapies and approaches to minimize corticosteroid use. Such evidence is needed to develop more comprehensive and robust recommendations about infection prophylaxis strategies for AV patients, similar to those that exist for other immunocompromised patient populations. <strong>Disclosures</strong>: None