From the Guidelines
The workup for Bacillus Calmette-Guérin (BCG) sepsis requires prompt recognition and treatment with antituberculous therapy, and administration of effective IV antimicrobials within the first hour of recognition is crucial 1.
Initial Evaluation and Treatment
When BCG sepsis is suspected, immediately start isoniazid 300mg daily, rifampin 600mg daily, and ethambutol 15mg/kg daily, as these are the most effective antimicrobials against Mycobacterium bovis 1.
- Add high-dose corticosteroids (prednisone 40-60mg daily) to manage the inflammatory response, as BCG sepsis represents an immunological reaction to mycobacterial antigens as well as actual infection.
- Initial evaluation should include:
- Blood cultures
- Complete blood count
- Liver function tests
- Chest X-ray
- Consider CT imaging of the abdomen and pelvis to identify disseminated infection.
Diagnostic Testing
- Obtain mycobacterial cultures from blood, urine, and any suspicious lesions, though these may take weeks to yield results.
- PCR testing for mycobacteria can provide faster results, and is recommended for early diagnosis 1.
Monitoring and Treatment Duration
- Monitor liver function closely as antituberculous medications can cause hepatotoxicity.
- Treatment typically continues for 6 months, with corticosteroids tapered over 1-2 months.
- Daily assessment for de-escalation of antimicrobial therapy in patients with sepsis and septic shock is recommended 1. BCG sepsis occurs when attenuated Mycobacterium bovis from BCG immunotherapy, commonly used for bladder cancer, disseminates systemically. Early recognition and treatment are crucial as mortality rates can reach 5% if treatment is delayed.
From the Research
Diagnosis and Treatment of BCG Sepsis
- BCG sepsis is a rare but life-threatening complication of intravesical BCG therapy for bladder cancer, and timely diagnosis and treatment are crucial for patient recovery 2, 3.
- The diagnosis of BCG sepsis can be challenging due to frequently negative microbiological results, and a high index of suspicion is necessary to initiate treatment promptly 2, 3.
- Treatment for BCG sepsis typically involves the use of antituberculosis agents, such as rifampicin, ethambutol, and isoniazid, and may also include the use of steroids 4, 3.
Clinical Presentation and Management
- Patients with BCG sepsis may present with symptoms such as fever, asthenia, and other systemic symptoms, and may rapidly deteriorate if left untreated 4, 3.
- The use of broad-spectrum antibiotics may not be effective in treating BCG sepsis, and antituberculosis therapy should be initiated as soon as possible 4.
- In some cases, patients with BCG sepsis may require intensive care and supportive therapy, such as mechanical ventilation and hemodynamic support 4.
Susceptibility Profiles and Treatment Regimens
- The susceptibility profiles of Mycobacterium bovis subsp BCG have been reported to vary, with rifampicin, ethambutol, and streptomycin being effective in most cases 5.
- A three-drug regimen, including rifampicin, ethambutol, and isoniazid, is commonly used to treat BCG sepsis, and may be adequate for treatment if initiated early 5, 3.