Prevention of Post Splenectomy Sepsis Guideline · Web viewThe availability of conjugate vaccines against meningococcus means that the older polysaccharide vaccines have become obsolete

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Canberra Hospital and Health ServicesClinical GuidelinePrevention of Post Splenectomy Sepsis (PSS)Contents

Contents....................................................................................................................................1

Introduction..............................................................................................................................2

Scope........................................................................................................................................ 2

Key Objectives...........................................................................................................................3

Section 1 – Treatment of Patients Post Splenectomy...............................................................3

What are the recommendations?.........................................................................................3

Section 2 – Vaccinations........................................................................................................... 4

Infections...............................................................................................................................4

What is the difference between a polysaccharide vaccine and a conjugate vaccine?..........5

When should the vaccines be administered?........................................................................7

Further Advice.......................................................................................................................7

Implementation........................................................................................................................ 7

Related Policies, Procedures, Guidelines and Legislation.........................................................8

References................................................................................................................................ 8

Search Terms............................................................................................................................ 8

Doc Number Version Issued Review Date Area Responsible PageCHHS16/062 1 12/05/2016 01/05/2019 Medicine 1 of 8

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Introduction

The recommendations in this guideline primarily apply to people who have undergone, or who are soon to undergo, splenectomy (removal of the spleen).

The aim of these recommendations is to ensure that people who have undergone splenectomy receive appropriate advice regarding the need to minimise the long-term risk of serious infections that may occasionally complicate this procedure.

The recommendations may also apply to people with congenital asplenia or functional hyposplenism.

These recommendations emphasise the following key steps:1. All patients undergoing elective splenectomy should receive their initial vaccinations at

least two weeks before surgery. 2. All patients who have undergone emergency splenectomy should receive their initial

vaccinations before being discharged from hospital (ideally 1-2 weeks following surgery).3. All patients who are undergoing / have undergone splenectomy should have at least one

consultation with an infectious diseases physician. Although not essential, for patients undergoing elective splenectomy this consultation should take place several weeks prior to surgery. For patients who have undergone emergency splenectomy a brief consultation can be undertaken in hospital, followed by a full consultation as an outpatient.

4. All patients who have undergone splenectomy should begin long-term antibiotic prophylaxis before being discharged from hospital.

5. All patients who have undergone splenectomy should be given advice regarding the prevention, recognition and management of fever, particularly if travelling away from home.

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Scope

This document provides guidelines to all Canberra Hospital and Health Services staff that manage patients (adults or children) who are undergoing or have undergone splenectomy.

This document applies to: medical teams referring patients for splenectomy (particularly Haematology) and surgical teams performing splenectomy (Trauma and General Surgery).

This guideline also applies to patients who have been discovered to have undergone splenectomy in the past and who may not have received the appropriate vaccinations and other recommendations.

Nursing and allied health staff should alert medical staff to the existence of this guideline if they are caring for patients who have undergone splenectomy .



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Key Objectives

1. To ensure that all patients who are undergoing / have undergone splenectomy are vaccinated appropriately.

2. To ensure that all patients who are undergoing / have undergone splenectomy are prescribed the appropriate prophylactic antibiotic.

3. To ensure that all patients who are undergoing / have undergone splenectomy are given an outpatient appointment with an infectious diseases physician.

4. To ensure that all patients who are undergoing / have undergone splenectomy are given written information about prevention of post-splenectomy sepsis.


Section 1 – Treatment of Patients Post Splenectomy

What are the recommendations?People who have had a splenectomy:1. Should be advised to take long-term oral prophylactic treatment against PSS using an

antibiotic such as amoxycillin 250 mg daily (if not allergic to penicillins). This is particularly recommended for the following individuals: Children less than five years of age; All people for the first 3 years after splenectomy; Some people who have certain underlying diseases that may weaken the immune

system such as certain malignancies (especially Hodgkin’s disease and other lymphomas) or diseases of the blood or immune system (especially thalassaemia);

People who have previously suffered an episode of PSS.

An oral macrolide antibiotic (roxithromycin 150 mg or erythromycin 250 mg or clarithromycin 250 mg daily) can be used by people who are allergic to penicillin. There may also be a case for short-term prophylaxis for people who will be travelling to places where prompt and adequate medical care may not be available.

Note:For further information on antibiotic doses please refer to the electronic Therapeutic Guidelines (eTG).

2. Should promptly report any fever to a doctor or hospital emergency department. Early treatment of fever with intravenous antibiotics may be life saving.

