What is the recommended treatment for a patient with systemic lupus erythematosus (SLE) who develops an upper respiratory tract infection (URTI)?

Treatment of SLE Patients with Upper Respiratory Tract Infection

Treat the upper respiratory tract infection with standard antimicrobial therapy when indicated (bacterial infection suspected or confirmed), while continuing hydroxychloroquine and maintaining glucocorticoids at the lowest effective dose, with aggressive infection surveillance given the 5-fold increased mortality risk in SLE patients. 1, 2

Immediate Management Approach

Continue Foundation SLE Therapy

• Maintain hydroxychloroquine at ≤5 mg/kg real body weight throughout the infection, as antimalarials have a well-known protective role against infection and should not be discontinued 3, 2
• Continue current glucocorticoid regimen if already prescribed, but avoid initiating high-dose steroids (>7.5-10 mg/day prednisone equivalent) during active infection unless absolutely necessary for lupus disease activity 2, 4

Antimicrobial Treatment for URTI

• For bacterial URTI (sinusitis, pharyngitis): Use amoxicillin-clavulanate 875 mg/125 mg every 12 hours or 500 mg/125 mg every 8 hours for respiratory tract infections 5
• For viral URTI: Provide supportive care with symptomatic treatment 4
• Duration of therapy should follow standard guidelines for the general population (typically 5-10 days for bacterial infections) 5

Critical Infection Risk Assessment

Screen for Serious Infection Before Escalating Immunosuppression

• If lupus flare is suspected during URTI, aggressively exclude serious bacterial, viral (including CMV), or fungal infection before intensifying immunosuppression 1
• CMV testing should be considered particularly in patients on high-dose glucocorticoids or pulse methylprednisolone 1
• Monitor for severe neutropenia (<500 cells/mm³), severe lymphopenia (<500 cells/mm³), or low IgG (<500 mg/dL), which increase infection risk 1

Immunosuppression Considerations During Active Infection

• Prednisone doses >7.5-10 mg/day are well-recognized risk factors for infection and should be avoided during active URTI unless lupus disease activity mandates higher doses 2
• High-dose methylprednisolone and cyclophosphamide are associated with increased infection susceptibility and should be deferred until infection resolves unless treating life-threatening lupus manifestations 1, 2
• Azathioprine may hamper immune response to infections but most patients still develop protective antibody levels 1

Prevention Strategies for Future URTIs

Vaccination (Administer When SLE is Inactive)

• Strongly encourage annual inactivated influenza vaccination, as it is safe, does not lead to SLE flares, and the majority of patients develop protective antibodies 1
• Administer pneumococcal vaccination (both PCV13 and PPSV23) according to CDC guidelines for immunosuppressed patients 1
• Vaccines should ideally be administered when SLE is inactive and preferably before initiating or escalating immunosuppressive therapy 1
• Live attenuated vaccines are absolutely contraindicated in patients taking immunosuppressive drugs and/or glucocorticoids at doses >20 mg/day 1

Screening Before Immunosuppression Escalation

• Screen for HIV, HBV, HCV based on patient risk factors before administering high-dose glucocorticoids or immunosuppressive drugs 1
• Screen for tuberculosis according to CDC recommendations before glucocorticoids and immunosuppressive drugs, especially in endemic areas 1

Common Pitfalls to Avoid

• Never discontinue hydroxychloroquine during URTI, as it provides infection protection and non-adherence increases mortality 3, 2
• Do not reflexively increase glucocorticoids for worsening symptoms during URTI without first excluding serious infection or lupus flare 1, 2
• Avoid initiating or escalating cyclophosphamide, high-dose methylprednisolone, or rituximab during active infection unless treating immediately life-threatening lupus manifestations 2
• Do not assume all respiratory symptoms represent lupus activity—bacterial infections are the most common cause of respiratory symptoms in SLE patients 4, 6

When to Escalate Immunosuppression Despite Active URTI

• Only escalate immunosuppression during active infection if lupus manifestations are immediately life-threatening (acute lupus pneumonitis, alveolar hemorrhage, severe neuropsychiatric lupus) 7, 8, 6
• In such cases, use pulse IV methylprednisolone (250-1000 mg daily for 1-3 days) combined with appropriate antimicrobial coverage 3, 9