Drug Interactions between moxifloxacin / triamcinolone and typhoid vaccine, live

CONTRAINDICATED: The administration of live, attenuated viral or bacterial vaccines during immunosuppressant or intense antineoplastic therapy may be associated with a risk of disseminated infection due to enhanced replication of vaccine virus or bacteria in the presence of diminished immune competence. Patients may be immunosuppressed if they have recently received or are receiving alkylating agents, antimetabolites, radiation, some antirheumatic agents, high dosages of corticosteroids or adrenocorticotropic agents (e.g., greater than or equal to 2 mg/kg/day or 20 mg/day of prednisone or equivalent for 14 consecutive days or more), or long-term topical or inhaled corticosteroids. These patients may also have increased adverse reactions and decreased or suboptimal immunologic response to vaccines.

MANAGEMENT: In general, live attenuated vaccines should not be used in patients receiving immunosuppressive therapy or cancer chemotherapy. Vaccination should be deferred until after such therapy is discontinued and immune function has been restored, usually 4 to 12 weeks after stopping immunosuppressive therapy. A longer waiting period may be necessary following treatment with agents that have a prolonged elimination half-life (e.g., leflunomide, teriflunomide). In most situations, patients who have recently been vaccinated with a live vaccine should not initiate treatment with immunosuppressive therapy for at least 2 weeks (possibly longer in some cases). Current local immunization guidelines and prescribing information for individual vaccines and immunosuppressive agents should be consulted for more specific recommendations. Vaccines may generally be administered to patients receiving corticosteroids as replacement therapy (e.g., for Addison's disease).

MONITOR CLOSELY: Concomitant administration of corticosteroids may potentiate the risk of tendinitis and tendon rupture associated with fluoroquinolone treatment. The mechanism is unknown. Tendinitis and tendon rupture have most frequently involved the Achilles tendon, although cases involving the rotator cuff (the shoulder), the hand, the biceps, and the thumb have also been reported. Some have required surgical repair or resulted in prolonged disability. Tendon rupture can occur during or up to several months after completion of fluoroquinolone therapy.

MANAGEMENT: Caution is recommended if fluoroquinolones are prescribed in combination with corticosteroids, particularly in patients with other concomitant risk factors (e.g., age over 60 years; recipient of kidney, heart, and/or lung transplant). Patients should be advised to stop taking the fluoroquinolone, avoid exercise and use of the affected area, and promptly contact their physician if they experience pain, swelling, or inflammation of a tendon. In general, fluoroquinolones should only be used to treat conditions that are proven or strongly suspected to be caused by bacteria and only if the benefits outweigh the risks.

ADJUST DOSING INTERVAL: The use of live, attenuated oral typhoid vaccine with antibacterial sulfonamides or other antibiotics may result in a diminished immunologic response to the vaccine. Some antibiotics may be active against the vaccine strain of Salmonella typhi (Ty21a), thereby preventing a sufficient degree of multiplication to occur in order to induce a protective immune response. Several antimalarial drugs such as chloroquine, mefloquine, and pyrimethamine-sulfadoxine also possess antibacterial activity, but concomitant administration did not significantly reduce immune response to the vaccine or compromise its efficacy in healthy adult study subjects. By contrast, concomitant administration of single agent proguanil did cause a significant decrease in the immune response rate, but the commercialized combination product atovaquone-proguanil did not have the same effect. The effects of other antimalarial agents have not been studied.

MANAGEMENT: Live, attenuated oral typhoid vaccine should not be administered during and for at least 3 days before and after treatment with antibacterial sulfonamides or other antibiotics. A longer interval should be considered following treatment with long-acting antibiotics (e.g., azithromycin). If malaria prophylaxis is needed, the same 3-day interval at the minimum should be observed between antimalarials and the vaccine. However, chloroquine, mefloquine, atovaquone-proguanil, and pyrimethamine-sulfadoxine may be given concomitantly with the vaccine. Alternatively, parenteral typhoid vaccine (typhoid Vi polysaccharide vaccine) may be considered if coadministration with antibacterial agents is required.