Bacteremia in patients receiving TNF-alpha antagonists--a prospective multicenter study.

OBJECTIVE: TNF-alpha antagonists have changed the outcome of various chronic inflammatory diseases. Their use has spread widely and many patients receive those treatments for years. Previous reports found that the use of TNF-alpha antagonists may be associated with an increased risk of serious bacterial infections. We report 47 prospective bacteremia cases from the RATIO registry. METHODS: A national prospective study was conducted in France between 2004 and 2007 to collect severe bacterial infections in patients receiving TNF-alpha antagonists. All reported cases of bacteremia were validated by an expert committee. RESULTS: Forty-seven bacteremic episodes were reported. Staphylococcus aureus represented the most frequent causative pathogen (40%) and was mostly associated with bones and/or joints infections (68%) and with a worse outcome compared to that observed with other bacterial pathogens. CONCLUSIONS: Patients receiving TNF-alpha antagonists may develop bacteremia and S. aureus has to be included in the spectrum of the initial empiric antimicrobial therapy.

Diagnostic accuracy of ACR/EULAR 2010 criteria for rheumatoid arthritis in a 2-year cohort.

OBJECTIVE: To evaluate the diagnostic accuracy of the 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) and 1987 ACR criteria for rheumatoid arthritis (RA), and the respective role of the algorithm and scoring of the ACR/EULAR. METHODS: In total, 270 patients with recent-onset arthritis of < 1 year duration were included prospectively between 1995 and 1997 and followed for 2 years. RA was defined as the combination, at completion of followup, of RA diagnosed by an office-based rheumatologist and treatment with a disease-modifying antirheumatic drug or glucocorticoid. We compared the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the criteria sets in the overall population, in the subgroup meeting the tree condition for ACR/EULAR scoring, and in the overall population classified according the full tree. RESULTS: At baseline, 111 of the 270 patients had better alternative diagnoses and 16 had erosions typical for RA; of the 143 remaining patients, 52 had more than 6 ACR/EULAR 2010 points (indicating definite RA) and 91 had fewer than 6 points. After 2 years, 11/16 patients with erosions and 40/52 with more than 6 points had RA. 100 of the 270 patients met the reference standard for RA. Sensitivity, specificity, PPV, and NPV of the ACR/EULAR (full tree) were 51/100 (51%), 153/170 (90%), 51/68 (75.4%), and 153/202 (75.7%), respectively. Diagnostic accuracies of the ACR/EULAR score and ACR 1987 criteria were not statistically different. CONCLUSION: Much of the improvement of the ACR/EULAR criteria was ascribable to the use of exclusion criteria in the algorithm.

Changes over time in the diagnosis of rheumatoid arthritis in a 10-year cohort.

OBJECTIVE: We assessed levels of agreement between a diagnosis of rheumatoid arthritis (RA) at inclusion in a recent-onset arthritis cohort, then 2 and 10 years later. Performance of American College of Rheumatology (ACR) criteria alone or combined with rheumatologist diagnosis, and of recent new criteria adding antibodies to cyclic citrullinated peptides ("anti-CCP-revised criteria") to existing ACR criteria, was evaluated. METHODS: In total, 270 patients with recent-onset arthritis of less than 1 year duration were included between 1995 and 1997 and followed for 2 years. A diagnosis was recorded by an office-based rheumatologist (OBR) at inclusion, then 2 years later. In 2007, a questionnaire was sent to each rheumatologist to collect the final diagnosis, which was considered the reference. RESULTS: Final diagnosis was available for 164 patients: 57 had RA. Agreement was low (kappa = 0.27) between the baseline and final diagnoses, and substantial (kappa = 0.69) between the 2-year and final diagnoses. Anti-CCP-revised criteria had sensitivity of 65% to 81% and specificity of 55% to 75%. Sensitivity and specificity of ACR criteria were 57.9% (44.1%-70.9%) and 74.8% (65.5%-82.7%) at inclusion, 80.7% (70.5%-90.0%) and 63.6% (54.5%-72.7%) at 2 years. The combination OBR diagnosis/ACR criteria after 2 years showed considerably increased specificity (87% vs 64%) and slightly decreased sensitivity (77% vs 81%). CONCLUSION: ACR criteria for RA showed poor performance even at 2 years. The absence of exclusion criteria may explain the lack of specificity, which improved when combined with the OBR diagnosis. Adding anti-CCP criteria to the existing criteria could help in diagnosing RA.