Question
In a splenectomized adult, what are the appropriate vaccinations and frequency of vaccination (ie, pneumococcus, influenza, and Haemophilus influenzae type b [Hib])? Also, should antibiotics be given to the patient to use in case a fever develops? My primary concern is inappropriate use by the patient of the antibiotic and ruining possible culture results, although I understand that timely treatment is vital to encapsulated bacteria causing infection.
Response from David R. Haburchak, MD, FACP
Professor of Medicine and Program Director of the Internal Medicine Residency Program, Medical College of Georgia, Augusta.
Splenectomized patients are indeed at risk for uncontrolled infection and poor outcome because of both encapsulated bacteria and a number of other organisms, such as some gram-negative rod infections, animal bites, protozoa (Babesia), and possibly yeast infections. The predominant organisms responsible for overwhelming sepsis in splenectomized patients are pneumococci (50%), meningococci, and H influenzae.[1] The risk of infection appears to be highest in younger children, particularly among those with sickle cell disease.
The spleen has at least 2 significant immunologic functions: (1) to filter the blood of pathogenic bacteria and fungi, much like a lymph node, and (2) to shelter or sustain IgM opsonin-producing memory B cells.[2] It has been customary to attempt immunization either 2 weeks before or 2 weeks after splenectomy to enhance immunogenicity, especially of polysaccharide vaccines.
Newer guidelines, particularly those from Great Britain,[3] have emphasized use of conjugated pneumococcal and meningococcal C vaccine, in addition to the conjugated Hib vaccine. The British guideline is evidence-based, with most evidence being either "well-conducted clinical trials" (no randomized control trials) or "expert opinion." According to this guideline, the polyvalent pneumoncoccal vaccine should be given either 2 weeks before or 2 weeks after splenectomy, and repeated in 5 years. Patients with sickle cell or lymphoproliferative disorders may need vaccination more frequently.
The guidelines recognized the potential superiority of the 7 valent, conjugated pneumococcal vaccine but had no current recommendation for its use. The Hib and meningococcus C conjugate vaccines should be given at least 2 weeks before or 2 weeks post splenectomy, but there is currently no indication for revaccination. If the person has been previously vaccinated against these organisms with conjugate or polysaccharide vaccines, there is no indication for revaccination. Finally, all splenectomy patients should receive influenza vaccination yearly.
American, French, and British guidelines all agree that oral phenoxymethylpenicillin or erythromycin should be given to young, splenectomized children (at least to age 5 years or for 5 years) and to adults for 2 years following splenectomy. The recent British guideline states: "Lifelong prophylactic antibiotics are still recommended.[3]" Unfortunately, this is practically very difficult to accomplish because of poor compliance and because pneumococci have become quite resistant precisely to these 2 antibiotics. The American and French approaches have been more pragmatic, but certainly all 3 guidelines need revision on the basis of data that are hard to obtain.
Finally, all of the guidelines recommend treating patients with signs of sepsis with empiric ceftriaxone in the office prior to admission to the hospital for observation and continued therapy.[4,5] The risk of overwhelming, rapid death warrants extreme caution in these patients. Blood cultures are likely to remain positive for a time despite antibiotics early in the course because the concentration of bacteria is so fantastically high. Early therapy, coupled with excellent supportive care, is the only hope for recovery. Patients and their families should be educated about the nature of this disease and seek medical evaluation early rather than to perform self-diagnosis and self-therapy.
Unfortunately, both the public and practicing physicians underestimate the severity and frequency of postsplenectomy sepsis because guideline compliance in multiple, developed countries is only 60% to 75%.[1,6]
Medscape Internal Medicine. 2004;6(1) © 2004 Medscape
Cite this: David R Haburchak. Vaccinations and Antibiotic Treatment Post Splenectomy - Medscape - May 07, 2004.
