Revised and reviewed 13 December 2013
- main issue is the increased risk of infection from encapsulated organisms which can (very rarely) lead to overwhelming post-splenectomy sepsis (OPSS)
- post-splenectomy patients have distinctive findings on FBC / blood film
CAUSES OF INFECTION
- Streptococcus pneumoniae
- Haemophilus influenzae
- Neiserria meningitidis
- Capnocytophaga canimorsus
- Salmonella spp
- leukocytosis (acutely)
- Howell-Jolly bodies (nuclear fragments within red cells normally removed by spleen)
- pitted red cells
- target cells
- Heinz bodies (indicates oxidative stress)
Immunisation (boosted every 5 years)
- Meningococcal C
Prophylactic antibiotics (advice largely based on data from children with sickle cell anaemia, little evidence in adults)
- e.g. amoxicillin
children less than 5 years of age with sickle cell anaemia (functionally asplenic)
at least 3 years following splenectomy (some experts advise no antibiotics in an otherwise well adult)
asplenic patients with severe underlying immunosuppression
at least 6 months after an episode of severe sepsis in asplenic patients
- must have prescription for empiric antibiotics ASAP (e.g. amoxicillin-clavulanate, cefuroxime, moxifloxacin, ceftriaxone)
- must seek medical attention ASAP
- Asplenic patients should carry a medical alert and an up-to-date vaccination card
- Asplenic patients require specific advice around travel as they are at increased risk of severe malaria (mosquitoes) and babeosis (tick bites) in endemic areas
- Asplenic patients require specific advice about animal handling as OPSS (due to Capnocytophaga canimorsus) may result from dog, cat or other animal bites
TIMING OF POST-SPLENECTOMY IMMUNISATION
This is controversial
- no difference in antibody titre whether vaccinated on Day 1, 7 or 14, but better functional activity when vaccinated at Day 14. However, this conclusion was based on lab results, not clinical outcome.
- splenectomised rat study demonstrated no difference in clinical outcome with vaccination on Day 1, 7 or 42 with subsequent intraperitoneal inocculation with pneumococcus, but a much greater mortality if not vaccinated at all.
- There is no good data at all on vaccine administration after angioembolization. Animal studies suggest that at least 50% of the spleen must be perfused by the splenic artery in order to maintain immune competence.
- Practice varies in different centres
- Timing is less important than ensuring that the patient does actually get vaccinated!
References and Links
- Shatz DV, Schinsky MF, Pais LB, Romero-Steiner S, Kirton OC, Carlone GM. Immune responses of splenectomized trauma patients to the 23-valent pneumococcal polysaccharide vaccine at 1 versus 7 versus 14 days after splenectomy. J Trauma. 1998 May;44(5):760-5; discussion 765-6. PubMed PMID: 9603075.
- Spelman D, Buttery J, Daley A, Isaacs D, Jennens I, Kakakios A, Lawrence R, Roberts S, Torda A, Watson DA, Woolley I, Anderson T, Street A; Australasian Society for Infectious Diseases. Guidelines for the prevention of sepsis in asplenic and hyposplenic patients. Intern Med J. 2008 May;38(5):349-56. doi: 10.1111/j.1445-5994.2007.01579.x. Epub 2008 Feb 14. Review. PubMed PMID: 18284463.
FOAM and web resources
- Trauma Professional’s Blog — Vaccines after Splenectomy (2010)