Prevention of sepsis in the asplenic patient
- Mark S Pasternack, MD
Mark S Pasternack, MD
- Associate Professor of Pediatrics
- Harvard Medical School
Splenic function is lost when the spleen has been surgically removed, is congenitally absent, has atrophied following repeated infarction (eg, sickle cell disease), or following splenic artery thrombosis . In addition, splenic function is reduced in the neonate and may be abnormally reduced (ie, hyposplenism or functional asplenia) when the spleen is engorged with blood (eg, splenic sequestration crisis associated with sickle cell disease, malaria, splenic vein thrombosis), or infiltrated (eg, sarcoidosis, amyloidosis, tumors, or cysts). (See "Approach to the adult patient with splenomegaly and other splenic disorders".)
Asplenic patients and those with impaired splenic function are at risk for a fulminant sepsis syndrome usually due to Streptococcus pneumoniae. The terms "postsplenectomy sepsis" and "asplenic sepsis" are largely interchangeable since the functional defects are the same regardless of whether the causative process is congenital or acquired. In this topic review, we will use the term "asplenic sepsis" to include all asplenic patients.
The prevention of sepsis will be reviewed here. The importance of the spleen for clearance of bacteria and humoral immune response, conditions leading to asplenia, clinical manifestations of infection in the asplenic patient, and management of sepsis in the asplenic patient are discussed separately. (See "Clinical features and management of sepsis in the asplenic patient".)
Patients must be instructed that the asplenic state carries a small risk of overwhelming and life-threatening infection. Fulminant sepsis in asplenic patients is classically caused by encapsulated organisms, particularly Streptococcus pneumoniae but also Haemophilus influenzae and Neisseria meningitidis [1,2]. Fulminant sepsis in asplenic patients has also been caused by Capnocytophaga canimorsus, which is almost exclusively observed after close contact with dogs (bites, scratches, or even saliva exposure). Asplenic individuals are also at risk for severe babesiosis, a tick-borne illness that is endemic in parts of the United States Northeast. These and other infections in asplenic patients are discussed in detail separately. (See "Clinical features and management of sepsis in the asplenic patient".)
It is crucial that asplenic individuals adhere to the preventive measures outlined below and that they inform all caregivers of their asplenic state. The combined use of pneumococcal immunization and early administration of oral empiric antibiotic therapy for fever offers a high level of protection against sepsis in asplenic patients . Asplenic individuals should also be counseled about avoiding dog bites, scratches, and contact with dog saliva to prevent C. canimorsus infection as well as avoiding tick bites in Babesia-endemic regions.
- Di Sabatino A, Carsetti R, Corazza GR. Post-splenectomy and hyposplenic states. Lancet 2011; 378:86.
- Rubin LG, Schaffner W. Clinical practice. Care of the asplenic patient. N Engl J Med 2014; 371:349.
- Konradsen HB, Henrichsen J. Pneumococcal infections in splenectomized children are preventable. Acta Paediatr Scand 1991; 80:423.
- Kim HS, Kriegel G, Aronson MD. Improving the preventive care of asplenic patients. Am J Med 2012; 125:454.
- Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2014; 58:e44.
- Shatz DV, Schinsky MF, Pais LB, et al. 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; 44:760.
- Konradsen HB, Rasmussen C, Ejstrud P, Hansen JB. Antibody levels against Streptococcus pneumoniae and Haemophilus influenzae type b in a population of splenectomized individuals with varying vaccination status. Epidemiol Infect 1997; 119:167.
- Nuorti JP, Whitney CG, Centers for Disease Control and Prevention (CDC). Prevention of pneumococcal disease among infants and children - use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine - recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2010; 59:1.
- Halasa NB, Shankar SM, Talbot TR, et al. Incidence of invasive pneumococcal disease among individuals with sickle cell disease before and after the introduction of the pneumococcal conjugate vaccine. Clin Infect Dis 2007; 44:1428.
- Centers for Disease Control and Prevention (CDC). Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among children aged 6-18 years with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2013; 62:521.
- Immunocompromised Children. In: Red Book: 2012 Report of the Committee on Infectious Diseases, 29th edition, Pickering LK. (Ed), American Academy of Pediatrics, Elk Grove Village, IL 2012. p.74.
- Centers for Disease Control and Prevention (CDC). Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2012; 61:816.
- French N, Gordon SB, Mwalukomo T, et al. A trial of a 7-valent pneumococcal conjugate vaccine in HIV-infected adults. N Engl J Med 2010; 362:812.
- Advisory Committee on Immunization Practices. Summary Report, February 22-23, 2012. http://www.cdc.gov/vaccines/recs/acip/downloads/min-feb12.pdf (Accessed on June 25, 2012).
- Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1997; 46:1.
- Akinsanya-Beysolow I, Advisory Committee on Immunization Practices (ACIP), ACIP Child/Adolescent Immunization Work Group, Centers for Disease Control and Prevention (CDC). Advisory Committee on Immunization Practices recommended immunization schedules for persons aged 0 through 18 years - United States, 2014. MMWR Morb Mortal Wkly Rep 2014; 63:108.
