Diagnostic Value of Synovial White Blood Cell Count and Serum C-Reactive Protein for Acute Periprosthetic Joint Infection After Knee Arthroplasty

Background

The diagnosis of periprosthetic joint infection (PJI) remains difficult, particularly in acute postoperative stage. The purpose of this study was to investigate the optimal cutoff value of synovial white blood cell (WBC) count, percentage of polymorphonuclear cells, erythrocyte sedimentation rate, and C-reactive protein (CRP) for diagnosing early postoperative infection after knee joint arthroplasty.

Screening for Periprosthetic Joint Infections With ESR and CRP: The Ideal Cutoffs

BackgroundThe purpose of this study was to (1) determine the sensitivity and specificity of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) when screening for a periprosthetic joint infection (PJI) using the standard MSIS cutoff of 30 mm/h and 10 mg/L, respectively, and (2) determine the optimal ESR and CRP cutoff to achieve a sensitivity ≥95%.MethodsWe retrospectively analyzed 81 PJI patients and 83 noninfected arthroplasty patients. We calculated the sensitivity and specificity (and 95% confidence intervals) for ESR and CRP at thresholds of 30 mm/h and 10 mg/L, respectively. We determined the optimal cutoff for both ESR and CRP to yield a sensitivity greater than or equal to 95%.ResultsThe ESR cutoff that resulted in a sensitivity ≥ to 95% (95% CI: 85.2-97.6%) was 10 mm/h, and the CRP cutoff that resulted in a sensitivity ≥ to 95% (95% CI: 87.1-98.4%) was 5 mg/L. The sensitivity and specificity with a combined ESR and CRP of 10 mm/h and 5 mg/L was 100% (95% CI: 94.1-100%) and 54.7% (95% CI: 46.4-62.3%).ConclusionWhen using ESR and CRP as a screening tool with the accepted cutoffs of 30 mm/h and 10 mg/L, there is an unacceptably low sensitivity and a high number of false negatives. Therefore, further recommendation must be given to lowering these thresholds to avoid the devastating morbidity of a missed PJI.Level of EvidenceIII.     

术前不明原因C-反应蛋白和红细胞沉降率升高对初次全膝关节置换术后早期假体周围感染的影响

目的 探讨术前不明原因的C-反应蛋白（CRP）和红细胞沉降率（ESR）升高对初次全膝关节置换术（total knee arthroplasty,TKA）术后早期假体周围感染（periprosthetic joint infection,PJI）的影响。方法 回顾性分析2016年11月至2021年10月在我院因膝骨关节炎行TKA治疗的病人,均排除CRP、ESR升高的明显诱因,经纳入和排除标准获得882例,男293例,女589例,年龄为（67.00±7.91）岁（43~98岁）。根据病人术前血CRP和ESR水平将病人分为四组：双阳组44例,CRP阳性组27例,ESR阳性组176例,双阴组635例。评估四组病人行TKA术后90 d内PJI的发生率,通过二元Logistic回归分析CRP和ESR升高的风险因素。结果 双阳组、CRP阳性组、ESR阳性组和双阴组术后90 d内的PJI发生率分别为6.82%（3/44）、0（0/27）、2.27%（4/176）、1.10%（7/635）,四组的感染率比较,差异有统计学意义（P=0.022）。合并糖尿病（OR=2.629,95% CI：1.535~4.502,P＜0.001）和身体质量指数（BMI）高（OR=2.575,95% CI：1.867~3.552,P＜0.001）是术前CRP水平升高的风险因素;女性（OR=2.701,95% CI：1.810~4.031,P＜0.001）、高BMI（OR=1.207,95% CI：2.435~3.942,P＜0.001）和合并糖尿病（OR=1.827,95% CI：1.218~2.739,P=0.004）是术前ESR水平升高的风险因素。结论 术前不明原因CRP和ESR升高增加初次TKA术后90 d内PJI发生风险,应结合性别、BMI、是否合并糖尿病,最后确定能否进行手术,是否需要围术期的额外治疗来预防和降低PJI的发生。     

Variation in Inflammatory Biomarkers Among Demographic Groups Significantly Affects Their Accuracy in Diagnosing Periprosthetic Joint Infection

