Synopsis
Predict infection risk from immune mechanism, host factors and exposure; complete pretreatment screening and vaccination; recognise muted infection; and coordinate treatment changes, prophylaxis and monitoring safely.
- Infection risk is the interaction of immune target, dose and duration, drug combinations, underlying disease, age, comorbidity, previous infection and environmental exposure.
- Before therapy, document infection history and examine for active infection, review vaccination, and complete the exact latent-infection and baseline tests required for that agent and patient.
- Different mechanisms create different patterns: neutropenia, T-cell suppression, B-cell depletion, cytokine blockade and complement inhibition do not confer interchangeable risks.
Key red flags
Fever, focal symptoms, unexplained inflammatory change or unresolved antimicrobial therapy should be assessed before initiating or escalating suppression.
Hypotension, confusion, hypoxia, oliguria or rapid functional decline can signal sepsis even without fever or raised CRP.
Reasoning priorities
Record every immunosuppressive agent, dose, duration, combination, last dose and expected recovery.
Predict which defence is impaired and for how long; product information and specialist protocols determine exact risk management.
Worked reasoning
An adult due to start adalimumab, a TNF inhibitor, has weight loss, night sweats and a productive cough after prolonged residence in a high-tuberculosis-incidence country.
- Defer administration pending urgent clinical assessment, examine for active infection and assess physiology; infection symptoms must not be reduced to a screening checkbox.
- Recognise epidemiology and symptoms as possible active tuberculosis, separating this from latent infection and inflammatory-disease activity.
- Contact the prescribing, respiratory and infection teams, apply respiratory isolation according to local TB policy, obtain a chest X-ray and send three respiratory samples—including an early-morning sample where feasible—for mycobacterial microscopy and culture, adding a rapid molecular test when current NICE NG33 criteria are met rather than relying on one latent-infection test.
- Start or resume immunosuppression only through the coordinated specialist plan after classification and treatment decisions, documenting responsibility and verifying follow-up.