Adults and Children Guidelines for Patients with Absent or

Dysfunctional Spleen
Contact Name and Job Title (author) Mr Adam Millington (Senior Clinical Pharmacist)
Mr Tim Hills (Lead Pharmacist Antimicrobials and infection Control)

Directorate & Speciality Diagnostics and Clinical Support

Date of submission Jan 2012
Date on which guideline must be reviewed (this should Jan 2014
be one to three years)
Explicit definition of patient group to which it applies (e.g. All patients with an absent or dysfunctional spleen
inclusion and exclusion criteria, diagnosis)

Abstract This guideline provides guidance on the required immunisations and

general management of patients with an absent or dysfunctional spleen

Key Words Asplenic, Spleen

Changes from previous guideline Large changes to the vaccination schedule including the addition of
Meningococcal ACWY conjugate vaccine.

Audit Plan This should be incorporated into the annual directorate audit plan. There is
an audit tool provided at the end of this guideline.

Statement of the evidence base of the guideline – has These guidelines have been produced by microbiology and pharmacy
the guideline been peer reviewed by colleagues? infectious diseases,
1a meta analysis of randomised controlled trials References include:

1b at least one randomised controlled trial

2a at least one well-designed controlled study without
randomisation
2b at least one other type of well-designed quasi-
experimental study
3 well –designed non-experimental descriptive studies (i.e.
comparative / correlation and case studies)
4 expert committee reports or opinions and / or clinical
experiences of respected authorities
Department of Health – Immunisation against infectious disease 2006. “The
Green Book” – Updated version available online.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/
digitalasset/dh_131000.pdf
John M. Davies et al. Review of guidelines for the prevention and treatment
of infection in patients with an absent or dysfunctional spleen. British
Journal of Haematology, 2011; 155, 308-317
Summary of Product Characteristics - http://www.medicines.org.uk:
Prevenar 13 – Wyeth Pharmaceuticals - Nov 2011

5 recommended best practise based on the clinical Summary of Product Characteristics - http://www.medicines.org.uk:
experience of the guideline developer Pneumovax II - Sanofi Pasteur MSD - June 2011

Summary of Product Characteristics - http://www.medicines.org.uk:

Menitorix – GlaxoSmithKline - March 2011

Summary of Product Characteristics - http://www.medicines.org.uk:

Menveo – Novartis - Oct 2011

BNF for Children 2011-2012. BMJ Group and RPSGB

Approval NUH antibiotics guidelines committee
NUH Drugs and therapeutics committee
Target audience All Trust Drs
Local Contacts Mr Tim Hills 65940

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and
application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague
or expert. Caution is advised when using guidelines after the review date.
Nottingham University Hospitals Antibiotics Committee
January 2012
Review: January 2014
1
Adults and Children Guidelines for Patients with Absent or Dysfunctional
Spleen

When to Immunise
ELECTIVE Immunise at least TWO (ideally four-six) weeks prior to surgery.
SPLENECTOMY Prophylactic antibiotics to start post surgery.

EMERGENCY Immunise at least TWO weeks post surgery, and when sufficiently
SPLENECTOMY well. Prophylactic antibiotics to be started immediately.

