Is traumatic catheterization a risk for BCG (Bacillus Calmette-Guérin) sepsis?

Traumatic Catheterization is a Significant Risk Factor for BCG Sepsis

Traumatic catheterization is a significant risk factor for BCG sepsis and should be avoided when administering intravesical BCG therapy for bladder cancer. This risk is well-documented in clinical evidence and represents a potentially life-threatening complication.

Mechanism and Risk

BCG (Bacillus Calmette-Guérin) is a live attenuated strain of Mycobacterium bovis used for intravesical immunotherapy in superficial bladder cancer. When traumatic catheterization occurs:

• Trauma to the urethra or bladder creates direct access to the bloodstream
• BCG organisms can enter systemic circulation through damaged tissue
• This can lead to disseminated BCG infection (BCGitis) or sepsis

Evidence for the Risk

Multiple studies have identified traumatic catheterization as a specific risk factor for BCG sepsis:

• Case reports document BCG sepsis occurring after traumatic instillation with bleeding 1
• In a large review of 2,602 patients treated with intravesical BCG, traumatic catheterization was identified as a specific risk factor for systemic BCG absorption and severe toxicity 2
• Among 169 patients treated with BCG, 3 out of 5 cases of BCGitis appeared after traumatic instillation with bleeding 3
• A case presentation described BCG sepsis with lung consolidation occurring in a patient after combined intravesical and intraurethral BCG 4

Clinical Presentation of BCG Sepsis

BCG sepsis typically presents with:

• Fever (often >38.5°C)
• Chills
• Malaise
• Progressive deterioration
• May develop hepatorenal failure if untreated
• Can include granulomatous inflammatory changes in multiple organs (liver, lungs)

Prevention Recommendations

To prevent BCG sepsis related to catheterization:

1. Delay BCG instillation if there is any evidence of traumatic catheterization
2. Postpone treatment if concurrent cystitis is present
3. Use strict aseptic technique during catheterization
4. Ensure gentle catheterization by experienced personnel
5. Avoid BCG administration for at least 2 weeks after traumatic urologic procedures

Management of BCG Sepsis

If BCG sepsis is suspected:

1. Immediately discontinue BCG therapy
2. Initiate antimycobacterial treatment:
   • Rifampicin
   • Isoniazid (though some BCG strains including Connaught strain may be resistant) 5
   • Consider adding ethambutol
3. Add corticosteroids (prednisone) for severe cases
4. Provide supportive care as needed

Important Caveats

• BCG sepsis can occur even after multiple successful treatments
• Symptoms may appear hours after instillation or be delayed for months
• Early recognition and treatment are critical for preventing mortality
• Isoniazid resistance is common among some BCG strains used for bladder cancer therapy, which may complicate treatment 5

The Infectious Diseases Society of America guidelines emphasize that severe sepsis associated with catheter-related infections requires prompt catheter removal and appropriate antimicrobial therapy 6. While these guidelines don't specifically address BCG sepsis, the principles of management apply.

Remember that traumatic catheterization is an absolute contraindication to proceeding with BCG instillation, and the procedure should be rescheduled after complete healing has occurred.