3. And who are not taking long term antibiotics should consider always carrying a single high dose of an oral antibiotic (such as amoxycillin 3g, if not allergic to penicillins) to be taken immediately should a fever occur. This is known as standby treatment and is particularly important when travelling to places where medical care may not be readily



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available. The fever should also be reported to a doctor or hospital emergency department as soon as possible.

4. Should promptly report any animal bite to a doctor or hospital emergency department. The wound must be cleaned adequately and a preventive antibiotic (e.g. amoxycillin/clavulanate, if not allergic to penicillins) must be administered for at least 5 days. Infected bites may lead to fatal septicaemia if not treated appropriately.

5. Who intend to travel to countries where malaria is present should discuss their travel health with a doctor who is experienced in the field of travel medicine. Travel to regions where malaria is present should involve adherence to all basic measures to prevent mosquito bites and will generally necessitate taking preventive medications against malaria. Travel to regions where the risk of malaria is high may be discouraged altogether. Any fever that occurs while travelling or following travel should be promptly reported to a doctor or hospital emergency department and should be assumed to be due to malaria until proven otherwise. Meningitis and septicaemia should also be considered. In addition, tick bites in certain countries should also be promptly reported to a doctor or hospital emergency department.

6. Are advised to either wear a ‘medical alert’ bracelet or pendant or carry a card in their wallet or purse indicating that they have had a splenectomy. Bracelets and pendants (including styles that may appeal to younger people) can be ordered and purchased through various websites.

Section 2 – Vaccinations

Pathogens – Pneumococcus, Meningococcus & HibThere are about 90 types of pneumococcus and 5 major types of meningococcus (types A, B, C, W and Y). There is only one major strain of Hib (Haemophilus influenzae Type b).

The number of types included in each vaccine depends on the biological type of the vaccine being administered. Broadly speaking, there are two main types of vaccines – polysaccharide and conjugate. There are vaccines of each of these types against pneumococcus and meningococcus but only a conjugate vaccine against Hib. The availability of conjugate vaccines against meningococcus means that the older polysaccharide vaccines have become obsolete.

For pneumococcus, the main 23 (out of 90) types are included in the polysaccharide vaccine, and 13 types in the conjugate vaccine. Both vaccine types are used for prevention of PSS. The conjugate vaccines for meningococcus contain four types (A, C, W and Y) in one vaccine and one type (B) in another. The main types that circulate in Australia are B and C. The polysaccharide vaccine for meningococcus is no longer used for prevention of PSS.



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Although splenectomy (and asplenia) is not a risk factor for influenza per se, influenza may predispose an individual to pneumococcal infection. The dominant strains of influenza virus vary from year to year and are included in the influenza vaccines available each year.

PSS may be fatal, the case-fatality rate being 10-30%. In particular, the septicaemic form of severe pneumococcal infection has a case-fatality rate of 30-50%.

What is the difference between a polysaccharide vaccine and a conjugate vaccine?Polysaccharide vaccines are old vaccines that stimulate a short-term (up to 5 years) antibody response. Following this type of vaccination the level of circulating antibodies starts off high but gradually declines with time, which means that the immune system’s ability to respond to an infection progressively weakens.

Conjugate vaccines are relatively new vaccines that stimulate ‘memory’ in the immune system. This means the body will respond quickly to an infection and produce new antibodies.

It is generally recommended that optimal prevention against pneumococcal PSS requires the administration of both the conjugate and the polysaccharide vaccines against pneumococcus. Whilst the former stimulates immune memory, the latter has the benefit of covering more types (23 versus 13). Conjugate vaccines should preferably be administered at least two months before polysaccharide vaccines.

If the polysaccharide vaccine happens to have been given first, the conjugate vaccine should then be deferred until at least a year later.

Of interest, it is worth noting that it is plausible that the recent inclusion of the conjugate pneumococcal vaccine for children in the Australian National Immunisation Schedule has resulted in a decrease in the incidence of PSS (as well as contributing to the known decrease in incidence of pneumococcal infections in much larger population groups, such as elderly people). This phenomenon – i.e. where immunisation of an individual contributes to protection of the community - is known as ‘herd immunity’.

