Critical Care Medicine

Volume 27 Number 4 April 1999

Copyright 1999 Lippincott Williams & Wilkins, Inc.

SPECIAL ARTICLES
Prevention and m anagem ent of overw helming postsplenec tomy infection -An update
Malcolm L. Brigden MD, FACP

Andy L. Pattullo MD, FRCP 2

From the Department of Medical Oncology (Dr. Brigden), BC Cancer AgencyCenter for the Southe rn Interior;
2
and the Department of Infectious Diseases (Dr. Patullo), Kelowna General
Hospital, Kelowna, BC, Canada.

Copyright 1999 by Lippincott Williams & Wilkins

Objectives: To review the diagnosis and managem ent of overwhelming
postsplenectomy infection and to discuss various preventative
measures.
Data Sources: Data used to prepare this article were drawn from
published articles and work in progress.
Study Selection: Articles were selected for relevance to the subject after
location by a MEDLINE key word sea rch.
Data Extraction: The literature was reviewed to summarize the etiology
and pathophysiology of postsplenectomy sepsis. Preventative strategies
were outlined with a particular emphasis on education,
immunoprophylaxis, and chemoprop hylaxis.
Data Synthesis: Although physicians have become increasingly aware of
over whe lming post splen ecto my inf ection in childr en, m any re main
unaware of the risk to asplenic or hyposplenic adults who may have no
underlying medical problems. Recent studies have shown that many
patients who have had splenectomies have had neither approp riate
vacc ination s nor t each ing tha t wo uld ex plain th e lifelon g nat ure o f their
risk. The increasing incidence of penicillin-resistant pneumococci
represents a major area of therapeutic and prophylactic concern. The
ident ificatio n of Ho well-J olly bo dies o n a pe riphe ral blo od sm ear s hould
alert physic ians to the ne ed fo r follow -up to docu men t pos sible
hypo splen ism. A ttent ion has focus ed on a thre e-pr onge d att ack to this

problem, including education, immunoprophylaxis, and

chemoprophylaxis.
Conclusions: Ove rwhe lming post splen ecto my inf ectio n shou ld be la rgely
preventable if appropriate precautions are taken. Physicians need to
know of the spectrum of diseases associated with hyposplenism and
how patients noted to have Howell-Jolly bodies should be investigated.
They should also be aware of appropriate guidelines for management of
patients with asplenia or hyposplenism. (Crit Care Med 1999; 27:836842)
K EY W ORDS: infection; asplenia; hyposplenism, overwhelming;
postsplenectomy; postsplenectomy sepsis syndrome; post-splenectomy
pneumococcal vaccine; splenectomy com plications

BACKGROUND
Fulminant, po tentially life-threatening infection represents a m ajor long-term
risk after splenectomy or in patients who have functional hyposplenism [1] [2] [3] [4]
. Splenic m acrophag es play a m ajor role in filtering , and pha gocytizing bacteria
and parasitized blood cells from the circulation and the spleen are also a
significant source of antibody production. In the absence of the spleen, the liver
can also perform this function, but higher concentrations of specific antibody and
an intact complement system are required [1] [2] . Overwhelming
postsple nectom y infection (O PSI) is also known a s postsp lenectom y sepsis
syndrome, or postsplenectom y overwhelming sepsis [1] [5] [6] . Although
meningitis or pneumonia will accompany OPSI in ~50% of cases, in many
patients there is no obvious site of bacterial colonization and a cryptic source
originating in the nasop harynx is p ostulated. T he initial prod rome m ay be m ild
and nonspecific with flu-like symptoms [1] [4] . These symptoms may include
fever, malaise, myalgias, headache, vomiting, diarrhea, and abdominal pain. The
presence of gastrointestinal symptoms should never prevent the attending
physician from entertaining a possible diagnosis of OPSI [2] . When sufficient
detail has been reported in the literature, many patients will have had true rigors
for a day or two before receiving definitive medical management. This initial
prodro me m ay be follo wed by rapid evo lution to full blo wn bacte remic sep tic
shock accompanied by hypotension, anuria, and clinical evidence of
disseminated intravascular coagulation, thus making this syndrome a true
medical emergency. Severe hypoglycemia may also be present. The subsequent
clinical course often m irrors that of the W aterhouse- Friderichsen syndrom e with
bilateral adrenal hemorrhages noted at autopsy [7] . Peripheral gangrene
requiring amputations has been reported in survivors, secondary to the
combination of hypotension and disseminated intravascular coagulation [1] [4] .
Despite a pprop riate antibiotics an d intensive th erapeutic inte rvention, th e overall
mortality in older published studies for established cases of OPSI varied from
50% to 70% [1] [2] [3] [4] . More recent information suggests that when informed
patients seek medical attention promptly, the mortality may be reduced to the

range of 10%. Of those patients who die, >50% die within the first 48 hrs of
hospital admission [1] [2] [4] . In those p atients who survive, oth er sequelae , in
addition to gangren e and am putations, have includ ed deafne ss associated with
either me ningitis or m astoid oste omye litis, and aortic ins ufficiency seco ndary to
endocarditis [1] .

