Thank you for your inquiry.

The first question you asked can be answered fairly conclusively. The admonition you cited against repeated pneumococcal immunization because of the risk of the induction of hyporesponsiveness is clearly stated in the Parameters you mentioned, and this concept is generally accepted. Therefore, I would not proceed with the strategy of pneumococcal boosters.

The second question cannot be answered as definitively. I would like to give you the best reference of which I am aware that deals with this issue. It is:

Yong PL, et al. Use of intravenous immunoglobulin and adjunctive therapies in the treatment of primary immunodeficiencies. A working group report of and study by the Primary Immunodeficiency Committee of the American Academy of Allergy Asthma and Immunology Clinical Immunology (2009).

This reference in its entirety is readily available to you online without charge. You can obtain it by Googling the reference itself. It is available in a pre-print version. The publisher is Elsevier.

For your convenience, I will summarize the paragraphs dealing with prophylactic antibiotocs.

According to this consensus report, there is little “evidence-based guidance” regarding the use of antibiotic prophylaxis in primary immunodeficiency disorders. However, 88.1% of focused and 47% of general immunologists reported using prophylactic antibiotics in some patients. There is no general accepted “drug of choice,” but the most commonly employed prophylactic antibiotic was amoxicillin. This was followed by trimethoprim-sulfamethoxazole. A few immunologists reported using macrolides in both children and adults. Fluoroquinolones were used occasionally in adults. Fifty-two percent of immunologists rotated antibiotics when used for prophylaxis.

In summary, I do not feel that boosting pneumococcal immunizations is indicated. Although there is a dearth of evidence-based data that has documented the efficacy of prophylactic antibiotics, in situations such as the one you described, they are clearly used with significant frequency.

Thus, with these observations in mind, my personal preference in your patient would be to employ a prophylactic antibiotic, and I would choose either amoxicillin or trimethoprim-sulfamethoxazole, but would extend the caveat as mentioned above that the decision to use prophylactic antibiotic therapy is based on clinical judgment rather than a substantial amount of evidence.

Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.