BackgroundDiagnosis of periprosthetic joint infection (PJI) is a multistep process that involves performing various tests including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The latter two tests, despite being used at all times for PJI diagnosis, are known to be nonspecific and substantially affected by demographic characteristics, including age, gender, race, and body mass index. It is unknown how these variations affect the diagnostic utility of serological markers for PJI.MethodsInstitutional databases were queried to identify patients undergoing revision arthroplasty between 2010 and 2018, in whom preoperative serum ESR and CRP was performed. Patient demographics were collected, and patients were cross-referenced with an internal database to determine their infection status. Analyses were performed to determine how ESR and CRP varied with respect to demographic factors, including age, gender, race, and infection status. Given that patient infection status was known at the time of revision, conclusions were drawn about the effect of these variations in inflammatory markers on the diagnostic utility of ESR and CRP.ResultsThe value of ESR increased by age was higher in females and African American race. No significant differences were observed in the value of CRP among the demographic factors, although a slight positive trend was observed with respect to age. The variation in inflammatory markers significantly affected the sensitivity, specificity, and accuracy of ESR and CRP for PJI diagnosis.ConclusionUnderstanding how the accuracy of diagnostic tests varies with respect to demographic factors can help physicians avoid subjecting patients to unnecessary additional testing and reach more accurate diagnoses of PJI.     

Combined Measurement of D-Dimer and C-Reactive Protein Levels: Highly Accurate for Diagnosing Chronic Periprosthetic Joint Infection

BackgroundDiagnosis of chronic periprosthetic joint infection (PJI) can be challenging and elusive in the absence of a gold standard. D-dimer plays an important role in inflammation that occurs during infections and therefore could be a valuable biomarker for PJI. This study aims to investigate the sensitivity and specificity of D-dimer in detecting chronic PJI and to improve the accuracy of chronic PJI diagnosis through combined measurement of serum D-dimer with C-reactive protein (CRP)/erythrocyte sedimentation rate.MethodsOne hundred twenty-two patients presenting with a painful knee or hip after total hip or total knee arthroplasty for surgical revision were included in this prospective trial. Our cohort consisted of 55 patients undergoing revision for chronic PJI and 67 patients undergoing revision for aseptic failure. PJI was defined using the Musculoskeletal Infection Society criteria. Receiver operating characteristic curves and area under the curve were analyzed for each biomarker.ResultsThe area under the curve for D-dimer was 0.915 and was more accurate than serum erythrocyte sedimentation rate 0.719 and CRP 0.761. 1170 ng/mL was determined to be the optimal threshold value of D-dimer for the diagnosis of chronic PJI, with a sensitivity of 92.73% and a specificity of 74.63% in the diagnosis of chronic PJI. The combination of D-dimer and CRP tests demonstrated a sensitivity of 98.11% and negative predictive value of 96.55% for the diagnosis of chronic PJI.ConclusionThe present study identified the D-dimer is a valuable biomarker in detecting chronic PJI. The combinations of serum D-dimer and CRP led to the improvement of sensitivity compared with those of the single-index test.     

Pseudogout in the Early Postoperative Period After Total Knee Arthroplasty

Postoperative pseudogout after total knee arthroplasty is rare. If pseudogout attacks are misdiagnosed as periprosthetic sepsis, patients may undergo unnecessary surgical procedures. We report a case of pseudogout in the early postoperative period. The attack ensued shortly after a nonsteroidal antiinflammatory drug was discontinued. The diagnosis was confirmed by aspiration, and the patient improved after readministration of the nonsteroidal antiinflammatory drug. Although rare, pseudogout should be considered in the differential when approaching a suspected infection after total knee arthroplasty.     

术后椎间盘炎的血沉与C反应蛋白分析比较

目的: 探讨腰椎术后椎间隙感染的ESR和CRP特征性改变及早期诊断价值。方法: 回顾 25例行椎板减压髓核摘除术并发椎间隙感染的患者以及前瞻性研究 50例同种手术无感染的患者, 分别于术前、术后 2d、1、2周以及 4周进行ESR和CRP分析对比。结果: 所有患者术后均出现不同程度的ESR和CRP增快, 与术前相比有显著性差异 (P<0. 01), 感染组与非感染组同期比较没有统计学差异 (P>0. 05); 同期CRP与ESR相比, 峰值出现更早, 持续时间更短。结论: 两组ESR和CRP虽没有统计学差异, 但仍是早期诊断椎间盘感染的一种简单、有效和经济的术后常规筛选检查指标, 而且动态监测时间越长, 升高越快, 诊断价值越大。     