RESPONSIBLE MICROORGANISMS
Most instances of serious infection are due to encapsulated bacteria, such as
Pneumococcus, ( Streptococcus pneumoniae ) [7] [8] . Pneumococcal infections
have actually accounted for 50% to 90% of cases reported in the literature and
may be asso ciated with a mortality of up to 60%. Haemoph ilus influenzae type
B, meningococcus, and grou p A Streptococci have accounted for an additional
25% of infections. Haemophilus infections are particularly important in children
[7]
.
Other implicated organisms include Capnocytophaga canimorsus (formerly called
DF-2), which can cause a fulminant sepsis following dog bites [9] . More rare ly
noted organism s include group B streptococci, Enterococcus species, Bacteroides
species, Salmo nella species, and Bartonella (both Salmo nella and Bartonella
infections may be linked with reticuloendo thelial blockade), Plesiomonas
shigelloid es, Eubac terium p lautii, and Pseudomonas pseudomallei [8] . Bacterial
proliferation in OPSI may be so extreme that bacteria are noted in buffy coat
preparations, or remarkably, in an extracellular location, or within the
neutrophils present on a blood film made from unspun peripheral blood [10] .
The splenectomized host is also more susceptible to infections with intraerythrocytic organisms. Protozoan infections following tick bites ( Babesia m icroti
in the United States or B. bovi in Europe) have been responsible for a fulminant
hemolytic febrile state in asplenic or hyposplenic individuals [11] . Fatal falciparum
malaria has also been noted more frequently in asplenic persons. An atypical
fulminant course for Plasmodium vivax and Plasmodium malariae infections has
also been cited in a few asplenic individuals [1] .

PATIENT CATEGORIES

Congenital Asplenia.
Congenital asplenia is frequently associated with cardiac abnormalities and
biliary atresia. In general, survival beyond 1 yr of life occurs in <5% of such
individuals [4] .

Operative Splenectomy.
Surgical removal of the spleen may be performed for severe splenic trauma,
splenic cysts, or as part of resective procedures for tumors of the spleen or
adjacent organs [12] [13] [14] [15] . Delayed splenic rupture may occur in up to 5% of
patients who sustained blunt trauma to the abdomen or chest, usually within 2
wks of injury. Spontaneous repture of the spleen may occur in splenomegaly due
to malaria or, rarely, infectious mononucleosis. Elective splenectomy is not
infrequently undertaken for a number of hematologic conditions, including
hematologic malignancies, primarily Hodgkin's disease, hemolytic states, and
idiopathic thrombocytopenic purpura [15] . Partial splenectomy with retention of
some splenic tissue is increasingly practiced in cases of splenic trauma [13] .
Another approach is splenic autotransplantation within the mesentery, but the
overall effectiveness of this procedure remains unknown [14] . Because of an
uncertainty regarding the degree of splenic function that persists following
partial splenectomy or autotransplantation of splenic tissue, similar measures
should be undertaken to prevent infection in these patients as for known
asplenic subjects [16] [17] .

