Objectives: To conduct an audit examining the rates of latent infection screening amongst Rheumatology outpatients on disease modifying anti-rheumatic drugs (DMARDs) in a tertiary hospital.
Background:
Immunosuppressive treatments in rheumatological diseases may trigger reactivation of latent pathogens. Consensus guidelines recommend screening for latent hepatitis B and C in patients prior to the commencement of conventional synthetic DMARDs (csDMARDs), targeted synthetic DMARDs (tsDMARADs) and biological DMARDs (bDMARDs). Latent tuberculosis (TB) screening is further indicated prior to the initiation of bDMARDs, and HIV testing is suggested where clinically indicated1. With rising rates of Strongyloides stercoralis, a tropical nematode disease, in non-endemic countries due to global migration2, and given reports of fatal disseminated Strongyloides infection with bDMARD treatment3, Strongyloides testing may also be indicated prior to bDMARD initiation.
Methods:
Electronic medical records were accessed for adults attending the Rheumatology outpatient clinics at a tertiary hospital in Sydney, Australia between February to May in 2022. For patients on DMARD therapy warranting screening (ts/bDMARD patients and csDMARD patients excluding those on hydroxychloroquine alone), rates of complete screening, defined as hepatitis C serology and hepatitis B anti-core, anti-surface antibody and anti-surface antigen for csDMARD patients, and additionally IGRA testing for ts/bDMARD patients, were determined. Strongyloides serology and HIV screening results were also recorded. Moreover, screening rates for patients diagnosed with rheumatoid arthritis or psoriatic arthritis specifically were ascertained.
Results:
429 patients met the inclusion criteria. 341 patients were on DMARD therapy requiring screening, with 300 (88%) receiving any screening test and 230 (67%) receiving a complete screening panel. Amongst screening tests, a full hepatitis B serology panel was least frequently performed, with 239 of 341 (70%) patients receiving all three Hepatitis B serology tests. 111 of the 429 patients had strongyloides serology (26%) and 204 had HIV screening (48%). Complete screening rates for rheumatoid arthritis and psoriatic arthritis patients were 60% and 61% respectively.
Discussion:
A sizeable proportion of patients on DMARDs did not have a complete latent infection screening panel visible on their electronic records. Rates of complete Hepatitis B screening, which consisted of three separate serology tests, were particularly low. Results from private laboratories or paper files were not audited and may have significantly lowered complete screening rates. Suggested improvements to current practice include standardising methods of recording screening results on outpatient electronic records. Strongyloides screening rates were low, and a review of the cost-effectiveness of widespread Strongyloides testing may be warranted.