First Time Myocardial Infarction in a Rheumatic Patient After Elective Arthroplasty

The management of perioperative cardiovascular risk in patients with rheumatoid arthritis (RA) is challenging due to the independent contribution to risk by high grade inflammatory mechanisms and the underestimation of risk by traditional cardiac risk factors alone. RA is associated with accelerated rates of subclinical atherosclerosis and markedly higher rates of both myocardial infarction and sudden cardiac death over non-RA controls. There is an absence of prospectively validated perioperative coronary heart disease (CHD) risk assessment tools for this unique patient population and available guidelines may fail to identify those patients most at risk. We examine a singular case of first time myocardial infarction after uncomplicated elective surgery in an adult RA patient with an unrevealing preoperative cardiac assessment. We also review the current literature for shared pathogenic mechanisms between systemic inflammation and atherosclerosis, discuss clinical and biologic markers such as C-reactive protein (CRP) in RA patients associated with heightened cardiac risk and discuss recommendations based on available evidence for cardiovascular risk management in this at risk cohort.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-012-9309-5) contains supplementary material, which is available to authorized users.     

Comparison of WBC, ESR, CRP and PCT serum levels in septic and non-septic burn cases

Diagnosis of sepsis is difficult, particularly in cases of burn where signs of sepsis may be present in the absence of a real infection. This study compared serum levels of procalcitonin (PCT), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and white blood cell (WBC) among 60 burned people with and without infection, in order to assess the value of the information for diagnosis of sepsis. A significantly higher PCT level was observed in the septic group compared to those without sepsis (8.45+/-7.8 vs. 0.5+/-1.0, respectively, p<0.001); no significant differences were found in CRP or WBC levels, neutrophil count or ESR. The area under the receiver operating characteristics curve in the diagnosis of sepsis was 0.97 for PCT (p<0.001) with sensitivity of 100% and specificity of 89.3%. Non-survivors had a mean PCT level significantly higher than that of survivors. Thus the serum PCT level was a highly efficient laboratory parameter for the diagnosis of severe infectious complications after burn, but WBC, neutrophil, ESR and CRP levels were of little value.     

Blood Utilization After Primary Total Joint Arthroplasty in a Large Hospital Network

Background

Since a study in orthopedic hip fracture patients demonstrated that a liberal hemoglobin (Hb) threshold does not improve patient morbidity and mortality relative to a restrictive Hb threshold, the standard of care in total joint arthroplasty (TJA) should be examined to understand the variability of red blood cell (RBC) transfusion following TJA.

Questions/purposes

The study aimed to answer the following questions: (1) What is the blood utilization rate after primary TJA for individual surgeons within a large hospital network? (2) What is the comparison of hospital charges, length of stay (LOS), and discharge locations among TJA patients who were and were not transfused?

Methods

A retrospective study was conducted on 3,750 primary total knee arthroplasties (TKAs) and 2,070 primary total hip arthroplasties (THAs), and data was retrospectively collected over a 15-month period on the number of RBCs transfused per patient, along with demographic and cost details. The number of patients who received at least 1 RBC unit and the number of RBCs transfused per patient was calculated and stratified by surgeon.

Results

In the postoperative period, 19.3% TKA patients and 38.5% THA patients received a RBC transfusion. Transfusion rates following TJA varied widely between surgeons (TKA 4.8–63.8%, THA 4.3–86.8%). Transfused TKA patients received an average of 1.65 ± 0.03 RBCs, and THA patients received an average of 1.97 ± 0.14 RBCs. LOS and hospital charges for blood transfusion patients were higher than nontransfused patients.

Conclusion

Blood utilization after primary TJA varies greatly among surgeons, suggesting that resources may be misallocated. These findings highlight the need to standardize RBC transfusion practice following TJA.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-013-9327-y) contains supplementary material, which is available to authorized users.     