VaccinesPeople who have a splenectomy should be offered immunisation (vaccination) against the following organisms/infections:



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Organism /Infection

Vaccine options (abbreviation)

Vaccine Type Recommendation

Pneumococcus(Streptococcus pneumoniae)

Prevenar® 13 (13vPCV)

Conjugate Administer 1 dose unless already given (i.e. as part of childhood immunisation schedule).Administer at least 2 weeks before elective splenectomy, or 1-2 weeks after emergency splenectomy (before discharge from hospital).Administer 2 months before polysaccharide vaccine for pneumococcus. If polysaccharide vaccine already administered, give pneumococcal conjugate vaccine at least 1 year later.

Pneumovax® 23(23vPPV)

Polysaccharide Administer 2 months after above pneumococcal conjugate vaccine.Repeat every 5 years up to total 3 doses.

Meningococcus(Neisseria meningitidis)(A, C, W135, Y)

Menveo®Menactra®Nimenrix®(4vMenCV)

Conjugate(tetravalent)

Administer 2 doses, 2 months apart, then 5-yearly thereafter.Administer at least 2 weeks before elective splenectomy, or 1-2 weeks after emergency splenectomy (before discharge from hospital).

Meningococcus C Meningitec®Menjugate®NeisVac-C®(MenCCV)

Conjugate *An alternative to 4vMenCV (as recommended by Spleen Australia), although does not cover types A, W135, Y.Administer 2 doses, 2 months apart, then 5-yearly thereafter

Meningococcus B Bexsero®(4CMenB)

Conjugate Administer 2 doses, 2 months apart (no further doses recommended at the time of writing).Administer at least 2 weeks before elective splenectomy, or 1-2 weeks after emergency splenectomy (before discharge from hospital).

Haemophilusinfluenzae Type b

Comvax®Hiberix®

Conjugate Administer once, unless already given (i.e. as part of childhood schedule).Administer at least 2 weeks before elective splenectomy, or 1-2 weeks after emergency splenectomy (before discharge from hospital).

Influenza virus Influvac®Fluvax®,Fluarix®Vaxigrip®(flu)

Inactivated Administer annually.



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When should the vaccines be administered?For a person undergoing elective splenectomy the vaccines should be administered well before surgery. Ideally, it is best to give the four conjugate vaccines at least 2-4 months prior to surgery, followed by the second meningococcal conjugate vaccines and a polysaccharide pneumococcal vaccine two months later.

All vaccinations should be completed at least two weeks prior to surgery. In practice, the initial vaccine course is often given closer to surgery and the remaining vaccines often deferred until after surgery.

Following an emergency splenectomy the vaccines should be given prior to discharge from hospital. If available, the four conjugate vaccines should be administered in hospital followed by the following vaccines two months later.

Further Advice All people who have undergone or are about to undergo splenectomy should have at least one consultation with an expert physician.

The infectious diseases physicians of The Canberra Hospital are available for consultation (Appointments: 6244 2105).

A follow-up appointment may be worthwhile around the time a person must decide whether or not to continue antibiotic prophylaxis beyond three years.


Implementation

This guideline is available to all general surgeons, infectious diseases physicians, medical oncologists, haematologists, anatomical pathologists and pharmacists. It should be available to all registrars and residents at the time of their orientation to CHHS.


Related Policies, Procedures, Guidelines and Legislation

PoliciesACT Health Consent and Treatment Policy ACT Health Consent and Treatment Procedure Management of Severe Allergic Reactions and Anaphylaxis in Adults and Children CHHS Medication Handling Policy



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GuidelinesAustralian Immunisation Handbook 10th Ed. 2013. The Australian Vaccine Storage Guideline, 2013, Strive for 5, 2nd Edition.


References

Royal Children’s Hospital – Asplenia/Hyposplenia Guidelines: mvec.vic.edu.au

Spelman D, Buttery J, Daley A, Isaacs D, Jennens I, Kakakios A, Lawrence R, Roberts S, Torda A, Watson D, Woolley I, Anderson T, Street A. Australasian Society for Infectious Diseases: Guidelines for the prevention of sepsis in asplenic and hyposplenic patients. Intern Med J. 2008 May; 38(5):349-56.

Therapeutic Guidelines, Version 15, 2015.

Victorian Spleen Service – Recommendations for the Prevention of Infection in Asplenic/Hyposplenic Patients: spleen.org.au


Search Terms

Spleen, Post Splenectomy, Splenectomy, Sepsis, Vaccine, Antibiotics, ImmunisationInfectious disease


Disclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEgg: 17 August 2014 Section 1 ED/CHHSPC Chair



Documents

Prevention of Post Splenectomy Sepsis Guideline · Web viewThe availability of conjugate vaccines against meningococcus means that the older polysaccharide vaccines have become obsolete