Pre-biologic infection screening and vaccination — Rapid

Synopsis

Complete a reproducible infection and immunisation safety assessment before biologic or targeted therapy, interpret tuberculosis and hepatitis results correctly, and time vaccines without leaving active rheumatic disease untreated.

Start with active infection: history, examination and symptom-directed tests come before latent-screen panels; a patient with sepsis or active TB does not proceed to biologic dosing.
Tuberculosis assessment combines exposure and residence history, symptoms, IGRA and chest imaging when indicated. Immunosuppression can produce a false-negative or indeterminate IGRA.
A positive latent-TB screen requires exclusion of active disease and referral to the TB service for preventive treatment and biologic timing; do not improvise a universal delay.

Key red flags

Cough, weight loss, fever, night sweats, haemoptysis, lymphadenopathy or TB exposure requires active-tuberculosis assessment regardless of an earlier negative IGRA.

Possible active tuberculosis

Persistent cough, weight loss, sweats, fever, lymph nodes or organ-specific symptoms with epidemiological risk requires microbiological and imaging assessment, not a latency label.

Investigation priorities

First-line clinical infection assessmentFirst stepFirst line

Identify an active focus that makes immediate immunosuppression unsafe.

Management branches

First gateExclude active infection before latent screening

Biologic or targeted treatment is planned and the patient enters the safety pathway.

Take a structured symptom, exposure, travel, recurrent-infection, device, wound, dental and vaccine history and examine any likely focus.
Investigate and treat active infection first, deferring immunosuppression when sepsis, active TB, uncontrolled hepatitis or significant untreated infection is credible.

Key medicines

Isoniazid plus rifampicin for latent TBA NICE adult preventive option is isoniazid 300 mg orally once daily plus rifampicin 600 mg once daily for three months, with weight adjustment and pyridoxine prescribed when neuropathy risk warrants it under the TB service.

Isoniazid for latent TBGive isoniazid 300 mg orally once daily for six months, with weight adjustment and pyridoxine for relevant neuropathy risk, as an alternative NICE preventive regimen selected by the TB service.

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