Which immunisations to give

Vaccine doses (adults and children)
®
Age at which patient Prevenar-13 0.5ml IM (Pneumococcal conjugate Vaccine - PCV 13)
®
presents with Pneumovax II 0.5ml IM (Pneumococcal Polysaccharide Vaccine - PPV)
®
splenectomy or splenic Menitorix 0.5ml IM (Haemophilus influenzae type b plus meningococcal C – Hib/MenC)
®
dysfunction Menveo 0.5ml IM (Meningococcal ACWY conjugate vaccine)
Influenza 0.5ml IM (influenza vaccine)
Month 0 Month 1 Later
®
A dose of Menveo
Complete according to After the second birthday, one
conjugate vaccine ®
routine childhood additional dose of Menitorix
should be given at ®
immunisation schedule and a dose of Pneumovax II
Under 2 years least one month after
including booster doses of ® should be given at least 2
the Menitorix and
®
Menitorix and Prevenar-13
® ® months after the last dose of
Prevenar-13 booster ®
and Influenza (if Sept. –April) Prevenar-13
doses
Over 2 years but under 5
® ®
years Menitorix booster and Pneumovax II
® ®
(Previously fully Prevenar-13 and Influenza Menveo at least 2 months after the
®
vaccinated - inc. (if September –April) last dose of Prevenar-13
®
Prevenar-7 )
Over 2 years but under 5
®
years Menitorix booster
® ®
(Previously fully and Pneumovax II and Menveo
vaccinated – inc. Influenza (if Sept. –April)
®
Prevenar-13 )
Second dose of
®
Over 2 years but under 5 Prevenar-13
®
years Menitorix and (two months after the first)
® ®
(Unvaccinated or partially first dose of Prevenar-13 Menveo and then
®
vaccinated with and Influenza (if Sept. –April) Pneumovax II
®
Prevenar-7 ) (at least 2 months after the
®
last dose of Prevenar-13 )
®
Over 5 years of age Menitorix and
® ®
(Vaccination history Pneumovax II and Influenza Menveo
irrelevant) (if Sept. –April)
Re-immunisation?

Influenza Yearly- from Sept to Nov.

Usually required every 5 years
Pneumovax II (Antibody levels may decline more rapidly in some patients and therefore pneumococcal antibody
level testing may help guide timing of vaccinations. Contact Immunology for further advice.
Nottingham University Hospitals Antibiotics Committee
January 2012
Review: January 2014
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 Antibiotic Prophylaxis Guidelines

Following splenectomy, patients are at risk of overwhelming infection. The length they remain at risk is
unknown.

Some papers report the risk to be greatest during the first few years, but Waghorn et al, (1997)
discovered that 60% of cases of overwhelming post-splenectomy infection (OPSI) occurred 10-30 years
later.

Susceptibility to infection may be greatest in the first few years following splenectomy, but persists
lifelong. However, compliance with lifelong antibiotics can be a problem.

All adults should therefore be offered antibiotic prophylaxis life long (preferably) following
splenectomy however if compliance is an issue this can be reduced. Patients must receive
prophylactic antibiotics for 2 years post splenectomy. Children should receive antibiotic cover
until 16 years of age (NB. older children should still receive at least a minimum 2 year course).

Lifelong antibiotic prophylaxis is always advised for all patients considered at continued high risk of
pneumococcal disease. High risk patients include:
o Patients who are under 16 or over 50 years of age.
o Patients who have an inadequate serological response to pneumococcal vaccination
o Patients with a history of previous invasive pneumococcal disease
o Patients undergoing splenectomy for an underlying haematological malignancy particularly in
the context of on-going immunosuppression

If compliance is a problem, an emergency supply of amoxicillin could be given to the patient, which
would be available for them to take at the first signs of any infection. Likewise following the two-year
prophylaxis course an emergency dose of amoxicillin 500mg or clarithromycin 500mg can be
prescribed for use at home prior to seeking urgent medical attention.

Adults Without Penicillin Allergy Adults With Penicillin Allergy

Penicillin V (oral) 500mg bd Clarithromycin (Oral) 250mg bd (if pregnant
use Erythromycin 500mg bd)

Children Without Penicillin Children With Penicillin Allergy

Allergy
Penicillin V (oral) : 1mth- 6yrs 125mg bd Erythromycin (Oral) : 1 mth – 2 yrs 125mg bd

6-12 years 250mg bd 2 – 8 years 250mg bd

>12 years 500mg bd 8 – 18 years 500mg bd

If a patient becomes nil-by-mouth following a splenectomy, IV benzylpenicillin should be given:

Adults: IV benzylpenicillin = 1.2g bd

Children: IV benzylpenicillin = 25mg/kg bd

Additional cover with IV benzylpenicillin is not required if the patient is already receiving antibiotics with
appropriate activity (e.g. cephalosporins, other β-lactam agents – if unsure check with microbiology). If
patient is allergic to penicillins discuss with microbiology.

