Splenectomised and hyposplenic patients are at increased risk of life-threatening infections due to encapsulated micro-organisms such as Streptococcus pneumoniae (90%), Neisseria meningitidis, and Haemophilus influenzae as well as certain parasitic infections such as Malaria and Babesiosis. The risk of sepsis is probably lifelong but can be reduced with simple measures, such as immunisation, the prophylactic administration of antibiotics, and patient education.
Hyposplenic patients should be immunised as soon as the diagnosis is made. Where a patient has had a splenectomy in the past, and has not received the required vaccines at the time, they should be immunised at the earliest possible opportunity. Advice is available from Public Health on 021 4927601.
Elective splenectomy:
Recommended vaccines should be completed at least 2 weeks and preferably 4 weeks or more before surgery (see below table for the details of individual vaccines). On admission ensure the patient has had the following:
- Pneumococcal vaccine (Prevenar 13®)
- Meningococcal vaccine (ACYW 135 and B)
- Haemophilus influenza B vaccine
- Influenza vaccine
Emergency procedures:
In the case of an emergency splenectomy or if immunisation is overlooked or incomplete pre operatively, recommended vaccines should be given at least 2 weeks post operatively, (the response to pneumococcal vaccine is poorer if given within 2 weeks of splenectomy).
Post-operatively (adult doses):
Patient should be prescribed either: IV Benzylpenicillin 1.2g q12h OR ORAL: either Phenoxymethylpenicillin 666mg po q12h (Calvepen®) OR Amoxicillin 500mg po q24h. In penicillin allergy: Clarithromycin* 250mg q12h po/iv. To be continued post-discharge from hospital – refer to chemoprophylaxis section for further information.
*Clarithromycin: several drug interactions – always check (following list not exhaustive): Statins: Increased risk of rhabdomyolysis. Simvastatin contraindicated with clarithromycin. Atorvastatin: max. 20mg /day, Pravastatin max. 40mg/day. Monitor for muscle pain and weakness. Warfarin: significant increase in INR with clarithromycin - INR must be monitored very closely and appropriate warfarin dose adjustments made as necessary. Novel oral anticoagulants (NOAC): check individual NOAC SPCs.
| Vaccination | Who should be immunised | Vaccination required | When should vaccine be given | Re-immunisation |
|---|---|---|---|---|
| Pneumococcal Conjugate Vaccine PCV ( Prevenar 13®) (13 serotypes) |
Aged under 2 years | Immunise with PCV13 vaccine in accordance with the routine schedule (2, 6 and 12 months). One additional dose PCV13 two months after last routine dose If incompletely immunised contact Public Health for specialist advice. |
If a second dose is indicated, it should be given two months after first dose. Course of Pneumococcal Conjugate Vaccine should be completed before receiving Pneumococcal Polysaccharide Vaccine. | There is no data to support reimmunisation at the present time |
| Aged 2 years and over |
|
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| Pneumococcal Polysaccharide vaccine (PPV) (Pneumovax II® 23 serotypes) |
All unimmunised patients aged 2 years and over, and those who received Pneumovax II® more than 5 years ago | Give single dose. A once only booster is recommended 5 years after first dose. | Course of Pneumococcal Conjugate Vaccine (PCV13) should be completed before receiving Pneumococcal Polysaccharide Vaccine (PPV). Pneumococcal Polysaccharide Vaccine (PPV) can be given 8 weeks after last Pneumococcal Conjugate Vaccine (PCV13) | Antibody levels may decline more rapidly, particularly in patients with sickle cell anaemia or lymphoproliferative disorders. A once only booster is recommended 5 years after first dose. The need for and benefit of repeated booster doses is unclear and not routinely recommended. |
| Influenza Vaccine | All patients, annually | Annually for all patients. Give a second dose one month later if the first year of receipt of influenza vaccine | First dose at the same time as other vaccines (at a different site of injection). Second dose (if indicated) one month later | Annually for hyposplenia or asplenic patients ideally at the start of flu season (September to October) |
| Haemophilus influenzae serotype B (HiB) | Aged under 13 months | Immunise with Hib vaccine in accordance with the routine schedule (2,4,6 and 13 months) |
|
There are no data to support routine reimmunisation at the present time. |
| All patients aged 13 months or older who were previously unimmunised | Give two doses of Hib vaccine, two months apart | |||
| Previously immunised patients who develop splenic dysfunction | Give one additional dose of Hib vaccine a minimum of 2 months after the last Hib dose given | |||
| Meningococcal Quadruvalent conjugate Vaccine ACYW135 (Menveo® or Nimenrix® aged over 1 year) |
Aged under 2 years | Immunise with MenC vaccine in accordance with the routine schedule (4 and 13 months) PLUS two additional dose of Men ACYW (Menveo® or Nimenrix®) | Child <12 months:
|
The need for additional doses in high risk groups has not been clearly established - not recommended for the present. |
| Aged 2 years and over | Give two doses of Meningococcal quadravalent conjugate vaccine covering ACYW (Menveo® or Nimenrix®) at least two months apart |
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| Meningococcal B vaccine* (Bexsero®) | Aged 2-<6 months | 2 doses at least 1 month apart. |
|
Booster at 12 months of age |
| 6 - <12 months | 2 doses at least 2 months apart | Booster over 12 months at least 2 months after primary series | ||
| 12 - <24 months | 2 doses at least 2 months apart | Booster 12- 23 months after the primary series | ||
| 2-<11 years | 2 doses at least 2 months apart | Not currently indicated | ||
| 11 years + | 2 doses at least 1 month apart | Not currently indicated |
Chemoprophylaxis
The risk for invasive pneumococcal infection is elevated throughout life but highest for those <16 and > 50 years of age. At minimum and regardless of immunisation status, antibiotic prophylaxis is recommended for children with asplenia (congenital absence or surgical removal) or sickle cell disease until 5 years of age and for otherwise healthy patients post splenectomy for a minimum of 1 to 2 years post splenectomy. Although the risk of infection decreases over time, continuing antibiotic prophylaxis throughout childhood and, for those considered at higher risk of infection, for life is recommended.