The Natural Course of Serum D-Dimer,C-Reactive Protein,and Erythrocyte Sedimentation Rate Levels After Uneventful Primary Total Joint Arthroplasty

BackgroundThis study aimed to assess the baseline levels of D-dimer, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) and monitor the natural course of these serum markers after uneventful primary total joint arthroplasty.MethodsThis prospective study enrolled 81 patients undergoing primary total knee arthroplasty or total hip arthroplasty. The level of serum D-dimer, CRP, and ESR was measured preoperatively and on postoperative days 1, 3, 5, 15, and 45. Mean peak values, peak times, and distribution were compared between D-Dimer, CRP, and ESR.ResultsThe mean preoperative serum D-dimer, CRP, and ESR level was 412 ± 260 (range 200-980) ng/mL, 2.93 ± 2.1 (range 1-18) mg/L, and 22.88 ± 17.5 (range 3-102) mm/h, respectively. The highest mean peak for D-dimer, CRP, and ESR was at postoperative day 1, 3, and 5, respectively.ConclusionD-dimer levels reached peak levels on postoperative day 1 and then declined rapidly to a plateau level by postoperative day 3. A second, albeit small, peak in the level of D-dimer occurred on postoperative day 15. The level of CRP and ESR remained elevated for much longer with CRP returning to baseline on postoperative day 45 and the level of ESR had not returned back to normal on postoperative day 45.     

Effectiveness of Different Wound Dressings in the Reduction of Blisters and Periprosthetic Joint Infection After Total Joint Arthroplasty: A Systematic Review and Network Meta-Analysis

BackgroundThe optimal type of dressing in the setting of total joint arthroplasty (TJA) remains uncertain. The aim of this network meta-analysis was to compare various wound dressings and identify the optimal type of dressings for blister reduction and prevention of periprosthetic joint infection (PJI) in patients after TJA.MethodsStudies comparing 2 or more dressing groups after TJA (hip or knee) were systematically searched on PubMed, Embase, and Scopus. Two authors performed the study selection, risk of bias assessment, and data extraction. Both outcomes were assessed using odds ratios (OR) with 95% confidence intervals (CI) and were ranked using surface under the cumulative ranking curve (SUCRA) probabilities to determine a hierarchy of dressings. A sensitivity analysis was performed to reduce the effect of intransitivity between studies.ResultsA total of 21 studies, consisting of 12 dressing types in 7293 TJAs, were included in the final analysis. The highest incidence of blisters occurred when using negative-pressure wound therapy (OR 9.33, 95% CI 3.51-24.83, vs gauze). All dressings ranked better than gauze in infection rate except for hydrofiber (OR 1.46, 95% CI 0.02-112.53) and fabric dressings (OR 1.46, 95% CI 0.24-9.02). For blister reduction, alginate (SUCRA = 87.7%) and hydrofiber with hydrocolloid (SUCRA = 92.3%) were ranked as the optimal dressings before and after a sensitivity analysis, respectively. Antimicrobial dressing (SUCRA = 83.7%) demonstrated the most efficacy for preventing PJI.ConclusionBased on the evidence from our analysis, an antimicrobial dressing is the optimal dressing to prevent PJI. If negative-pressure wound therapy is used, surgeons should be aware of an increased incidence of blister formation. Further studies should focus on the alginate versus hydrofiber and hydrocolloid dressing to determine the optimal dressing to reduce blisters.     

Normal Range of the Inflammation Related Laboratory Findings and Predictors of the Postoperative Infection in Spinal Posterior Fusion Surgery

Background

Inflammation related hematological parameters vary greatly depending on patients. It is not well known how much increase of which parameter warrants suspicion of postoperative infection. This study proposes to identify the normal range and the predictive factors for postoperative infection by conducting a time series analysis of the hematological parameters of patients after the spinal posterior fusion.

Methods

A retrospective study was done with 608 patients who underwent spinal posterior fusion with pedicle screw fixation. Laboratory assessment including the leucocyte, neutrophil, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) of patients for 2 weeks after operation. The patients were divided into the one-level fusion group (group I), the two-level fusion group (group II), the three or multi-level fusion or reoperation group (group III), and the postoperative infection group (group IV). Blood was drawn before breakfast prior to the operation, and then 2-3 days, 4-7 days, 8-11 days, and 12-14 days after the operation. The leucocyte count, neutrophil count, CRP, and ESR were measured.

Results

From 4-7 days after the operation, the CRP and neutrophil count of group IV were significantly higher than those of group I and II, and from 8-11 days after operation, the CRP and neutrophil counts were significantly higher than those of all groups. Twelve to fourteen days after the operation, the neutrophil count of group IV was significantly higher than that of group I and II, while the neutrophil count of group III was also higher than that of group I. The lower limit of the 95% confidence interval (CI) of the CRP and neutrophil count group IV was greater than the upper limit of the 95% CI of group I and II. The ESR of group IV was significantly higher than that of group I and III.

