Management of BCG Sepsis with Fever, Difficulty Breathing, and Hypotension
Patients experiencing fever, difficulty breathing, and hypotension after BCG administration should immediately receive broad-spectrum antibiotics, anti-tuberculosis drugs, and be transferred to the ICU for intensive supportive care. 1
Immediate Management
- Immediately stop BCG treatment when sepsis occurs 1
- Transfer the patient to the ICU for intensive monitoring and supportive care 1
- Collect blood and urine cultures for bacteria and acid-fast bacilli before starting antimicrobial therapy 1
- Initiate fluid resuscitation with volume substitution under hemodynamic monitoring (central venous pressure, blood pressure, heart rate, cardiac output) 1
Pharmacological Management
- Administer broad-spectrum antibiotics immediately 1
- Start anti-tuberculosis drugs (isoniazid and rifampicin) 1
- Add corticosteroids to reduce inflammatory response 1
- For severe cases without renal failure, consider oral cycloserine with careful monitoring of blood concentration 1
- If mean arterial pressure remains <65 mmHg despite adequate fluid resuscitation, initiate norepinephrine (0.1-1.3 μg/kg/min) 1
- For sepsis-related myocardial depression with low cardiac output despite adequate volume, add dobutamine 1
Respiratory Support
- For moderate to severe respiratory insufficiency, provide appropriate ventilatory support 1
- In awake, cooperative patients with minor gas exchange disturbance (PaO₂/FiO₂ > 200), consider intermittent continuous positive airway pressure (CPAP) 1
- For patients without hypotension or altered mental status, non-invasive positive pressure ventilation is preferred 1
- Early initiation of non-invasive ventilation before development of severe hypoxemia is recommended 1
- If respiratory status deteriorates or fails to improve, proceed to endotracheal intubation and controlled mechanical ventilation 1
Monitoring and Follow-up
- Monitor vital signs, including temperature, blood pressure, heart rate, and respiratory rate continuously 1
- Assess urine output and renal function regularly 1
- Monitor for signs of progressive organ dysfunction 1
- Follow lactate levels to assess tissue perfusion 1
- Continue antimicrobial therapy until clinical improvement is evident 1
Prevention and Risk Factors
- Strictly follow contraindications to BCG instillations 1
- BCG treatment should be started at least 2 weeks after TURBT (transurethral resection of bladder tumor) to reduce risk of sepsis 1
- Patients with immunodeficiencies should not receive BCG 1
- Avoid BCG in patients with active infections or fever 1
Long-term Considerations
- BCG instillation is no longer recommended after the patient recovers from BCG sepsis 1
- Consider alternative treatment options for the underlying condition 1
- Monitor for delayed complications of BCG sepsis, including granulomatous hepatitis or pneumonitis 1
Special Considerations
- For patients with a history of BCG sepsis, live bacterial vaccines should be avoided in the future 1
- Patients with innate immune defects should seek specialist advice regarding future use of live vaccines 1
- Patients with phagocytic cell defects should not receive live bacterial vaccines such as BCG 1
This management approach prioritizes rapid intervention to address the life-threatening systemic inflammatory response while providing appropriate supportive care for organ systems affected by BCG sepsis.