Vaccinations and Screening Before Starting Infliximab

Inactivated Vaccines

The American College of Rheumatology recommends that all inactivated vaccines should be administered at least 2 weeks before initiating infliximab 1, 2
Influenza vaccine should be given annually, ideally ≥2 weeks before starting infliximab to optimize immune response 3, 2
Pneumococcal vaccination is strongly recommended before initiating therapy, with PCV20 as the preferred single vaccine or PCV15 followed by PPSV23 at least 8 weeks later 4, 2, 5
Hepatitis B vaccine series should be completed before starting infliximab if the patient lacks immunity 6
Tetanus/diphtheria/pertussis (Tdap) booster should be current 7, 8
COVID-19 vaccination should be administered at least 2 weeks before starting immunosuppressive therapy 5
Meningococcal vaccine should be considered, particularly for patients with additional risk factors 9
Haemophilus influenzae type B (Hib) vaccine may be considered in specific high-risk situations 8
Hepatitis A vaccine is recommended for patients at risk, such as those receiving frequent blood products 8
Human papillomavirus (HPV) vaccine should be given if indicated by age (9-45 years), though immune response may be reduced 8

Live attenuated vaccines must be held for 1 dosing interval before infliximab and avoided for 4 weeks after administration 1
Herpes zoster vaccine (recombinant RZV/Shingrix) is the preferred option for patients ≥50 years and can be given safely at least 2 weeks before starting infliximab 4, 2, 5
Measles, mumps, rubella (MMR) vaccine should be updated if needed, given at least 4 weeks before infliximab 1, 10
Varicella (chickenpox) vaccine should be administered if the patient lacks immunity, ideally 4 weeks before starting therapy 1, 10
Other live vaccines (yellow fever, oral typhoid, oral polio) should be deferred or replaced with inactivated alternatives when available 1

All patients must undergo TB screening before infliximab initiation, including clinical history, chest radiograph, and tuberculin skin testing or interferon-gamma release assay 3
Screen all patients for HBsAg, anti-HBc, and anti-HBs before starting infliximab, with HBsAg-positive patients requiring antiviral prophylaxis with entecavir or tenofovir starting 2 weeks before infliximab 3