Functional Hyposplenism.
Either asplenia or functional hyposplenism may be suspected when the
peripheral blood film shows red cells containing Howell-Jolly bodies ( Fig. 1 ) [1] [4]
[18]
. These small round remnants of the original erythrocyte nucleus should be
readily apparent on microscopic examination of a peripheral blood film. The
finding of Howell-Jolly bodies, although not completely sensitive to minor
degrees of hypo splenism , does ide ntify the deg ree of hyp osplenism though t to
represent a risk for OPSI [19] . Although som e of the newer hem atology analyzers
may, on occasion, flag Howell-Jolly bodies, if a question of asplenia or
hyposp lenism ex ists, the clinician sh ould alwa ys reques t a standard b lood film
review by a hemato logist or p athologis t. While the p resence of H owell-Jo lly
bodies is not patho gnom onic for hy posplen ism, the n ature of othe r hemato logic
conditions or disease processes with which they may be associated should be
apparent from the history or other changes in the hematology picture. One
reference laboratory processing more than 100,000 peripheral blood smears per
year reported an incidence of new patients showing Howell-Jolly bodies of one
per 200, or 0.5% [20] . Many of these p atients, as well as their physicians, were
unaware of their asplenia or hy posplenism .
Splenic d ysfunction may o ccur secon dary to a varie ty of gastroin testinal,
immunologic, inflammatory, infiltrative, and hematologic diseases, many of
which have been linked to individual case reports of OPSI ( Table 1 ) [1] [18] . In
routine clinical practice, liver disease or celiac disease are probably the two most
comm on causes. While m ost liver-related cases of splenic hyp ofunction are
secondary to cirrhosis and portal hypertension, there is also evidence of
hyposplenism in acute alcoholism, apparently secondary to a direct toxic effect
of alcohol on the spleen [21] . Bone marrow transplantation is increasingly utilized

and is a well-recognized cause of functional hyposplenism associated with an

increased incidence of pneumococcal bacteremia and H. influenzae pneum onia
[22]
. Typically, these infections occur 6 mos after bone marrow transplantation at
the time th at Pneum ocystis prophylaxis has been stopped. Patients undergoing
high-dose corticosteroid therapy or splenic irradiation as part of cancer therapy
may also manifest decreased or abnormal splenic phagocytic function and an
increased risk for OPSI [23] . Functional hyposplenism has also been described as
a feature of human immunodeficiency virus infection [24] . There has also been a
rare case of OPSI reported [2] , despite the apparent presence of a normal
spleen, raising the possibility of idiopathic hyposplenism in an otherwise healthy
person. While the individual degree of risk of OPSI for any patient with functional
hyposplenism cannot be accurately predicted, the persistent detection of
unexplained Howell-Jolly bodies on the peripheral blood film should be
investigated as per the alg orithm o utlined in Fig ure 2 . If ques tions rem ain as to
the actual physical presence or functioning of the spleen, a radionucleotide
spleen/liver scan may be beneficial
TABLE 1 -- Various cond itions that may be associated with hyposplenism

Type
Hem atologic

Disorder
Sickle cell disease
Other hem oglob inopathies (SC, SE , S-BTh all)
Throm bocyto penia
Malignan t histiocytosis

Gastrointestinal

Celiac sprue
Derm atitis herpetiform is
Ulcerative co litis
Liver disease
Portal hypertension
Acute alcoholism

Imm unolog ic

Systemic lupus erythematosus

Rheum atoid arthritis
Graves' disease
Polyarteritis no dosa (sp lenic infarct)

Infiltrative

Thorium dioxide administration

Amylo idosis
Sarcoido sis

Miscellaneous

Bartonellos is
HIV infection
Graft versus host disease
Post bone marrow transplantation
Total parenteral nutrition
Cancer therapy
High-dose steroid therapy a
Splenic irradiation a

SC, hemo globin SC; SE, hemoglobin SE; S-BThall, hemoglobin SmB-thalassemia; HIV,
human immunod eficiency virus.
a

Has not been conclusively proven.

RISK FACTORS FOR OPSI

The precise incidence of OPSI remains controversial, and published estimates
vary considerably. In one retrospective review of 5,902 post-splenectomy
patients studied between 1952 and 1987 [25] , the inciden ce of OP SI was 4.4 % in
children <16 yrs and 0.9% in adults. Another recent study [26] calculated the
risk of sepsis as 0.73 per 1,000 person years after splenectom y for hereditary
spherocytosis. Unfortunately, most of the published data antedate the
widespread availability of the pneumococcal and H. influenzae vaccines and
current rates may be lower. For instance, a Danish study [27] found that the
incidence of pneumococcal infection in splenectomized children decreased
dramatically following the introduction of the pneumococcal vaccine and the
promo tion of early penicillin therapy for febrile episo des.
Overall, the most reliable data relating to incidence are probably those of
Schwarz and co-workers [28] derived by applying actuarial methods to a
population free of selection bias with consistent long-term follow-up. This study
[28]
estimated the risk of fulminant infection as reasonably low, being in the
range of 1 c ase per 500 person y ears of obs ervation. H owever, the overall
cumulative risk of infection severe enough to require hospitalization was 33% by