Conclusions

If the postoperative CRP and neutrophil counts are high, or if the CRP begins to rise again 8 days after the operation, the likelihood of infection increases, but caution must be exercised in interpreting the results. If the hematological parameters are higher than the lower limit of the 95% CI of the postoperative infection group, infection must be strongly suspected.     

Dilute Betadine Lavage Reduces the Risk of Acute Postoperative Periprosthetic Joint Infection in Aseptic Revision Total Knee and Hip Arthroplasty: A Randomized Controlled Trial

BackgroundThe purpose of this randomized, controlled trial is to determine whether dilute betadine lavage compared to normal saline lavage reduces the rate of acute postoperative periprosthetic joint infection (PJI) in aseptic revision total knee (TKA) and hip arthroplasty (THA).MethodsA total of 478 patients undergoing aseptic revision TKA and THA were randomized to receive a 3-minute dilute betadine lavage (0.35%) or normal saline lavage before surgical wound closure. Fifteen patients were excluded following randomization (3.1%) and six were lost to follow-up (1.3%), leaving 457 patients available for study. Of them, 234 patients (153 knees, 81 hips) received normal saline lavage and 223 (144 knees, 79 hips) received dilute betadine lavage. The primary outcome was PJI within 90 days of surgery with a secondary assessment of 90-day wound complications. A priori power analysis determined that 285 patients per group were needed to detect a reduction in the rate of PJI from 5% to 1% with 80% power and alpha of 0.05.ResultsThere were eight infections in the saline group and 1 in the betadine group (3.4% vs 0.4%, P = .038). There was no difference in wound complications between groups (1.3% vs 0%, P = .248). There were no differences in any baseline demographics or type of revision procedure between groups, suggesting appropriate randomization.ConclusionDilute betadine lavage before surgical wound closure in aseptic revision TKA and THA appears to be a simple, safe, and effective measure to reduce the risk of acute postoperative PJI.Level of EvidenceLevel I.     

Reevaluating Current Cutoffs for Acute Periprosthetic Joint Infection: Current Thresholds Are Insensitive

BackgroundDiagnosing acute periprosthetic joint infection remains a challenge. Several studies have proposed different acute cutoffs resulting in the International Consensus Meeting recommending a cutoff of 100 mg/L, 10,000 cell/μL and 90% for serum C-reactive protein (CRP), synovial white blood cell count (WBC), and polymorphonuclear percentage (PMN%), respectively. However, establishing cutoffs are difficult as the control group is limited to rare early aseptic revisions, and performing aspiration in asymptomatic patients is difficult because of a fear of seeding a well-functioning joint arthroplasty. This study (1) assessed the sensitivity of current thresholds for acute periprosthetic joint infection (PJI) and (2) identified associated factors for false negatives.MethodsWe retrospectively reviewed patients with acute PJIs (n = 218), defined as less than 6 weeks from index arthroplasty, treated between 2000 and 2017. Diagnosis of PJI was based on 2 positive cultures of the same pathogen from the periprosthetic tissue or synovial fluid samples. Sensitivities of International Consensus Meeting cutoff values of CRP, synovial WBC, and PMN% were evaluated according to organism type. Multiple logistic regression analysis was performed to determine associated factors for false negatives.ResultsOverall, the sensitivity of CRP, synovial WBC, and PMN% for acute PJI was 55.3%, 59.6%, and 50.5%, respectively. Coagulase-negative Staphylococcus (CNS) demonstrated the lowest sensitivity for both CRP (37.5%) and WBC (55.6%). CNS infection was identified as an independent risk factor for false-negative CRP.ConclusionsCurrent thresholds for acute PJI may be missing approximately half of PJIs. Low virulent organisms, such as CNS, may be responsible for these false negatives. Current thresholds for acute PJI must be reexamined.     

High Early Major Complication Rate After Revision for Mechanically Assisted Crevice Corrosion in Metal-on-Polyethylene Total Hip Arthroplasty

Background

Failed total hip arthroplasty caused by mechanically assisted crevice corrosion (MACC) has serious consequences such as adverse local tissue reaction. Revision is currently indicated for significant hip pain, stiffness, and dysfunction; hip instability; progressive bone loss; and soft tissue destruction. Outcomes of this revision surgery are not yet completely understood.

