General precautions:

Evaluate patient for risk or presence of infection and obtain recent travel history with each encounter.

Respiratory or neurologic symptoms, fever, and constitutional symptoms should prompt thorough investigation.

Stop biologic agents with signs of serious illness.

Maintain a high suspicion for and consider coverage for unusual pathogens during serious illness.

Empiric treatment for meningitis should include coverage for Listeria.

Recall that TNF-a mediates fever, weight loss, and night sweats and serious infection may present atypically.

Viral Hepatitis and HIV

Obtain hepatitis panel before use of biologic agents.

If positive, obtain transaminase, coagulation, and viral load studies.

Consider baseline liver biopsy before initiation.

Consider co-administration of antiviral, such as lamivudine for HBV or ribavirin for HCV.

Enlist concurrent care with an HIV specialist when considering use of these agents in patients with HIV.


Conduct a thorough assessment for LTBI: PPD, chest radiograph, birth, social, lifetime travel, and contact histories.

A negative PPD does not exclude LTBI. Consider two-step testing. Repeat PPD every 12 months while on therapy.

An induration of >5 mm is positive and requires treatment for LTBI including those with history of bacille Calmette-Guerin vaccine.

Strongly consider prophylaxis for suspected LTBI or patients at very high risk.

Consider postponing TNF inhibition until completion of treatment for LTBI.

Educate patients on signs, symptoms, and risk factors for TB.

Endemic mycoses

Consider serum and urine screening studies for endemic mycoses or suggestive history before biologic therapy.

Educate patients on risk factors, signs, and symptoms of endemic mycotic disease.

Instruct patients to stop medication and contact physician with development of high fever and respiratory symptoms.

Counsel on recreational and occupational activities leading to transmission.

Preventive measures include mask-wearing when gardening, in proximity to construction, and tending bird roosts.

Food safety

Educate patients on food preparation and safety.

Thoroughly wash vegetables to be eaten raw.

Thoroughly cook meat and eggs; avoid precooked meats, such as hot dogs and deli-meats, unless thoroughly recooked.

Avoid unpasteurized dairy products and soft cheeses, such as camembert and feta.


Influenza vaccine seems to be safe during TNF-a blockade.

Provide pneumococcal vaccine at least 2 weeks before biologic use.

Administer pneumococcal vaccine if patient on anti-TNF therapy and has not received vaccine.

Consider meningococcal vaccine

Consider HBV immunization series.

Consider hepatitis A vaccine for patients in communities with high incidence and for men who have sex with men.

Varicella vaccine should be considered in patients being considered for immunosuppressive therapy.

Avoid live vaccines during use of infliximab, adalimumab, etanercept, rit-uximab, and abatacept.

Avoid live vaccines for 2 months and 3 months after treatment with infliximab and abatacept, respectively.

Additional preventive measures against serious infection

Consider oral home dose of fluoroquinolone to take with onset of fever, chills, and rigors on route to medical facility.

TMP-SMX prophylaxes against P carinii pneumonia; Listeria; toxoplasmosis; and possibly Aspergillus, nocardiasis, and Pneumococcus.

Sexually transmitted diseases:

Obtain routine pap smears for women before biologic therapy and in accordance with current guidelines. Counsel patients on impact of safer sex.


Consider above guidelines for all biologic agents until specifics about infectious pathology can be delineated. REPORT ALL ADVERSE EVENTS to:

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