Adverse reaction	Suggested treatments
Local reaction
Common, occurs at the injection site, IgE-mediated, manifested primarily by wheal and flare with pruritus, usually begins 20 to 30 minutes after injection	Local cold pack; oral antihistamine; topical steroid; if reaction recurs, consider premedication with an antihistamine; rinse the syringe with diphenhydramine (Benadryl) or epinephrine before vaccine; consult allergist for dose adjustment
Large local induration
Occurs at injection site, IgG complex (Arthrus) reaction, manifested by pain, tenderness, and hard swelling	Oral steroids, nonsteroidal anti-inflammatory drug, oral antihistamine
Systemic reactions
Low incidence (< 0.05 to 3.5 percent), manifestations can include: urticaria, angioedema, increased respiratory symptoms (nasal or pulmonary), increased ocularsymptoms, and hypotension.	Tourniquet above injection site; aqueous epinephrine 1:1,000 IM: (adults, 0.3 mL; children, 0.01 mL per kg; readminister every 10 minutes if systemic symptoms persist, up to three times); diphenhydramine, IM or IV (adults, 25 to 50 mg; children, 1 to 2 mg per kg); histamine H2receptor blockers IV or orally for epinephrine-resistant hypotension; IV fluids or vasopressors, as needed; consider glucagon if patient is taking a beta blocker; consult allergist before any additional doses.
Delayed reaction
May be local or systemic	Oral antihistamine (liquid is preferred); prednisone, 5 to 20 mg orally every 12 hours for two doses (depending on the patient’s weight); epinephrine is not helpful; consult allergist for dose adjustment.