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Three Part Question

In [children with a BCG abscess] does [treatment with antibiotics] [lead to earlier resolution]?

Clinical Scenario

A 4 month old asian child presented to the paediatric ward with a fluctuant, non-tender abscess on the left upper arm. He had been born at 35 weeks gestation and was given the BCG vaccination into this area at 5 weeks of age when he left the special care baby unit. On examination he was afebrile, thriving, there was no history of travel abroad, and no family members were unwell. The abscess was aspirated and acid fast bacilli were seen on microscopy. He was commenced on a 3 month course of isoniazid and attended the outpatient clinic at the end of this period. A discharging sinus was noted and he was referred for surgical management.

Search Strategy

Cochrane database and Medline using PubMed interface.
Search terms: 'BCG Vaccine' AND 'Abscess'
'BCG Vaccine' AND 'adverse reactions'
'BCG Vaccine' AND 'erythromycin'
'BCG Vaccine' AND 'isoniazid'
Limits: language: English

Search Outcome

Search Outcome: 306 hits; 8 directly relevant to the question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Power J.T. Stewart I.C. Ross J.D. 1984	6 patients	Case series	Healing of lesions	All lesions healed with a 2-4 week therapy of erythromycin	Uncontrolled study.
Warren J.P. Nairn D.S. Robertson M.H. 1984	1 adult	Case Report	Healing of lesion	Lesion healed with 2 months of isoniazid, surgical drainage and addition of erythromycin for further two months
Singh G. Singh M 1984	4/12 old infant and 3/12 old infant	Case Report	Healing of lesions	Complete resolution of lesions with 2 week course of erythromycin
Hanley S.P. Grumb J. McFarlane J.T. 1985	18 children	Randomised single blind trial	Healing of lesions	No difference in resolution of lesions	Randomised to receive either erythromycin or isoniazid, no control group. Erythromycin did not resolve lesions within one month. Neither antibiotic more effective.
Murphy J.P. 1989	Two adult Americans (husband and wife)	Case Report	Healing of Lesions	Complete resolution in 3 and 4 weeks respectively with erythromycin

Comment(s)

Bacille Calmette-Guerin (BCG) has been extensively used as a vaccine for over 70 years. It is an attenuated from of Mycobacterium bovis, sensitive to Rifampicin and Isoniazid. As BCG is a live attenuated vaccine, infectious complications occasionally occur. An Australian national study in 2002 reported a total of 53 adverse reactions in 916 vaccinees (5%) and injection site abscesses accounted for 43% of these(Turnbull et al). In their series sixteen resolved spontaneously whilst seven required treatment. This included surgical excision or oral antibiotics. BCG abscesses usually present between one and five months after vaccination, but some may present later. In this report we review the treatment of BCG abscesses only, not lymphadenitis. Much of the published data regarding the medical management of BCG abscesses is in the form of anecdotal reports of Erythromycin or Isoniazid (see table). The first documented use of erythromycin in the treatment of BCG abscess was in 1984 when Power and his colleagues performed an uncontrolled study on a population of six patients, 3 with post BCG abscesses and 3 with discharging ulcers (Power et al). They noted that all lesions healed within 2-4 weeks of commencing therapy. This report was followed, by two further anecdotal case reports. One reported the accidental inoculation of a healthcare worker with BCG vaccine(Warren et al). She was treated with a month's course of isoniazid, surgical drainage and then addition of rifampicin for a further two months. Due to the resolution of the lesion it was suggested that early isoniazid therapy would prevent cold abscess formation. The second report concerned two infants aged 3 and 4 months repectively(Singh G. Singh M). Aspiration of their abscesses revealed acid fast bacilli (AFB) and a 15 day course of erythromycin resolved lesions in both cases. Murphy et al in 1989 documented the treatment of BCG abscesses with erythromycin in a husband and wife team after aspiration led to complete resolution in 3 and 4 weeks respectively (Murphy J P). In 1985 Hanley reported on 18 children with post BCG abscesses or ulcers treated with a months course of either isoniazid or erythromycin(Hanley et al). Their study found no difference between the two treatment groups, but did not support the reports that erythromycin could lead to complete resolution of the lesions within a month. Again there was no placebo group. There are few studies and no randomised controlled trials looking at the effect of medical therapy for treatment of BCG abscesses. The present recommendation in the UK is to aspirate pus to confirm BCG and/or other organisms (Grange J.M). The guideline makes no recommendation on the use of antimicrobials and recognises the limited evidence. The Canadian guidelines on the management of BCG abscesses suggest reassurance, and antimicrobial therapy with erythromycin to be used only if there is evidence of superimposed bacterial infection(Mark Fitzgerald J).

Clinical Bottom Line

Antibiotic therapy has not been shown to speed resolution of BCG abscesses Most BCG abscesses will resolve spontaneously

References

1. Power J.T. Stewart I.C. Ross J.D Erythromycin in the management of troublesome BCG lesions. Br. J. Dis. Chest. 1984;78:192-194
2. Warren J.P. Nairn D.S. Robertson M.H. Cold Abscess after accidental BCG innoculation. Lancet. 1984;Aug:289
3. Singh G. Singh M Erythromycin for BCG cold abscess Lancet. 1984;Oct:979
4. Hanley S.P. Grumb J. McFarlane J.T. Comparison of Erythromycin and isoniazid in treatment of adverse reactions to BCG vaccination. BMJ. 1985;290:970
5. Murphy J.P. Cure of bacille Calmette-Guerin vaccination abscesses with erythromycin. Rev. Infect. Dis 1989;11(2):335-337
6. Turnbull F.M. McIntyre P.B. Achat H.M. Wang H. Stapledon R. Gold M. Burgess M.A. National Study of adverse reactions after vaccination with Bacillus Calmette-Guerin. CID. 2002;34:447-453
7. Grange J.M. Complications of Bacillus Calmette-Guerin (BCG) vaccination and immunotherapy and their management. Communicable disease and Public Health. 1998;1(2):84-88
8. Mark Fitzgerald J. Management of adverse reactions to Bacillus Calmette-Guerin vaccine. CID. 2000;31(suppl. 3): 75-76