Management of BCG Sepsis

Immediate Management

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
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) 2

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) 2
For sepsis-related myocardial depression with low cardiac output despite adequate volume, add dobutamine 2

For moderate to severe respiratory insufficiency, provide appropriate ventilatory support 2
In awake, cooperative patients with minor gas exchange disturbance, consider intermittent continuous positive airway pressure (CPAP) 2
For patients without hypotension or altered mental status, non-invasive positive pressure ventilation is preferred 2
Early initiation of non-invasive ventilation before development of severe hypoxemia is recommended 2
If respiratory status deteriorates or fails to improve, proceed to endotracheal intubation and controlled mechanical ventilation 2

Monitor vital signs, including temperature, blood pressure, heart rate, and respiratory rate continuously 1, 2
Assess urine output and renal function regularly 2
Monitor for signs of progressive organ dysfunction 2
Follow lactate levels to assess tissue perfusion 2
Continue antimicrobial therapy until clinical improvement is evident 1

Strictly follow contraindications to BCG instillations 1
BCG treatment should be started at least 2 weeks after TURBT to reduce risk of sepsis 1
Patients with immunodeficiencies should not receive BCG 3
Avoid BCG in patients with active infections or fever 1

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

For patients with a history of BCG sepsis, live bacterial vaccines should be avoided in the future 3
Patients with innate immune defects should seek specialist advice regarding future use of live vaccines 3
Patients with phagocytic cell defects should not receive live bacterial vaccines such as BCG 3