To the Editor: The lack of a functioning spleen is associated with a lifelong risk of overwhelming post-splenectomy infection (OPSI). Historically, mortality rates associated with OPSI have been in excess of 50%.1-3 OPSI is a preventable illness through vaccination, education, prophylactic antibiotic use and other measures, as summarised in the national Australasian Society for Infectious Diseases (ASID)-endorsed guidelines for prevention of sepsis in asplenic and hyposplenic patients.4
We performed a retrospective cohort study among adult patients who had undergone post-traumatic splenectomy at a tertiary referral centre in Sydney, to assess compliance by health professionals and identify factors that could improve uptake of ASID recommendations. We reviewed hospital medical records and discharge summaries to assess compliance with recommendations before and after the publication of the ASID guidelines.
The Research and Ethics Office of the South Western Sydney Local Health District granted site-specific approval on the basis of low and negligible risk.
A total of 79 patients were identified, 37 in the preguideline group (January 2003 – June 2008) and 42 in the postguideline group (July 2008 – December 2013). Our findings are summarised in the Box.
Overall, compliance with the recommendations was poor, except for the rate of first vaccination against Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae type b (Box). At discharge, most patients were advised to follow up with their general practitioner; however, GPs were neither provided with the information on the type of vaccination given in the hospital, nor with the appropriate recommendation on follow-up vaccinations.
Our study highlights gaps in best practice and areas for quality improvement and education. Lack of awareness of the guidelines among the surgical teams was found to be a notable factor in the poor compliance with the 2008 ASID guidelines. Asplenia and hyposplenia care should involve a multidisciplinary approach with involvement of surgeons, infectious diseases physicians, haematologists, pharmacists and clinical nurse coordinators.
We recommend the ASID 2008 guidelines be updated, as there have been changes in the vaccination recommendations since publication. A national spleen registry could be considered, for sending vaccination reminders and providing long-term follow-up and ongoing support. This would also allow prospective data collection for assessing compliance and measuring rates of OPSI.
Compliance with recommendations in the ASID management guidelines for prevention of sepsis in patients with asplenia or hyposplenia,4 before and after guideline publication in 2008
Number of patients* | |||||||||||||||
Areas of compliance | Preguideline (n = 37) | Postguideline (n = 42) | P | ||||||||||||
Patient education | 8 | 22 | 0.08 | ||||||||||||
First vaccination after surgery | |||||||||||||||
Pneumococcal | 34 | 39 | 0.87 | ||||||||||||
Meningococcal | 34 | 39 | 0.87 | ||||||||||||
Haemophilus influenzae type b | 34 | 38 | 0.82 | ||||||||||||
Influenza | 2 | 5 | 0.31 | ||||||||||||
Day of first vaccination,† median (range) | 7 (− 7 to 44) | 7 (1 to 45) | 0.47 | ||||||||||||
Prophylactic antibiotic use‡ | 11 | 17 | 0.32 | ||||||||||||
Reserve antibiotic supply | 1 | 5 | 0.20 | ||||||||||||
Risk-reduction measures | |||||||||||||||
Patient alerts (eg, bracelet) | 1 | 9 | 0.04 | ||||||||||||
Splenic salvage | 0 | 0 | – | ||||||||||||
Risk of sepsis included in histology report | 0/36 | 0/42 | – | ||||||||||||
Risk of sepsis reported if Howell-Jolly body seen in peripheral blood smear | 0/15 | 0/19 | – | ||||||||||||
Meningococcal vaccination for travellers to high-risk areas | 0 | 0 | – | ||||||||||||
Informing the patient of malaria risks | 1 | 3 | 0.61 | ||||||||||||
Informing the patient of Babesia risks | 0 | 1 | > 0.99 | ||||||||||||
Patient warned of risks associated with animal bites | 1 | 1 | – | ||||||||||||
Spleen registry referral | 0 | 3 | 0.24 | ||||||||||||
ASID = Australasian Society for Infectious Diseases. * Unless otherwise indicated. † Optimal timing uncertain; ideally 14 days after emergency splenectomy, or earlier if there is a risk of loss of the patient to follow-up. ‡ Amoxicillin 250 mg daily was the most commonly prescribed prophylactic antibiotic, with a variable duration of recommendation (1 year to lifelong). | |||||||||||||||
- 1. Lynch AM, Kapila R. Overwhelming postsplenectomy infection. Infect Dis Clin North Am 1996; 10: 693-707.
- 2. Davidson RN, Wall RA. Prevention and management of infections in patients without a spleen. Clin Microbiol Infect 2001; 7: 657-660.
- 3. Evans DI. Postsplenectomy sepsis 10 years or more after operation. J Clin Pathol 1985; 38: 309-311.
- 4. Spelman D, Buttery J, Daley A, et al. Guidelines for the prevention of sepsis in asplenic and hyposplenic patients. Intern Med J 2008; 38: 349-356.
No relevant disclosures.