Should Dupixent (dupilumab) be held in a patient with a Salmonella infection?

Management of Dupixent (Dupilumab) in Patients with Salmonella Infection

Dupixent should be temporarily withheld until resolution of active Salmonella infection to reduce the risk of severe infection complications. 1, 2

Rationale for Temporary Discontinuation

• Patients receiving immunosuppressive agents are at risk of more severe infections with Salmonella enteritidis and S. typhimurium, making temporary discontinuation necessary 1
• The European Crohn's and Colitis Organization (ECCO) guidelines explicitly recommend temporarily withholding immunosuppressive therapy until resolution of active Salmonella infection 1
• Immunosuppressive therapy is considered a high-risk predisposing condition for intestinal or systemic Salmonella infections 1

Treatment Approach for Salmonella Infection

• Treat with appropriate antibiotics based on susceptibility testing 1, 2:
  • Fluoroquinolones (primarily ciprofloxacin) are usually first-line for adults 1, 3
  • Third-generation cephalosporins may be used based on local susceptibility patterns 1, 3
  • For severe infections, combination therapy with sulphamethoxazole/trimethoprim, ceftriaxone, or carbapenems may be considered 1, 2
• Antibiotic therapy should be continued until complete resolution of all infection manifestations 1, 2
• For invasive infections (osteomyelitis, septic arthritis), a combination of antibiotics and surgical treatment may be required 1

When to Restart Dupixent

• Dupixent can be restarted only after complete resolution of the active Salmonella infection 1, 2
• Clinical indicators for safe resumption include:
  • Resolution of all clinical symptoms 1, 2
  • Negative follow-up cultures (if previously positive) 2
  • Complete disappearance of any skin or other lesions if present 1, 2

Monitoring After Restarting Therapy

• Once Dupixent is restarted, monitor closely for:
  • Signs of recurrent infection 2
  • New systemic symptoms such as fever 2, 3
  • Gastrointestinal symptoms that could indicate relapse 4, 5
• Be aware that antibiotic treatment can lead to bacteriologic relapse in up to 53% of cases, which may require re-evaluation of Dupixent therapy 5

Prevention of Recurrence

• Educate patients about preventive measures:
  • Avoid consumption of raw or partially cooked eggs, dairy, fish, or meat products 1, 2
  • Practice good hand hygiene, especially after handling pets and before eating 1, 6
  • Evaluate household contacts for asymptomatic carriage to prevent recurrent transmission 1, 3

Special Considerations

• For patients with recurrent Salmonella infections after restarting Dupixent:
  • Consider longer-term antibiotic prophylaxis 1, 2
  • Re-evaluate the risk-benefit ratio of continuing Dupixent 2, 7
• For severe or systemic Salmonella infections, consult with an infectious disease specialist before restarting Dupixent 2

Common Pitfalls and Caveats

• Avoid continuing Dupixent during active Salmonella infection, as this may lead to more severe or prolonged infection 1
• Do not restart Dupixent prematurely before complete resolution of infection 1, 2
• Be aware that antibiotics may prolong Salmonella detection in stools and could mask ongoing infection 4
• Consider that antibiotic treatment itself can lead to relapse of Salmonella infection in some cases 5, 8