- Bridges CB, Coyne-Beasley T, Advisory Committee on Immunization Practices. Advisory committee on immunization practices recommended immunization schedule for adults aged 19 years or older: United States, 2014. Ann Intern Med 2014; 160:190.
- Mourtzoukou EG, Pappas G, Peppas G, Falagas ME. Vaccination of asplenic or hyposplenic adults. Br J Surg 2008; 95:273.
- Musher DM, Ceasar H, Kojic EM, et al. Administration of protein-conjugate pneumococcal vaccine to patients who have invasive disease after splenectomy despite their having received 23-valent pneumococcal polysaccharide vaccine. J Infect Dis 2005; 191:1063.
- American Academy of Pediatrics. Haemophilus influenzae infections. In: Red Book: 2012 Report of the Committee on Infectious Diseases, 29th edition, Pickering LK. (Ed), American Academy of Pediatrics, Elk Grove Village, IL 2012. p.345.
- Cimaz R, Mensi C, D'Angelo E, et al. Safety and immunogenicity of a conjugate vaccine against Haemophilus influenzae type b in splenectomized and nonsplenectomized patients with Cooley anemia. J Infect Dis 2001; 183:1819.
- Cohn AC, MacNeil JR, Clark TA, et al. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2013; 62:1.
- Centers for Disease Control and Prevention (CDC). Infant meningococcal vaccination: Advisory Committee on Immunization Practices (ACIP) recommendations and rationale. MMWR Morb Mortal Wkly Rep 2013; 62:52.
- Borrow R, Joseph H, Andrews N, et al. Reduced antibody response to revaccination with meningococcal serogroup A polysaccharide vaccine in adults. Vaccine 2000; 19:1129.
- MacLennan J, Obaro S, Deeks J, et al. Immune response to revaccination with meningococcal A and C polysaccharides in Gambian children following repeated immunisation during early childhood. Vaccine 1999; 17:3086.
- Centers for Disease Control and Prevention (CDC). Prevention and control of seasonal influenza with vaccines. Recommendations of the Advisory Committee on Immunization Practices--United States, 2013-2014. MMWR Recomm Rep 2013; 62:1.
- Jugenburg M, Haddock G, Freedman MH, et al. The morbidity and mortality of pediatric splenectomy: does prophylaxis make a difference? J Pediatr Surg 1999; 34:1064.
- Gaston MH, Verter JI, Woods G, et al. Prophylaxis with oral penicillin in children with sickle cell anemia. A randomized trial. N Engl J Med 1986; 314:1593.
- National Institutes of Health, National Heart, Lung, and Blood Institute. The Management of Sickle Cell Disease. NIH Publication No. 02-2117, US Department of Health and Human Services, 2002.
- Section on Hematology/Oncology Committee on Genetics, American Academy of Pediatrics. Health supervision for children with sickle cell disease. Pediatrics 2002; 109:526.
- Falletta JM, Woods GM, Verter JI, et al. Discontinuing penicillin prophylaxis in children with sickle cell anemia. Prophylactic Penicillin Study II. J Pediatr 1995; 127:685.
- Cullingford GL, Watkins DN, Watts AD, Mallon DF. Severe late postsplenectomy infection. Br J Surg 1991; 78:716.
- Eber SW, Langendörfer CM, Ditzig M, et al. Frequency of very late fatal sepsis after splenectomy for hereditary spherocytosis: impact of insufficient antibody response to pneumococcal infection. Ann Hematol 1999; 78:524.
- Davies JM, Lewis MP, Wimperis J, et al. Review of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen: prepared on behalf of the British Committee for Standards in Haematology by a working party of the Haemato-Oncology task force. Br J Haematol 2011; 155:308.
- Keenan RD, Boswell T, Milligan DW. Do post-splenectomy patients take prophylactic penicillin? Br J Haematol 1999; 105:509.
- De Rossi SS, Glick M. Dental considerations in asplenic patients. J Am Dent Assoc 1996; 127:1359.
- Tong DC, Rothwell BR. Antibiotic prophylaxis in dentistry: a review and practice recommendations. J Am Dent Assoc 2000; 131:366.
- Gillis S, Dann EJ, Berkman N, et al. Fatal Haemophilus influenzae septicemia following bronchoscopy in a splenectomized patient. Chest 1993; 104:1607.
- Avoid splenectomy
- - Timing of immunizations
- - Pneumococcal vaccine
- - Routine schedule
- - Catch-up schedule
- - Supplemental dose
- Revaccination in children and adults
- Vaccination after invasive pneumococcal disease
- - Haemophilus influenzae vaccine
- Catch-up schedule
- Vaccination after invasive Hib disease
- Hib titers
- - Meningococcal vaccine
- - Influenza vaccine
- - Other vaccines
- Antibiotic prophylaxis
- - Daily prophylaxis
- - Duration
- - Antibiotics for fever
- Antibiotic prophylaxis for procedures
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS
- Prevention of sepsis
- - Immunizations
- - Antibiotic prophylaxis
- - Antibiotics for fever