Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Disseminated infection or sepsis
Hypotension, confusion, hypoxia, rapidly spreading severe pain, necrosis, crepitus, extensive vesicles, ocular symptoms, neutropenic sepsis or organ dysfunction can progress despite little fever or inflammation during immunosuppression.
Action: Use an emergency ABCDE and sepsis pathway, obtain cultures without delaying antimicrobial or antiviral treatment, seek surgical review for suspected necrotising infection, involve ophthalmology for ophthalmic zoster, and withhold relevant immune-modifying drugs with immediate specialist advice while maintaining necessary corticosteroid cover.
Synopsis
Prevent, recognise and safely manage cutaneous and disseminated infection in people receiving immune-modifying treatment, while distinguishing routine precautions from emergencies and avoiding abrupt corticosteroid withdrawal or dangerous antimicrobial interactions.
Define the regimen precisely: infection risk depends on mechanism, dose, duration, combination treatment, comorbidity and residual drug half-life rather than the label immunosuppressed alone.
Ask about tuberculosis, hepatitis, HIV, previous varicella or zoster, recurrent HSV, chronic wounds, diabetes, travel, exposure and vaccination before treatment begins.
Complete indicated vaccines before immune suppression where possible; non-live vaccines are generally safe, whereas live vaccines require Green Book and agent-specific timing.
Key red flags
Disproportionate pain, rapid extension, skin anaesthesia, dusky or necrotic change, crepitus, hypotension, confusion, breathlessness, disseminated vesicles, forehead or eye involvement, severe mucosal disease, profound neutropenia, or infection soon after high-dose immune suppression requires same-day emergency care.
Blunted systemic illness
New functional decline, confusion, tachypnoea, hypotension or rigors can be more informative than absent fever, normal neutrophils or modest CRP after immune suppression.
Investigation priorities
01
Baseline infection and vaccine assessmentFirst step
Identify preventable and reactivatable infection before immune suppression.
Management branches
First-line preventionReduce risk before treatment
A systemic immune-modifying medicine is planned or intensified.
Define drug, dose, combinations and expected duration and identify age, comorbidity, exposure, wound, travel and previous-infection modifiers.
Complete the agent-specific TB, viral and laboratory screen, treat active infection and refer latent TB or hepatitis risk before starting.
Persistent lesionLook beyond routine organisms
A lesion progresses despite appropriate standard therapy or has nodular, deep or sporotrichoid morphology.
Key medicines
ValaciclovirFor immunocompetent adult shingles, 1 g orally three times daily for 7 days; use the specialist regimen for immunocompromise and reduce by renal function.
Intravenous aciclovirFor herpes zoster in an immunocompromised adult, 10 mg/kg intravenously every 8 hours, infused over 1 hour, with renal and weight-based adjustment under specialist care.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
UKHSA Green Book chapter 7Live and non-live vaccine timing, degrees of immunosuppression and household-contact precautions.