Nottingham University Hospitals Antibiotics Committee

January 2012
Review: January 2014
3
Administration of Vaccines

All of the necessary vaccines in this guideline can be given on the same day, preferably rotating the
injection site.

Vaccines are routinely given intramuscularly into the upper arm or anterolateral thigh. This is to reduce
the risk of localised reactions, which are more common when the vaccine is given subcutaneously. For
individuals with a bleeding disorder, however, vaccines should be given by deep subcutaneous injection
to reduce the risk of bleeding.

Vaccines must be administered by a suitably qualified member of staff who is competent to do so.

Identification of patients with an absent or dysfunctional spleen

Clear identification of these patients is essential, so as to prevent fever being misdiagnosed as viral,
before bacterial infection has been ruled out.

All information concerning immunisation and antibiotic prophylaxis should be conveyed to the patient’s
GP, using the notification letter - available on the antibiotic website, trust guideline intranet or from
pharmacy.

Patients should be given, and encouraged to carry, a DoH splenectomy-warning card which can be
obtained from pharmacy. (Surgical satellite pharmacy at QMC campus, ext. 65030 and the inpatient
pharmacy at the City campus ext. 55982)

Patient information leaflets are also available from the antibiotic website and ward E15 QMC campus.

Patients can also sign up for ‘Medic-Alert’ bracelets (http://www.medicalert.org.uk or freephone 0800
581420).

Chemotherapy (or other immunosuppressive treatment)

Immunisations should be delayed, whilst ensuring adequate antibiotic cover is prescribed in the interim.

Pregnancy / Breast-feeding

All vaccines within this guideline are inactivated but have limited or no evidence for use in pregnancy
and lactation.

Since inactivated vaccines cannot replicate they cannot cause infection in either the mother or the
foetus. However, inactivated vaccines should be administered to pregnant women only if protection is
required without delay.

As asplenic patients are at high risk of infection and sepsis, the benefit of administration of vaccines are
generally considered to outweigh the potential risk to the foetus.
Travel

Patients with an absent or dysfunctional spleen are at increased risk of severe falciparum malaria.
Guidance should be given on appropriate malaria prophylaxis and the need for close adherence to it.

Nottingham University Hospitals Antibiotics Committee

January 2012
Review: January 2014
4
Animal Bites

All animal bites need to be treated quickly, to reduce the chance of infection from Capnocytophaga
canimorsus, which can lead to fulminant sepsis. Antibiotics are usually prescribed.

Tick Bites

~1/3 of cases of clinical human babesiosis have occurred in splenectomised individuals. It is a rare tick
borne infection that can cause moderate to severe disease, including haemolytic anaemias. Therefore
it is essential to take precautions against being bitten in endemic areas (if camping, cover exposed
skin).

Infection

Patients should be advised to see a doctor immediately if they develop any signs of infection e.g. sore
throat, fever, malaise, severe headache, and flu-like symptoms.

Nottingham University Hospitals Antibiotics Committee

January 2012
Review: January 2014
5
 Suggested NUH Splenectomy Audit Form
MS word copies available from the authors if adaption required
Relevant Past
Demographics Medical History
NHS Number
Initials
DOB
Allergies
GP Surgery
GP address Indication:
Emergency / Elective
Date of Admission
GP Tel. No if for Date of Splenectomy
followup. Date of Discharge

Vaccinations Antibiotic Prophylaxis given during inpatient

Vaccine Dates Given stay (post-op including treatment courses)
®
Pneumovax II Regimen Started Finished
®
Prevenar - 13 Penicillin V 500mg bd
Combined Clarithromycin 250mg bd
HIB/Men C Penicillin V
®
(menitorix ) Clarithromycin
Meningococcal Others:
ACYW
®
(Menveo )
Influenza
Other

Discharge information
Was the standard GP letter
completed and a duplicate filed Y / N
in the notes?
If no…..
Was information on what
vaccines were given during the
Y / N
stay provided on the TTO or
discharge letter?
Was information on what Regimen
antibiotic prophylaxis should be Y / N
given provided on the TTO or Duration
discharge letter? Y / N

Comments

Nottingham University Hospitals Antibiotics Committee

January 2012
Review: January 2014
6