Canterbury DHB

Prevention of Infection Pre-splenectomy and in Splenic Atrophy

• The incidence of post-splenectomy sepsis and mortality has been calculated to be 4.4% and 2.2% respectively for children, and 0.9% and 0.8% respectively for adults. Patients having splenectomy for ITP, hereditary haemolytic anaemias, and malignancy have a higher incidence than those who have been splenectomised for trauma.
• Pneumococci accounted for 59% of deaths, Haemophilus influenzae 3.6%, Neisseria meningitidis 4%, E. coli 5%, Pseudomonas 3.6%, Streptococci 1.5%, gram negative bacilli 1%, Staphylococci 1%, with miscellaneous organisms accounting for 4.5% and no organism identified in the remainder.
• For antibiotic prophylaxis we recommend either phenoxymethylpenicillin 250 mg twice daily orally or amoxicillin 250 mg daily orally. One of these antibiotics should be given daily for two years. At 2 years patients must be informed again of the dangers of sudden and overwhelming infection while at the same time emphasising this is a rare event. If the patient opts not to continue with daily antibiotics on a long-term basis they should carry amoxicillin 3 g and take this if they feel suddenly unwell and at the same time seek medical advice urgently.

Management and Recommendations

See advice on Community HealthPathways.

Patients proceeding to a splenectomy should receive:

• A form for a medical alert bracelet, stating "Post-splenectomy".
• Instructions to present themselves to their GP or Accident and Emergency in the event of a fever, so that blood cultures may be taken and IV antibiotics commenced.
• The current Australasian Infectious Disease Society protocol advises the use of antibiotics for at least 2 years. It acknowledges that the data on this is lacking other than in the situation of hyposplenic sickle cell patients who should have prophylaxis for life.
• Therefore current practice is to recommend phenoxymethylpenicillin 250 mg twice daily PO or amoxicillin 250 mg ONCE daily PO for at least two years.
• Emergency antibiotics: patients should have a reserve or emergency supply of oral antibiotics with instructions when to commence them, e.g. at onset of fever or rigor, especially if early medical review is not possible, e.g. amoxicillin 3 g starting dose followed by 1 g three times a day or amoxicillin + clavulanate 500 + 125 mg three times a day. If allergic, cefalexin 500 mg three times a day, or moxifloxacin (requires Named Patient Pharmaceutical Assessment).
• Information regarding the need to be revaccinated against Pneumococcus at 5 years (once only) and Meningococcal every 3-5 years by their GP. It is important to remember that this does not give protection for Meningococcal B.
• An explanation of the need for good prophylaxis if travelling to a malarious area, as there is an increased susceptibility, and prompt treatment with amoxicillin/clavulanic acid for dog bites
• A Splenectomy Patient Card.
• For adults:
  • Splenectomy Information for Patients outlining the instructions above.
  • Refer general practitioners to the Splenectomy management information on HealthPathways.
  • Refer to the Splenectomy Vaccinations Prescription Chart.
• For children under 16 years, refer to the Child Health eGuidelines for the vaccination schedule and parent information.

Note: At 2 years post-splenectomy, patients may prefer to stop daily penicillin or and as an alternative may carry 3 g amoxicillin.

The above recommendations are taken from the Australasian Society of Infectious Disease Guidelines (Int Med Journal 2008; 38 (5):349-356).

Topic Code: 5075