Background/Purpose: Many children with rheumatic diseases require immunosuppressive treatments, however these medications put them at risk for contracting opportunistic infections leading to severe morbidity and mortality. Although the CDC’s Advisory Committee on Immunization Practices and Infectious Diseases Society of America have published guidelines on the use of vaccination and prophylactic regimens in certain high-risk patients, these recommendations are not fully applicable in the practice of pediatric rheumatology. This quality improvement study aims to develop consensus treatment plans for when and how prophylaxis should be initiated in immunocompromised pediatric rheumatic patients at our large academic institution.
Methods: An initial literature review using PubMed was performed. Specific questions regarding vaccination and prophylactic antimicrobials were formulated with the guidance of both an experienced pediatric rheumatologist and infectious disease specialist. Invitation for a consensus meeting was sent to various pediatric subspecialties that treat immunocompromised patients. Level of immunosuppression for specific DMARDs as shown in figure 1 was adapted from a EULAR publication about vaccination in pediatric rheumatic patients (MW Heijstek et al 2011). Background and relevant research were presented to the forum prior to utilizing nominal group technique to reach consensus statements. Confidential voting was tallied.
Results: Many pediatric subspecialties were represented at the meeting. Sixteen attendees are shown in Table 1. Our team of pediatric subspecialists agreed that regarding vaccination and use of antimicrobial prophylaxis: (1) Live virus vaccines (MMR and varicella) should be given to patients on moderate immunosuppression but held for 1-2 weeks prior to receiving these vaccines for optimal response, (2) moderate immunosuppression should be held for 4 weeks after administration of vaccine, (3) prefer using atovaquone/dapsone for pneumocystis pneumonia prophylaxis in SLE, while trimethoprim-sulfamethoxazole in other pediatric rheumatic diseases, and (4) all patients on high level immunosuppression who live in coccidioidomycosis endemic regions should receive antifungal prophylaxis, in addition, patients with high risk for developing disseminated coccidioidomycosis on moderate level immunosuppression living endemic regions should also receive antifungal prophylaxis.
Conclusion: We have developed actionable consensus treatment plans for children on moderate and high level immunosuppressive therapy necessary to control rheumatic disease with multidisciplinary input to improve the quality of care provided in the pediatric rheumatology clinic. Our next steps will be to implement of these protocols and determine if measured outcomes in our pediatric patient population demonstrate deceased adverse events.
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