Q:

6/5/2013
I have a 69 year-old patient with significant co-morbid conditions including congestive heart failure, COPD, DM, CAD and 4 MIs s/p 4-5 stent placements, rheumatoid arthritis, anemia and reported hepatitis referred for immunologic screen due to history of recurrent sinusitis and episode of pneumonia in the past 6 months. In April started methotrexate 12.5mg daily for RA and has been on a couple courses of systemic steroids in the past several months, last in March.

Evaluation started in April included: CBC with differential normal aside from a mild stable anemia, normal IgA, IgM, IgG levels, protective diphtheria and tetanus titers. Only 1/23 protective (>1.3mcg/ml) pneumococcal titers.

Four weeks after pneumovax administered, 4 titers were >1.3mcg/ml with at least 2-4 fold increase and another 7 titers had 2-4 fold increase but did not reach protective levels of >1.3mcg/ml. Based on this information it appears he has mild-moderate selective antibody deficiency.

I have a couple questions regarding this case. One is based on a colleague recommendation to "boost" with PCV13 followed by repeat PPV23 in one month intervals but according to the recent Jordan et al practice update it appears this may actually lead to hypo-responsiveness even if just revaccination with PCV13 in patients >70 (which he is close to) who previously received PPV23. Second, based on his age and other co-morbid conditions, how would you advise antibiotic prophylaxis (and which antibiotic) versus immunoglobulin replacement in this patient? Thanks.

A:

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.

AAAAI - American Academy of Allergy Asthma & Immunology