Background: Cytomegalovirus (CMV) is a ubiquitous virus that has been identified to cause opportunistic infections in the setting of autoimmune rheumatologic diseases. In view of the significant morbidity and mortality associated with CMV infection, predicting its occurrence to facilitate timely management is important. The CMV Infection Pre-emptive Inpatient Management Guideline (CMVi-PMG) was jointly developed by the Singapore General Hospital (SGH) Department of Rheumatology and Immunology, and Department of Infectious Diseases to provide guidance on surveillance for CMV infection and pre-emptive management of CMV disease [1–3].

Objectives: The study objectives were to evaluate the utility of CMVi-PMG and identify risk factors for CMV infection.

Methods: Retrospective cross-sectional study on admissions to the SGH Department of Rheumatology and Immunology, involving patients with underlying autoimmune rheumatologic disease and at least 21 years old was conducted. The incidence of CMV infection before implementation of CMVi-PMG (1 January 2017 – 18 December 2018) and after implementation on 19 December 2018 (1 January 2019 –31 December 2020) was compared. Pearson’s Chi Square test or Wilcoxon rank sum test was utilized to compare patient characteristics, and logistic regression analysis was conducted to examine potential risk factors of CMV infection.

Results: A total of 1373 admissions were included: 730 in the pre-implementation cohort and 643 in the post-implementation cohort. More patients in the post-implementation cohort had received pulsed methylprednisolone (p=0.036) and rituximab (p=0.021). CMV infection was detected in 25 (1.8%) admissions over the 4-year study period. There was lower incidence of CMV infection (incidence risk ratio [IRR]=0.757, 95% confidence interval [CI] 0.342 – 1.673) and CMV disease (IRR=0.699, 95% CI 0.291 – 1.675) in the post-implementation cohort. After adjusting for implementation of CMVi-PMG, duration of admission (adjusted odds ratio [OR]=1.058; 95% CI 1.036 – 1.080) and oral prednisolone ≥ 0.5mg/kg/day for at least 4 weeks (adjusted OR=13.249, 95% CI 5.189 – 33.833) were found to be significantly associated with CMV infection. Adherence to CMVi-PMG recommendations on CMV monitoring was low, at only 12.8% of the admissions with at-risk patients in the post-implementation period.

Conclusion: Incidence of CMV infection and disease among admitted patients with autoimmune rheumatologic disease were numerically reduced post-implementation of CMVi- PMG, suggesting positive impact of the strategy.

REFERENCES: [1] Winthrop KL, Novosad SA, Baddley JW, Calabrese L, Chiller T, Polgreen P, Bartalesi F, Lipman M, Mariette X, Lortholary O, Weinblatt ME, Saag M, Smolen J. Opportunistic infections and biologic therapies in immune-mediated inflammatory diseases: consensus recommendations for infection reporting during clinical trials and postmarketing surveillance. Ann Rheum Dis. 2015 Dec;74(12):2107-16.

[2] Takizawa Y, Inokuma S, Tanaka Y, Saito K, Atsumi T, Hirakata M, Kameda H, Hirohata S, Kondo H, Kumagai S, Tanaka Y. Clinical characteristics of cytomegalovirus infection in rheumatic diseases: multicentre survey in a large patient population. Rheumatology (Oxford). 2008 Sep;47(9):1373-8.

[3] Lee KY, Yoo BW, Ahn SS, Bae WH, Lee H, Jung SM, Lee SW, Park YB, Song JJ. Predictors of mortality in autoimmune disease patients with concurrent cytomegalovirus infections detected by quantitative real-time PCR. PLoS One. 2017 Jul 25;12(7):e0181590.

Acknowledgements: NIL.

Disclosure of Interests: Xin Ying Tay: None declared, Cheryl Yu Ling Lim: None declared, Yih Jia Poh: None declared, Andrea Low Paid as speaker for Boehringer-Ingelheim and Johnson & Johnson (previously Actelion), Paid consultant for Boehringer-Ingelheim and Johnson & Johnson (previously Actelion), Education and research grants from Boehringer-Ingelheim and Johnson & Johnson (previously Actelion), Pei Zhi Benjamin Cherng Honorarium for presenting in a COVID-19 Webinar for Brunei healthcare professionals organized by DCH Auriga on 21/9/2022, Zhe Han: None declared.