Sex and infection

At the recent meeting of the American Shoulder and Elbow Surgeons, Doctor Dominique Rouleau gave a most informative presentation on the relationship between sex, gender and the risk of infection. She pointed us to this article Sex and Gender Differences in Bacterial Infections, that makes some clinically relevant points:

Biological sex (defined by sex chromosome complement, sex steroid hormones, and reproductive organs) has been shown to influence susceptibility to infection, pathophysiology, immune responses, clinical presentation, disease severity, and response to treatment and vaccination. Women tend to have stronger immune responses to self and foreign antigens than men, resulting in sex-based differences in autoimmunity and infectious diseases. Males are generally more susceptible than females to bacterial infections. 

On the other hand, gender roles (referring to characteristics that are socially constructed) and social norms can influence risk factors and exposure to infection, determine health-seeking behaviors, quality of health care, adherence to treatment recommendations, and can affect therapeutic decisions.

Genetic factors.

Female sex is determined by having two X chromosomes. The additional X enhances the strength and diversity of the female's immune response.

Immune response

Females tend to have stronger innate and adaptive immune responses than males. Females have higher neutrophil counts in peripheral blood and more efficient antigen-presenting cells. Females have greater antibody responses, higher B cell numbers, higher IgM and IgG levels,

Sex Hormones

After puberty, concentrations of estrogens and progesterone in females and androgens in males rise significantly. During this period, there is generally a male bias in infectious diseases, with males being more frequently and more severely affected by bacterial, viral, and parasitic infections, whereas females are more affected by autoimmune disease. Estrogen, progesterone and androgens influence immune responses by binding to specific receptors expressed in immune cells, including lymphocytes, macrophages, and dendritic cells, and can also have a direct effect over bacterial metabolism, growth, and expression of virulence factors.

Gender

Gender-related occupational and recreational activities can affect exposure to pathogens. Women are more likely to assume caretaking roles, making them more exposed to childhood diseases. On the other hand, men wash their hands less often than women. 

Sex and Gender Differences in Bacterial Diseases

Females have higher rates of upper respiratory infections while men more commonly have lower respiratory infections.

Urinary tract infections are more common in females but more severe in males.

Gastointestinal infections are more common in males.

Men have more frequent and more severe sexually transmitted diseases.

Men are more prone to have sepsis than females.

Comment: This article provides an overview of sex and gender differences in pathophysiology, incidence, clinical presentation, disease course, response to treatment, and outcome. It found that biological and gender factors come into play and their recognition is essential to improving patient care. Behavioral differences play an important role in the exposure to pathogens, whereas sex differences in the immune response are directly influenced by sex chromosome complement and concentrations of sex steroid hormones.

While the article did not deal with orthopaedic infections or with the more common bacteria we encounter in our practices - cutibacterium, streptococcus species and staphylococcus species - we can suspect that sex and gender differences are important considerations in our practices. For example, it is recognized that cutibacterium infections are more common in young men and in those with high testosterone serum levels. This knowledge informs our preoperative discussions with patients, our use of prophylaxis, and our suspicion of infection when the clinical outcome is not as expected.

Of note, the only serious Cutibacterium periprosthetic shoulder infection we've encountered was in a woman body builder who used large doses of supplemental testosterone.

Further research will show us how we can understand and manage our patients' risk factors for infection and autoimmune diseases.

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