High risk patients include poor clinic attendees, patient with sickle cell disease with surgical splenectomy, splenectomised patient with malignancy, and those with poor antibody response to pneumococcal vaccination. Physicians may elect to use antibiotic prophylaxis in other hyposplenic states.
Antibiotic prophylaxis should only be discontinued if the patient is fully immunized and education and counselling is given regarding the risks of pneumococcal, meningococcal and haemophilus B infection and the need for prompt early management of febrile illness (refer to general information below)
| Antibiotics prophylaxis | Prophylaxis Dose | Treatment Doses (adult)* |
Notes |
| Phenoxymethylpenicillin | 1 month to < 6 years: 125mg po q12h 6 years to < 12 years: 250mg po q12h ≥ 12 years: 666mg po q12h (Calvepen®) (666mg po q24h can be given if compliance is a problem) | Oral absorption of phenoxymethylpenicillin can be unpredictable and plasma concentrations variable so it should not be used for serious infections. For emergency self initiated therapy of a suspected systemic infection, treatment doses of amoxicillin are preferable (see below). | |
| Amoxicillin | 20mg/kg po q24h (max 500mg po q24h) | 500-1000mg po q8h | If need H. influenzae cover |
| Clarithromycin* | 250mg po q12h (500mg LA po q24h if compliance a problem) (For dosing in children seek specialist advice) |
500mg po q12h | If penicillin allergic |
*Clarithromycin: several drug interactions – always check (following list not exhaustive): Statins: Increased risk of rhabdomyolysis. Simvastatin contraindicated with clarithromycin. Atorvastatin: max. 20mg /day, Pravastatin max. 40mg/day. Monitor for muscle pain and weakness. Warfarin: significant increase in INR with clarithromycin - INR must be monitored very closely and appropriate warfarin dose adjustments made as necessary. Novel oral anticoagulants (NOAC): check individual NOAC SPCs.
general information for all patients
- The patient’s GP should be informed regarding the prophylactic antibiotic regimen and all vaccinations.
- Patients should be educated on how to reduce the risk of infection.
- Patients should be advised that prophylaxis may fail and educated on recognising the first signs and symptoms of infection.
- Patients should be given written information and carry a card to alert other healthcare professionals of their risk of overwhelming infection. These are available from Public Health.
- Patients should be encouraged to obtain a medical alert bracelet.
- Patients should be alerted to the risks of overseas travel to countries where malaria is endemic or where they may be exposed to unusual infections.
- Patients should be alerted to the risk of infection following dog and tick bites.
- Patients developing symptoms and /or signs of infection despite appropriate prophylactic antibiotics and immunisations must be admitted to hospital and prescribed parenteral antibiotics.
Other information
- For patients not allergic to penicillin where infection is suspected, a dose of 1g of amoxicillin should be taken immediately and medical attention sought.
- Patients taking clarithromycin* as prophylaxis who suspect infection should seek medical attention immediately and take a dose of 500mg clarithromycin* or change to an alternative broader spectrum preparation (e.g. moxifloxacin or levofloxacin).
- Patient records should be clearly labelled to indicate the underlying risk of infection. Vaccination and re-vaccination status should be clearly and adequately documented. Patients should be provided with emergency supplies of antibiotics to take at first signs of infection.
- Empiric treatment of hypo/asplenic patients with acute infection: ceftriaxone 2g IV q24h. Take blood samples before commencing antibiotics. May need to increase dose if meningitis suspected. Seek advice from microbiology in patients with anaphylaxis to penicillin.
*Clarithromycin: several drug interactions – always check (following list not exhaustive): Statins: Increased risk of rhabdomyolysis. Simvastatin contraindicated with clarithromycin. Atorvastatin: max. 20mg /day, Pravastatin max. 40mg/day. Monitor for muscle pain and weakness. Warfarin: significant increase in INR with clarithromycin - INR must be monitored very closely and appropriate warfarin dose adjustments made as necessary. Novel oral anticoagulants (NOAC): check individual NOAC SPCs.
References:
- Immunisation Guidelines for Ireland 2013 Edition (updated 25th August 2015), National Immunisation Advisory Committee, Royal College of Physicians of Ireland available at https://www.hse.ie/portal/eng/health/immunisation/hcpinfo/guidelines/immunisationguidelines.html
- Vaccination specialist advice from Public Health, October 2015.