Guidlines for prevention of infection following splenectomy

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The following Guidelines are Published by the Drug and Therapeutics Committee:-

1. Prophylaxis with penicillin V 250mg bd p.o. should be given for a minimum of two years following splenectomy. No alternative need be prescribed for patients allergic to penicillin although erthromycin 250mg bd p.o. is suitable if tolerated.

2. Patients should be given a supply of antibiotics for self-administration at the onset of any respiratory infection. These should be:

Augmentin 1 tab. tds for the majority of patients OR Cefuroxime axetil 250mg bd for penicillin-allergic patients (patients should be reminded to check the expiry date on the pack and request a replacement when necessary).

3. Patients should be advised to have annual influenza vaccinations and to be meticulous about malaria prophylaxis, if and when it is required.

4. Patients should carry a card stating that they have had a splenectomy.

5. Pneumococcal vaccine - a single dose is recommended (see notes).

 

Notes:

1. Lifelong penicillin. - The risk of overwhelming sepsis appears to decrease over time and this accounts for the advice, given by some authorities, which stresses the importance of prophylaxis in the first two years after splenctomy. It is probably unreasonable to expect lifelong compliance with antibiotic prophylaxis. Oral penicillin V for two years is a practical recommendation, as part of a package of advice. There are, however, many published and unpublished anecdotes and reports of fatal infection twenty or more years after splenectomy.

2. Antibiotics for early self-medication - Because fatal infections may be caused by organisms other than the pneumococcus (such as Haemophilus influenza type b) the patients, whether taking prophylaxis or not, should have a supply of antibiotics to be taken at the first sign of a respiratory infection. Amoxycillin plus clavulanic acid (Augmentin) covers penicillinase-producing H influenza, pneumonococcae and a variety of other pathogens.

3. Influenza Vaccine - As many serious bacterial respiratory tract infections are secondary to viral infection, splenectimised patients should either receive annual influenza vaccination or be included in high-priority lists for vaccination in epidemic years.

4. Malaria - This is a particular hazard to people without spleens and if it is not practical for them to avoid malaria zones, they must take the strictest precautions against infection.

5. The Hib vaccine (against H influenza type). - The is not at present licensed for use in adults. If and when it is, it will remain to be seen whether it is effective in splenectomised individuals.

6. Meningococcal Vaccine. - The majority of infections in the UK are due to the type b meningococcus and are not prevented by the vaccine which is currently available. The vaccine might be appropriate for some overseas patients.

7. Pneumococcal vaccine - The case for this is not very strong, even when it is given before splenectomy and in the immunocompetent. The available vaccine does not cover all stereotypes and antibody response is unpredictable even in the immunocompetent patient. Antibody level estimation is not helpful as it correlates poorly with the protective effect. A single dose only is recommended, as the risk of severe local systemic reactions outweighs the small boosting effect of second and subsequent doses.

 


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