What prophylaxis is recommended in splenectomy patients?
Please note this is a study note, keeping the exam in mind. This is not a guideline and should not be used for that purpose. It is not for clinical use either. You should contact your doctor for clinical advice.
Patients with an absent or dysfunctional spleen (AoDS) are at increased risk of infection, especially with capsulated bacteria.
What are the organisms that can cause infection in patients with AoDS?
Streptococcus pneumoniae (commonest)
Neisseria meningitidis
Haemophilus influenzae type B
Capnocytophaga canimorsus
Bordetella holmesii
Babesia microti
Plasmodium falciparum
Salmonella (in cases of sickle cell anaemia)
Anaplasma may present with a recurrent/prolonged and severe infection in AoDS
Prevention of infection – vaccines, antibiotic prophylaxis
Antibiotic
Antibiotic prophylaxis reduces incidents of sepsis (in children) by up to 50% and mortality by up to 90%.
However, Prophylactic antibiotics are not absolute protection against infection. Vaccines should be given in conjunction.
Lifelong prophylaxis is recommended.
What is the risk of sepsis?
The risk of death from sepsis is 600 times more than the general population; the estimated lifetime risk of sepsis is 5%. [Lynch 1996]
When is the risk of infection highest?
children up to 16 years of age,
adults over 50 years of age and
for two years post-splenectomy.
Who must be considered for lifelong prophylaxis?
those who have had an invasive pneumococcal disease,
those treated for splenic malignancy
those who have received splenic irradiation or
those who have ongoing graft versus host disease.
Who can be considered for discontinuation of prophylaxis?
Splenectomy following trauma can be considered for stopping prophylaxis if appropriately counselled.
Children over 5 years of age with sickle cell disease - can be considered for stopping antibiotic, if they have received pneumococcal vaccination and does not have a history of severe pneumococcal disease. Patients’ consultants should be consulted/expert opinion taken.
What are the preferred antibiotics?
Phenoxymethylpenicillin PO
< 1 year: 62.5mg BD
1 – 5 years: 125 mg BD
>5 years: 250mg BD
Amoxicillin PO (additional cover for H influenzae, in children)
1 mo – 5 years: 125mg twice daily
5 – 12 years: 250mg twice daily
12 – 18 years: 500mg twice daily
Erythromycin PO
1 mo – 2 years: 125mg twice daily
2 – 8 years: 250mg twice daily
> 8 years: 500mg twice daily
Other antibiotics that have been used – Azithromycin, cefalexin
An emergency rescue pack of antibiotics can be used if regular prophylaxis is not possible – Coamoxiclav, levofloxacin etc.
Vaccine
When should we give the vaccine?
Elective splenectomy: vaccine should be given two weeks before splenectomy.
Emergency splenectomy: vaccine should be given two weeks after splenectomy.
What vaccine should we give?
Additional points to consider
Immunosuppressed patient
Immunisation should be delayed for at least 3 months after immunosuppressive radiotherapy or chemotherapy. Antibiotic prophylaxis should be prescribed in the interim.
Foreign travel
Malaria prophylaxis should be considered.
Tick bite
A higher risk of babesiosis should be considered.
Animal bite
Asplenia is a risk factor for Capnocytophaga infection.
Coeliac disease
30% of patients with coeliac disease have splenic dysfunction. They should be considered for vaccination as any patient with splenic dysfunction.
Exception – Splenic dysfunction is usually not a problem in patients who are diagnosed with coeliac disease in childhood. It correlates with gluten exposure. In these cases, extra vaccine on top of routine immunisation is not required.
