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 ©Copyright
 Published: 28/11/2011

Guidelines for the prevention of
sepsis in asplenic and hyposplenic patients

Dr Sally Roberts


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Outline

Guidelines for the prevention of sepsis in asplenic and hyposplenic patients
Dr Sally Roberts

For more infomation:
- The Victorian Spleen Registry http://www.baysidehealth.org.au/infectious_diseases_unit/
- Journal article. Guidelines for the prevention of sepsis in asplenic and hyposplenic patients.
Intern Med J. 2008 May;38(5):349-56

Introduction
- Role of the spleen
- Asplenia and hyposplenia
- Sepsis in patients post-splenectomy or with hyposplenism
- Vaccines
- Evidence
- Recommendations in the NZ setting

Role of the spleen
- Secondary lymphoid tissue
    - Important filtration site for clearance of microbial pathogens
    - Not a site for lymphatic drainage
    - Antigens, bacterial and cells enter via the splenic artery
- Red and White pulp
    - Red – macrophages and red cells
    - White – T cells proximal to central arteriole surrounded by aggregates of B cells

Structure

Function
- Spleen receives about 5% of total cardiac output per minute
- 90% of this blood enters the “open circulation” systems of sinusoids of the red pulp →venous sinuses
- During this process splenic macrophages remove defective blood cells and other particles such as bacteria and parasites
- Main site for the synthesis of IgM antibody, tuftsin and properdin
- Maintains survival of IgM memory B cells.

Removal of pathogens
- Bacteria
    - Opsonisation of antibody-coated and complement-coated bacteria
    - Intracellular pathogens → T cell mediated cytolytic killing
- Viruses
    - T cell mediated cytolytic killing

Definitions
- Asplenia
- Absence of spleen
    - Congenital
    - Surgical
- Hyposplenism
    - Loss of function
- Filtering role – Howell-Jolly bodies, acanthocytes, target cells, Heinz bodies, Pappenheimer bodies, leucocytosis and thrombocytosis
- Fighting infection

Causes of hyposplenism
- Common cause
    - Coeliac disease
    - Sickle cell anaemia
    - Alcoholism
    - Lupus
    - Post-BmTx

Overwhelming post-splenectomy infection (OPSI)
- Clinical features
    - No obvious primary source
    - Short, non-specific prodromal phase
    - Massive bacteraemia
    - Septic shock with DIC
    - Waterhouse-Fredrichsen syndrome
    - Death may ensue in 24-48 hours
    - High mortality (50 to 70%)

OPSI
- Risk
    - 0.42 per 100 person years (Australia)
    - 0.18 – 7.6 per 100 person years
or
    - 3.2-4.4% in asplenic/hyposplenic children <16 years
    - 0.9% in asplenic/hyposplenic adults
- Mortality
    - Overall 40-50%

OPSI
- Bacterial pathogens
    - Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis
    - Capnocytophaga caniomorsus, Babesia spp., Bordetella holmseii
    - Salmonella spp. in children with SCD
- Duration of risk
    - ??
    - First few years vs lifelong

Prevention
v Vaccination
    - Live, killed, subunit vaccines
    - Polysaccharide vaccines
- – induce T-cell-independent immune responses (B cell) that do not produce booster effects
    - Protein vaccines
- T-cell-dependent immune responses with immunologic memory, boost on repeat injection
- Education
    - Victorian Spleen Registry
- Long-term antibiotics

Pneumococcal vaccine
- 23-valent polysaccharide
    - Older children and Adults
- 7-valent pneumococcal conjugate vaccine
    - Children <9 years
    - T-cell-mediated immune memory
- Australia and NZ
    - 2-3 doses of conjugate 2-6/12, then 23vPPV at 2 years
    - Different schedule for older children
    - Adults
- 23vPPV – 2/52 post splenectomy
- Revaccinate in 5 years

Haemophilus influenzae vaccine
- H. influenzae serogroup b
    - Added to the national immunization schedule in 1982
    - Vaccine - polysaccharide molecule linked to a protein
    - If vaccinated pre-splenectomy do not require vaccine
    - Use in unvaccinated adults unclear

Meningococcal vaccination
- Evidence for increased risk is poor
- Quadrivalent (A,C,W,Y135) polysaccharide vaccine
- Protein conjugate Meningococcal C vaccine
- Recommendations
    - Australia
- Conjugate C followed by Quadrivalent
    - New Zealand
- Quadrivalent

Further strategies
- Alerts
    - Medical records
- Travel to countries with malaria
- Avoid animal bites
- Asplenic registry

Education
- All patients and families educated about potential risks
- Medialert
- Good communication between medical carers
- Prompt presentation following onset of symptoms

Antibiotic Use
- Prophylaxis
    - Data from children with SCD
- Standby treatment

Adherence to Guidelines
ANZ J Surg 2006; 76: 542-7
- Retrospective review
    - N= 111 patients with splenectomy
- Post-trauma 32
- haematological 32
- Surgery 24
- Iatrogenic 12
- Others 11
     - Education 22%
     - Vaccination for all three bacteria 84%
     - Prophylactic antibiotics for 1-2 years – 67%

Victorian Spleen Registry
  spleenregistry@alfred.org.au
- Regular updates about relevant health information
- Yearly reminder for influenza vaccine
- Travel advice
- Cost effective


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