Clemente Daniel, Cuadros Esmeralda Núñez, Lovillo Marisol Camacho, Hernández Joan Calzada, Martín Sara Guillén, Silveira Laura Fernández, Cruz María José Lirola, Tagarro Alfredo, Rueda Rosa María Alcobendas, López López Agustín, Aritziturri Miren Satrustegi, Calvo Cristina
Pediatric Rheumatology Unit, Hospital Infantil Universitario Niño Jesús, Madrid, Spain.
Pediatric Rheumatology Unit, UGC Pediatría, Hospital Regional Universitario de Málaga, Instituto de investigación biomédica de Málaga (IBIMA), Málaga, Spain.
Eur J Pediatr. 2024 Feb;183(2):915-927. doi: 10.1007/s00431-023-05295-4. Epub 2023 Dec 4.
The objective of this study is to provide practical recommendations on the management of pediatric patients with immune-mediated rheumatic diseases receiving immunosuppressive therapies. The recommendations specifically address the cases of surgery, fever, and opportunistic infections (varicella, herpes-zoster, tuberculosis, invasive fungal disease). A qualitative approach was applied. A narrative literature review was performed via Medline. Primary searches were conducted using MeSH terms and free text to identify publications on infections and vaccinations in pediatric patients with immune-mediated rheumatic diseases receiving immunosuppressive therapies. The results were presented and discussed in a nominal group meeting, comprising a committee of 12 pediatric rheumatologists from the Infection Prevention and Treatment Working Group of the Spanish Society of Pediatric Rheumatology. Several recommendations were generated. A consensus procedure was implemented via a Delphi process; this was extended to members of the Spanish Society of Pediatric Rheumatology and Spanish Society of Pediatric Infectious Disease of the Spanish Association of Pediatrics. Participants produced a score ranging from 0 (totally disagree) to 10 (totally agree). Agreement was defined as a vote ≥ 7 by at least 70% of participants. The literature review included more than 400 articles. Overall, 63 recommendations (19 on surgery, fever, and opportunistic infections) were generated and voted by 59 pediatric rheumatologists and other pediatric specialists. Agreement was reached for all 63 recommendations. The recommendations on special situations cover management in cases of surgery, fever, and opportunistic infections (varicella, herpes-zoster, tuberculosis, and invasive fungal disease). Conclusions: Hereby, we provided consensus and updated of recommendations about the management of special situations such as surgery, fever, and opportunistic in children with immune-mediated rheumatic diseases receiving immunosuppressive therapies. Several of the recommendations depend largely on clinical judgement and specific balance between risk and benefit for each individual and situation. To assess this risk, the clinician should have knowledge of the drugs, the patient's previous situation as well as the current infectious disease, in addition to experience. What is Known: • Infectious diseases and related complications are a major cause of morbidity and mortality in patients with immune-mediated rheumatic diseases. • Information on how to manage the treatment in situations of fever, opportunistic infections, and surgery in children is limited, and guidelines for action are often extrapolated from adults. What is New: • In the absence of strong evidence, a literature review and a Delphi survey were conducted to establish a series of expert recommendations that could support the clinical practice, providing a practical and simple day-to-day approach to be used by pediatric rheumatologists.
本研究的目的是就接受免疫抑制治疗的免疫介导性风湿疾病儿科患者的管理提供实用建议。这些建议特别针对手术、发热和机会性感染（水痘、带状疱疹、结核病、侵袭性真菌病）的情况。采用了定性研究方法。通过Medline进行了叙述性文献综述。使用医学主题词和自由文本进行初步检索，以识别关于接受免疫抑制治疗的免疫介导性风湿疾病儿科患者感染和疫苗接种的出版物。研究结果在一次名义小组会议上进行了展示和讨论，该会议由西班牙儿科风湿病学会感染预防与治疗工作组的12名儿科风湿病学家组成的委员会参加。提出了若干建议。通过德尔菲法实施了共识程序；该程序扩展到了西班牙儿科风湿病学会和西班牙儿科学会西班牙儿科传染病学会的成员。参与者给出的评分范围为0（完全不同意）至10（完全同意）。达成共识的定义是至少70%的参与者投票≥7。文献综述纳入了400多篇文章。总体而言，59名儿科风湿病学家和其他儿科专家提出并对63条建议（19条关于手术、发热和机会性感染）进行了投票。所有63条建议均达成了共识。关于特殊情况的建议涵盖手术、发热和机会性感染（水痘、带状疱疹、结核病和侵袭性真菌病）情况下的管理。结论：在此，我们提供了关于接受免疫抑制治疗的免疫介导性风湿疾病儿童手术、发热和机会性感染等特殊情况管理的共识和更新建议。其中一些建议很大程度上取决于临床判断以及针对每个个体和情况的风险与益处之间的具体平衡。为评估这种风险，临床医生除经验外，还应了解所用药物、患者既往情况以及当前的传染病情况。已知信息：• 传染病及相关并发症是免疫介导性风湿疾病患者发病和死亡的主要原因。• 关于如何处理儿童发热、机会性感染和手术情况的治疗信息有限，且行动指南通常是从成人情况推断而来。新内容：• 在缺乏有力证据的情况下，进行了文献综述和德尔菲调查，以制定一系列专家建议，这些建议可为临床实践提供支持，为儿科风湿病学家提供一种实用且简单的日常处理方法。