A Multicenter Study of Irrigation and Debridement in Total Knee Arthroplasty Periprosthetic Joint Infection: Treatment Failure Is High

Background

In total knee arthroplasty (TKA) periprosthetic joint infection (PJI), irrigation and debridement (I&D) with component retention is a treatment option with a wide variation in reported failure rates. The purpose of this study was to determine failure rates, outcomes, and factors that predict failure in I&D for TKA PJI.

Preoperative C-Reactive Protein/Albumin Ratio,a Risk Factor for Postoperative Delirium in Elderly Patients After Total Joint Arthroplasty

BackgroundPostoperative delirium (POD), as an acute brain failure, is widely reported as a very common postoperative complication, and it is closely associated with increased morbidity and mortality. This study aimed to investigate potential risk factors including C-reactive protein/albumin ratio (CAR) for POD in elderly subjects after total joint arthroplasty (TJA).MethodsA total of 272 elderly patients (aged 65～85 years) who were scheduled to undergo elective TJA with epidural anesthesia were consecutively recruited. The data of baseline characteristics, operation-associated indexes, and preoperative laboratory tests were collected. POD assessment was performed daily within postoperative 7 days. Receiver operating characteristic curve analysis was utilized for evaluating the predictive and cut-off value of CAR for POD. Risk factors for POD were evaluated by the binary univariate and multivariate logistic regression analyses.ResultsWithin postoperative 7 days, there were 55 patients who had suffered POD with an incidence of 20.2% (55/272). The area under the curve of CAR for POD was 0.804, with the cut-off value of 2.35, a sensitivity of 66.82%, and a specificity of 80.00%, respectively (95% confidence interval [CI]: 0.737-0.872, P < .001). Age (odds ratio: 2.02, 95% CI: 1.03-3.96, P = .038) and preoperative CAR level (odds ratio: 3.04, 95% CI: 1.23-7.23, P = .016) were 2 independent risk factors for POD in elderly subjects undergoing TJA.ConclusionsPreoperative CAR level may be a promising predictor for POD in elderly subjects following TJA.     

Reduced paraspinous muscle area is associated with post-colectomy complications in children with ulcerative colitis

Background and objectives

Sarcopenia, defined as reduced muscle mass, is typically assessed by CT scans, which are infrequently performed in children. Using MRI to measure sarcopenia, we determined the association with postoperative complications after colectomy for ulcerative colitis (UC).

High anti-CCP antibody titres predict good response to rituximab in patients with active rheumatoid arthritis

ObjectivePrevious studies reported that anti-CCP antibody positivity predicts good response to rituximab (RTX) in rheumatoid arthritis (RA). A quantitative approach to such possibility could be a good way to detect the subset of patients most likely to respond. We investigated whether serum anti-CCP antibody titres could predict response to RTX in RA patients.MethodsWe retrospectively investigated RA patients who received RTX. The primary criterion was decrease in DAS28 > 1.2 at 6 months (M6). Secondary efficacy criteria included a good response and remission according to EULAR. Predictors of response were investigated by multivariate logistic regression analysis.ResultsWe included 114 RA patients (81.6% female, median age 53.5 [IQR 45.7–61.2] years, median disease duration 8.5 [4.0–16.0] years). Anti-CCP antibodies were present in 93 patients (81.6%), with median anti-CCP antibody titres 583 [195–1509] U/mL. In all, 44 patients (38.6%) showed decreased DAS28 > 1.2 at M6. On univariate analysis, high anti-CCP titres were associated with response rather than non-response to RTX (median 1122 [355–1755] vs. 386 [149–800] U/mL, P = 0.0191) at M6. On multivariate regression analysis, with a cut-off of 1000 U/mL, anti-CCP antibody titres ≥ 1000 was associated with a decrease in DAS28 > 1.2 (OR 5.10 [1.97–13.2], P = 0.0002); a EULAR good response (4.26 [1.52–11.95], P = 0.0059); and a trend for EULAR remission (2.52 [0.78–8.12], P = 0.1207).ConclusionHigh anti-CCP antibody titres predict response to RTX in RA. This factor, easily assessed in clinical practice, can help with personalized medicine and selecting the best candidates for RTX treatment.