Asplenia medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Anum Dilip, M.B.B.S[2], Kalpana Giri, MBBS[3]

Overview

Emergency Medical Management of suspected sepsis in Asplenic patient with antibiotics and immunization.

Medical Therapy

Emergency Medical Management of suspected sepsis in Asplenic patient

Asplenia can cause sepsis and require immediate management:

• Children with asplenia for every febrile illness, must be seen by a physician immediately.
• Sepsis in individuals with asplenia or hyposplenia is a medical emergency as these patients can die within several hours of fever onset despite appearing well initially.
• Administration of antibiotic therapy should not be delayed and blood culture should be performed unless there is an obvious nonbacterial source.
• Ceftriaxone: 100 mg/kg/dose, (maximum 2 g/dose) should be given in all asplenic patients.
• Administer both ceftriaxone and vancomycin (60 mg/kg/day in divided doses every 6 h) in case of intermediate or high penicillin-resistant pneumococci.
• If the patient is treated in a clinic or office setting, refer immediately to the nearest emergency department.
• Clinical deterioration can be rapid even after antibiotic administratin so changes in antibiotics should be done after culture reports available.
• Vancomycin and ciprofloxacin can be used if the patient has an allergy to penicillin or cephalosporin. Changes in antibiotics should be done after culture reports available.
• According to the Surviving Sepsis Campaign guidelines, to avoid poor outcomes, patients suspected of sepsis should be started on antibiotics within 1 hour and as per standard sepsis guidelines, aggressive intravenous (IV) hydration should also be promptly initiated as a part of supportive care.
• Also, asplenic patients are prone to developing septic shock, they may require vasopressors to maintain their blood pressure and if patients develop respiratory failure, mechanical ventilation may be necessary for certain circumstances.

To minimize the risks, antibiotic & vaccination protocols have been established, but are often poorly adhered to by doctors and patients.

Antibiotic prophylaxis

Because of the increased risk of infection, physicians administer oral antibiotics as a prophylaxis after a surgical splenectomy. The duration suggested varies: one suggestion is that antibiotics be taken for two years or until the age of sixteen years old is reached, whichever is longer.

Patients are also cautioned to start a full-dose course of antibiotics at the first onset of an upper or lower respiratory tract infection (for example, sore throat or cough), or at the onset of any fever.

Vaccinations

It is suggested that splenectomized persons receive the following vaccinations, and ideally prior to planned splenectomy surgery:

• pneumococcus every 6 years (a conjugated form is used for children under 2 years)
• Haemophilus influenzae - whilst in many countries now routinely given to all children, a single booster is advised following the development of asplenia, but for those adults who have not been previously vaccinated, two doses given two months apart were advised in the new 2006 UK vaccination guidelines (in the UK may be given as a combined Hib/MenC vaccine).
• meningococcus-'C' conjugate vaccine - again routinely given to children in many countries, previously vaccinated adults require a single booster and non-immunised adults advised, in UK since 2006, to have two doses given two months apart.
• annual flu vaccinations - to help prevent getting secondary bacterial infection.

Travel measures

In addition to the normal immunizations advised for the countries to be visited, Group A meningococcus should be included if visiting counties of particular risk (e.g. sub-Saharan Africa). The non-conjugated Meningitis A&C vaccines usually used for this purpose give only 3 years coverage and provide less effective long-term cover for Meningitis C than the conjugated form already mentioned.

Those lacking a functional spleen are at higher risk of catching malaria and dying from this. Travel to malarial areas will carry greater risks and may be best avoided. Travelers should take the most appropriate anti-malarial prophylaxis medication and be extra vigilant over measures to prevent mosquito bites.

The pneumococcal vaccinations may not cover some of the other strains of pneumococcal bacteria present in other countries. Likewise, their antibiotic resistance may also vary, requiring a different choice of stand-by antibiotic.

Additional measures

• Surgical and Dental procedures - Antibiotic prophylaxis may be required before certain surgical or dental procedures.
• Animal bites - adequate antibiotic cover is required after even minor dog or other animal bites. Asplenic patients are particularly susceptible to infection by C. canimorsus and should receive a five-day course of co-amoxiclav (erythromycin in patients allergic to penicillin).
• Tick bites - Babesiosis is a rare tick-borne infection. Patients should check themselves or have themselves inspected for tick bites if they are in an at-risk situation. Presentation with fever, fatigue, and hemolytic anaemia requires diagnostic confirmation by identifying the parasites within red blood cells on blood film and by specific serology. Quinine (with or without clindamycin) is usually an effective treatment.
• Alert warning - Consider carrying a card, or wearing a special bracelet or necklet which says that you do not have a working spleen. This would alert a doctor to take rapid action if you are seriously ill and cannot tell them yourself.

References

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