Can Dupixent (dupilumab) be continued in a patient with a salmonella skin infection?

Management of Dupilumab in a Patient with Salmonella Skin Infection

Dupilumab should be temporarily withheld until resolution of the active Salmonella skin infection, as immunosuppressive therapy is considered a high-risk predisposing condition for Salmonella infections. 1

Rationale for Temporary Discontinuation

• Immunosuppressive therapy, including biologic agents, is considered a high-risk predisposing condition for Salmonella infections and should be temporarily withheld until resolution of the active infection 1
• Patients receiving immunosuppressive agents are at risk of more severe infections with Salmonella enteritidis and S. typhimurium 1
• The European Crohn's and Colitis Organization (ECCO) guidelines specifically recommend temporarily withholding immunomodulators until resolution of active Salmonella infection 1

Treatment Approach for the Salmonella Skin Infection

• The patient should be treated with appropriate antibiotics based on susceptibility testing 1:

  • Fluoroquinolones (e.g., ciprofloxacin) or third-generation cephalosporins are the first-line treatments 1
  • For skin infections specifically, sulphamethoxazole/trimethoprim and/or ceftriaxone or carbapenems alone or in combination may be used 1
  • Specialist advice should be sought for management 1

• Antibiotic therapy should be prolonged until the complete disappearance of all skin lesions 1

  • It is advisable to continue antibiotics until complete resolution of all lesions to prevent recurrence 1

When to Restart Dupilumab

• Dupilumab can be restarted after complete resolution of the active Salmonella infection 1
• There is no specific guidance on the exact timing, but clinical practice suggests waiting until:
  • Complete resolution of all skin lesions 1
  • Negative follow-up cultures (if obtained) 1
  • Resolution of systemic symptoms 1

Monitoring After Restarting Therapy

• Once dupilumab is restarted, the patient should be monitored closely for:
  • Signs of recurrent infection 1
  • New skin lesions 1
  • Systemic symptoms such as fever 1

Important Considerations

• While dupilumab has shown a favorable safety profile regarding infections in general, with studies showing no increased risk of overall infections compared to placebo 2, 3, specific data on Salmonella infections during dupilumab treatment is limited
• Long-term studies of dupilumab (up to 4-5 years) have shown low rates of serious infections (1.39 patients/100 patient-years) 3, 4, but these studies did not specifically address Salmonella infections
• The decision to restart therapy should involve careful risk-benefit evaluation 1

Prevention of Recurrence

• Educate the patient about preventive measures:
  • Avoid consumption of raw or partially cooked dairy, fish, or meat products 1
  • Avoid unpasteurized milk or milk products 1
  • Wash salads thoroughly 1
  • Practice good hand hygiene 1
  • Avoid contact with potentially contaminated water or food 1

Special Considerations

• If the patient experiences recurrent Salmonella infections after restarting dupilumab, consider:
  • Longer-term antibiotic prophylaxis 1
  • Evaluation of household contacts for asymptomatic carriage 1
  • Reassessment of the risk-benefit ratio of continuing dupilumab 1