What are the post-vaccination care and potential treatment options for a patient who received a BCG (Bacillus Calmette-Guérin) vaccination?

Post-BCG Vaccination Care and Management

Expected Normal Reactions

Most patients receiving BCG vaccination will experience expected local reactions that require only observation and reassurance. Normal reactions include moderate axillary or cervical lymphadenopathy, induration, and subsequent pustule formation at the injection site, which can persist for up to 3 months after vaccination 1. A bluish-red pustule typically forms within 2-3 weeks, ulcerates after approximately 6 weeks (forming a lesion approximately 5 mm in diameter), and heals with scab formation within 3 months, usually resulting in permanent scarring 1.

Routine Post-Vaccination Care

• Keep draining lesions clean and bandaged until healing occurs 1
• Document tuberculin reactivity by performing a tuberculin skin test 3 months after BCG administration, recording results in millimeters of induration 1
• Educate patients that hypertrophic scars occur in 28%-33% of vaccinees and keloid scars in approximately 2%-4% 1

Management of Local Complications

Injection Site Reactions (Ulceration, Abscess)

Conservative management is recommended for most injection site reactions, as 95% show complete resolution within 6 months. 2 The majority (88%) of children with injection site reactions were successfully managed without intervention 2.

• Observe without intervention for mild to moderate injection site ulceration or abscess formation 2
• Self-resolution occurs within one month in 80% of abscess cases 3
• Avoid surgical drainage unless absolutely necessary, as most cases resolve spontaneously 2

Regional Lymphadenitis

Management of BCG lymphadenitis varies based on whether nodes are adherent/fistulated versus nonadherent:

• Nonadherent lymph nodes heal spontaneously without treatment and should be observed 1
• For adherent or fistulated lymph nodes, the WHO recommends drainage with direct instillation of an anti-TB drug into the lesion 1
• Conservative management alone was successful in 46% of lymphadenitis cases, with complete resolution in 59% overall 2
• Self-resolution occurs within one month in 100% of lymphadenopathy cases when managed conservatively 3

Important caveat: Controlled studies have not been conducted to determine optimal treatment, and recommendations range from no treatment to surgical drainage, anti-TB drugs, or combination therapy 1. Given the high rate of spontaneous resolution, conservative management should be attempted first.

Management of Serious Complications

Disseminated BCG Infection

Anti-TB therapy is mandatory for disseminated BCG infection, but pyrazinamide must never be used because all BCG strains are resistant to it. 1

• Initiate multi-drug anti-TB therapy immediately (excluding pyrazinamide) for any signs of disseminated disease 1
• Consider interferon-gamma as adjunctive therapy, particularly in immunocompromised patients, as 60% of disseminated cases responded to four anti-mycobacterial drugs plus interferon-gamma 4
• Recognize that fatal disseminated BCG disease occurs at a rate of 0.06-1.56 cases per million doses, primarily in immunocompromised persons 1

BCG Osteitis

BCG osteitis affecting the epiphyses of long bones can occur 4 months to 2 years after vaccination and requires anti-TB medications, with surgery sometimes necessary. 1

• Treat skeletal lesions with anti-TB medications (excluding pyrazinamide) 1
• Consider surgical intervention if medical therapy is insufficient 1
• Risk varies by country and vaccine strain, ranging from 0.01 cases per million in Japan to 43.4 per million in Finland 1

Special Populations and Precautions

HIV-Infected Patients

Persons infected with HIV are at greater risk for lymphadenitis and disseminated complications from BCG vaccine. 1

• Monitor more closely for adverse reactions in HIV-infected individuals 1
• Disseminated BCG disease has occurred in at least one child and one adult infected with HIV 1
• BCG-related complications can occur several years after vaccination in symptomatic HIV infection 1

Immunocompromised Patients

Severe immune-compromised infants are at greatest risk for disseminated disease and respond poorly to standard therapies. 4

• Primary immunodeficiency disorders (severe combined immunodeficiency, chronic granulomatous disease, cell-mediated immune defects) carry highest risk 4
• 60% of disseminated cases in immunocompromised patients had known primary immune deficiency disorders 4

Surveillance and Reporting

All suspected adverse reactions to BCG vaccination should be reported to the manufacturer and to the Vaccine Adverse Event Reporting System (VAERS) at (800) 822-7967. 1

• Report reactions even if they occur >1 year after vaccination 1
• Document all complications including injection site reactions, lymphadenitis, osteitis, and disseminated disease 1

Common Pitfalls to Avoid

• Do not use pyrazinamide for any BCG-related infection, as all strains are resistant 1
• Do not rush to surgical intervention for lymphadenitis, as most cases resolve spontaneously 2, 3
• Do not assume all local reactions require treatment, as 88% of injection site reactions resolve with conservative management 2
• Do not overlook immunodeficiency in patients with severe or disseminated BCG complications 4