Here we review the common BCG side effects, the prevention and treatment of these effects.
Common BCG Side Effects:
- Mild Urinary Symptoms (5-90%) [1,2]
- Hematuria (1-34%) 
- Malaise (Fatigue)
- Fever (3-17%) [3-5]
How to treat mild symptoms & side effects:
- Treatment for mild symptoms can include:
- phenazopyridine hydrochloride
- nonsteroidal anti-inflammatory drugs
- If the side effects are tolerable (not increasing and not requiring medication), simply postponing treatment until all symptoms have resolved is the most appropriate approach.
- While 6 weekly instillations are the optimal induction course for BCG, this is an arbitrary schedule that does not necessarily fit everyone.
- Consider dose reduction.
- The recommended logarithmic reduction to 1/3, 1/10, 1/30 and 1/100th dose, for decades has shown that most symptoms can be managed with no observable reduction in efficacy. [6,7]
- Consider prophylactic antibiotics.
- Standard dose BCG plus ofloxacin 200 milligrams (mg) at 6 hours post instillation and the following morning has been demonstrated to have a significant reduction in local side effects with no reduction in efficacy. 
- Isoniazid prophylaxis did not reduce the side effects of BCG in a large EORTC study. 
How to treat moderate symptoms or BCG cystitis:Moderate symptoms are often characterized by prolonged malaise, loss of appetite, night sweats and low grade fever which suggest a systemic infection. BCG cystitis is characterized by persistent severe frequency, urgency and dysuria, characteristic of BCG cystitis. The response to fluoroquinolones often occurs more promptly than the response to other types of antibiotics but should not be given for significant BCG infection as a single antibiotic.
- A two-drug combination is generally sufficient for milder reactions treated early.
- ofloxacin (200 to 400 mg every 12 hours)
- ciprofloxacin (500 mg every 12 hours)
- levofloxacin (500 mg every 24 hours)
- Isoniazid 300 mg daily
- For more intense or prolonged symptoms, a three drug combination is needed:
- Rifampin 600 mg daily and/or
- Ethambutol 1200 mg daily
- Monthly eye examinations are recommended to optic neuritis (6%). 
- Treatment is recommended for 3 to 6 months and symptoms may not even begin to improve for months after initiation of appropriate antibiotic therapy.
- Prednisone (30-60 mg daily, gradual taper) may be used in addition to antimicrobials if symptoms are unresponsive and intolerable.
- Bladder contracture can occur is the rare circumstance that frequency and dysuria are not treated effectively.
How to treat severe BCG-related symptoms and BCG-sepsis:
- Prompt hospital admission
- Broad-spectrum antibiotic coverage (triple antitubercular antibiotics)
How to treat patients who cannot tolerate BCG treatments:
|Nilay M. Gandhi, MD|
This entry was written by Nilay M. Gandhi, MD, senior assistant resident at the Brady Urological Institute at Johns Hopkins.
Some of the data is extracted from the chapter Presentation and Management of Significant Side Effects from Bacillus Calmette-Guérin Bladder Instillation by Nilay M. Gandhi and Donald L. Lamm, which will appear in newest edition of The Textbook of Bladder Cancer.
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