Open Access Research article

Risk of infection in patients with lymphoma receiving rituximab: systematic review and meta-analysis

Simone Lanini1*, Aoife C Molloy2, Paul E Fine3, Archibald G Prentice4, Giuseppe Ippolito1 and Christopher C Kibbler2

Author Affiliations

1 National Institute for Infectious Diseases, INMI-Lazzaro Spallanzani Via Portuense, 292 00149 Rome, Italy

2 Department of Medical Microbiology, Royal Free Hospital, Pond Street, London NW3 2QG, UK

3 London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK

4 Department of Haematology, Royal Free Hospital, Pond Street, London NW3 2QG, UK

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BMC Medicine 2011, 9:36  doi:10.1186/1741-7015-9-36

Published: 12 April 2011



The addition of Rituximab (R) to standard chemotherapy (C) has been reported to improve the end of treatment outcome in patients affected by CD-20 positive malignant lymphomas (CD20+ ML). Nevertheless, given the profound and prolonged immunosuppression produced by R there are concerns that severe infections may arise. A systematic review and meta-analysis were performed to determine whether or not the addition of R to C may increase the risk of severe infections in adults undergoing induction therapy for CD20+ ML.


Only randomised controlled trials comparing R-C to C standard alone in adult patients with CD20+ ML were included. Meta-analysis was performed on overall incidence of severe infection, risk of dying as the consequence of infection, risk of febrile neutropenia, risk of severe leucopenia, risk of severe granulocytopenia and overall response assuming a fixed effect model. Heterogeneity was investigated, if present and I2 >20%, according to several predefined baseline characteristics of the study populations.


Several relevant results have emerged. First, the addition of R to standard C does not increase the overall risk of severe infections (RR = 1.00; 95% CI 0.87 to 1.14) nor does it increase the risk of dying as a consequence of infection (RR = 1.60; 95% CI 0.68 to 3.75). Second, we confirmed that the addition of R to standard C increases the proportion of overall response (RR = 1.12; 95% CI 1.09 to 1.15), but it also increases the risk of severe leucopenia (RR = 1.24; 95% CI 1.12 to 1.37) and granulocytopenia (RR = 1.07; 95% CI 1.02 to 1.12).


R-C is superior to standard C in terms of overall response and it does not increase the overall incidence of severe infection. However, data on special groups of patients (for example, HIV positive subjects and HBV carriers) are lacking. In our opinion more studies are needed to explore the potential effect of R on silent and chronic viral infections.