Table 4.

Therapeutic strategies for patients with specific antibody deficiency (SAD).

Recommendation by	Recommendation
	Antibiotics	Immunoglobulin (Ig) replacement therapy	Vaccines
American Academy of Allergy, Asthma and Immunology American College of Allergy, Asthma and Immunology Joint Council of Allergy, Asthma and Immunology (12)	Treatment decisions should be based on the immunologic classification of mild, moderate, severe, and memory SAD
	Patients with SAD might benefit from intensified use of antibiotics (grade of recommendation C)	In some cases patients with SAD might benefit from a period of IgG replacement therapy (grade of recommendation C) A determination can be made that IgG replacement is needed if they do not respond to other medical treatment; immunologic and clinical severity are the determining factors For patients who have responded to IgG replacement, selected patients who are deemed stable enough and are not likely to have a severe recurrence of symptoms can discontinue treatment after 1–2 years for a period of 4–6 months and then be re-evaluated. However, such treatment discontinuation must be deemed appropriate by the treating physician	Patients with SAD may benefit from additional immunization with conjugate pneumococcal vaccines (grade of recommendation C) If patients have not received the conjugate pneumococcal vaccine, immunization with the conjugate vaccine with the largest number of serotypes available is recommended in all patients with recurrent infections
Third National Immunoglobulin Database Report (UK) (51) AND Department of Health Recommendations (UK) (52)	Primary treatment	Dose Initiate at 0.4–0.6 g/kg/month; dose requirements may increase and should be based on clinical outcome Criteria for administration Approval by a clinical immunologist, AND Severe, persistent, opportunistic, or recurrent bacterial infections despite continuous oral antibiotic therapy for 3 months, AND Documented failure of serum antibody response to unconjugated pneumococcal or other poly saccharide vaccine challenge	[Not mentioned]
Expert opinions
Wall et al. (24)	Antibiotic prophylaxis should be considered, especially in young patients who are likely to outgrow SAD	Indicated for patients with mild, moderate, or memory phenotypes who experience persistent infections despite appropriate management. In these patients, treatment should be discontinued after a period of 1–2 years and re-evaluated 4–6 months after discontinuation Patients with the severe phenotype or who have already developed permanent organ damage may be placed directly on Ig replacement and do not require re-evaluation	In patients with poor immunologic memory, re-immunization with 23-valent pneumococcal polysaccharide vaccine may re-establish protective antibody levels Most clinicians recommend waiting at least 1 year before re-immunization There is no indication to administer the vaccine again in patients who showed complete absence of response to an initial dose
Ocampo and Peters (40)	Yes	Yes	[Not mentioned]
Garcia-Lloret et al. (53)	Primary treatment	Ig replacement should only be for recurrent pyogenic infections poorly controlled with antibiotic therapy Children with SAD are started on intravenous Ig, the recommendation is to re-evaluate them after a year; if antibody responses improve and infections do not recur, therapy should be discontinued	[Not mentioned]