What is the relationship between Pneumonia and Rheumatoid Arthritis (RA)?

From the Guidelines

Patients with rheumatoid arthritis (RA) should receive pneumococcal vaccination, including both PCV13 and PPSV23, as well as annual influenza vaccination, to prevent pneumonia and other infections, as recommended by the 2020 EULAR guidelines 1. The risk of pulmonary infection is particularly high for patients with RA, with a study showing that the highest rate of hospitalization for infection was due to pneumonia (37%) 1. The 2020 EULAR guidelines recommend pneumococcal vaccination for the majority of patients with autoimmune inflammatory rheumatic diseases, including RA, to prevent pneumococcal disease 1. The guidelines also recommend influenza vaccination for the majority of patients with RA, as the risk of influenza infection is increased in these patients, and vaccination can help prevent influenza and its complications 1. In terms of treatment, RA patients with pneumonia should receive appropriate antibiotics, and temporary discontinuation of immunosuppressive medications, especially biologics and JAK inhibitors, may be necessary during active infection 1. Prevention strategies, including vaccination and screening for latent tuberculosis, are crucial to prevent infections in RA patients 1. Key points to consider in the management of RA patients with pneumonia include:

• Pneumococcal vaccination, including both PCV13 and PPSV23
• Annual influenza vaccination
• Screening for latent tuberculosis before starting biologics or JAK inhibitors
• Temporary discontinuation of immunosuppressive medications during active infection
• Prompt evaluation of respiratory symptoms to prevent delayed diagnosis and treatment.

From the Research

Pneumonia in Rheumatoid Arthritis

• Pneumonia is a major cause of mortality and morbidity in rheumatoid arthritis (RA) patients 2
• The risk of pneumonia hospitalization is increased in RA patients, with a dose-related relationship between prednisone use and pneumonia risk 2
• RA patients with pneumonia are more likely to have underlying respiratory disease, and the most frequent causative microbial agents of pneumonia in RA patients are Streptococcus pneumoniae, Pseudomonas aeruginosa, Haemophilus influenzae, Mycoplasma pneumoniae, and influenza virus 3

Risk Factors for Pneumonia in RA Patients

• Female sex, non-smoker, and respiratory comorbidities are statistically more frequent in RA patients than non-RA patients 3
• Polymicrobial infection is more frequent in RA patients than non-RA patients 3
• P. aeruginosa, H. influenzae, M. catarrhalis, and polymicrobial infection are statistically more frequent etiologies of pneumonia in RA patients than non-RA patients 3
• RA itself is an independent risk factor for mortality from pneumonia 3

Treatment and Prophylaxis

• Prophylactic antibiotics should be considered for RA patients who are scheduled to receive antirheumatic therapy, especially those at risk of Pneumocystis jirovecii pneumonia (PCP) 4
• Short-term prophylaxis with trimethoprim-sulfamethoxazole is effective in controlling P. jirovecii infection and preventing future outbreaks of PCP among RA patients 4
• Levofloxacin treatment has been shown to be effective in improving the signs and symptoms of rheumatoid arthritis in patients receiving methotrexate 5

Pneumocystis Jirovecii Pneumonia in RA Patients

• PCP is a serious complication that may occur early in the course of infliximab therapy in RA patients 6
• The median length of time from the first infliximab infusion to the development of PCP is 8.5 weeks 6
• Patients with PCP have significantly lower serum albumin levels and lower serum IgG levels than patients without PCP 6