the end of a 10-yr follow-up. Major factors for stratifying risk include the age at
which splenectomy occurs, the reason for splenectomy, and the subsequent time
interval from splenectomy.
Infants do not acquire specific antib odies aga inst encaps ulated org anisms u ntil
relatively late in the development of the normal range of antibody responses.
Asplenic children <5 yrs, especially infants splenectomized for trauma, may have
an infection rate of>10% [29] [30] . Children with sickle cell anemia or
heterozygotes for hemoglobin S and C or S and beta-thalassemia are at
especially high risk for OPSI [1] . This high incidence is probably related to the
fact that both the coating of bacteria with opsonizing antibodies and the tortuous
splenic microcirculation are key factors in the phagocytosis of encapsulated
organisms.
Splenectomy perform ed for a hematologic disorder, such as thalassemia,
hereditary spherocytosis, or lymphoma appears to carry a higher risk than
splenectomy performed as a result of trauma [15] . A majo r contributin g factor in
this regard is th e frequent e xistence of sp lenic imp lants or access ory spleen s in
traumatized patients. Sm all implan ts of splenic tissu e or spleno sis are found in
the peritoneum in 50% of patients who undergo splenectomy for trauma [1] [31] .
About 10% of such patients may also have accessory spleens. Unfortunately, the
degree of protection offered by splenosis or accessory spleens appears to be
both variable and unpredictable [15] [17] . A number of reported cases of OPSI
have occurred in the face of remaining splenic tissue or splenic implants, and
such patients should always be treated as if they were asplenic in nature [17] .
An individual's overall immune status is also an important variable. Conditions
known to possibly be associated with defects in cellular immunity, such as
Hodgkin's disease, hypo-gammaglobulinemia, the administration of
chemotherapy, radiation therapy, or the post bone marrow transplant state, may
have a major effect on the ability to amount an effective antibody response and
increase the risk for OPSI [1] [7] .
The time interval from the date of splenectom y is also an impo rtant risk factor.
Several studies [30] [31] [32] [33] have shown that 50% to 70% of admissions to a
hospital for serious infections occur within the first 2 yrs following splenectomy.
In young children w ho have h ad a splen ectomy , 80% o f OPSI cases occu r within
this time fram e. How ever, it mu st be realized th at some degree o f risk persists
for the duration of life. Thirty-three percent of postsplenectomy pneumoco ccal
infections and 42% of OPSI occurred >5 yrs postsplenectomy [2] . There are also
individual case reports [6] of OPSI occurring >40 yrs after splenectomy.
In summary, while various risk factors for OPSI have been identified, at present
there are no tests that will reliably differentiate whether a specific asplenic or
hyposplenic individual belongs to the small group who will develop OPSI vs. the
majority who will not experience significant infectious problems.

MANAGING PATIENTS WITH OPSI

Treatment of an Acute Infection.

Suspected pneumococcal, meningococcal, or other serious infection involving the
asplenic or hyposplenic individual constitutes a potential medical emergency [5]
[7] [8]
. The critical point in management remains the early recognition of the
patient at risk fo llowed im media tely by agg ressive interve ntion. Wh ile there is
currently no proof that early treatment will prevent incipient bacteremia from
progressing to full-blown OPSI, the literature does support an aggressive
approac h as imp roving su rvival [3] . Diagnostic work-up should never delay the
use of empiric therapy. Possible choices of empiric antimicrobial agents useful for
the initial treatm ent of OP SI are includ ed in Table 2 . Intraveno us penicillin
therapy has generally been superseded by broad-spectrum antibiotic therapy
active against penicillin-resistant pneumococci, beta-lactamase-producing H.
influenzae and other possible organisms (especially Gram-negative organisms
such as Escherichia c oli and Salmo nella) which are not normally penicillinsensitive. Any local resistance patterns should be taken into account in selecting
an
TABLE 2 -- Empiric treatment for suspected overwhelming postsplenectomy
infection
Adult Dose a

Drug
Cefotaxime
Ceftriaxone
b

+/- Ge ntamyc in or
+/- Ciproflox acin
+/- Van comy cin d

Pediatric Dose a

2 g iv every 8 hrs

25-50 mg /kg iv every 6 hrs

2 g iv every 12-24 hrs

50 mg/k g iv every 12 hrs

5-7 mg/ kg iv every 24 hrs

2.5 mg/k g iv every 8 hrs

400 mg iv ev ery 12 hrs

1-1.5 g iv every 1 2 hrs

30 mg/k g iv every 12 hrs

Doses are for normal renal function and should be adjusted if creatinine
clearance is reduced;
b
gentamycin or ciprofloxacin may be added if an enteric or urologic source of
infection is suspected;
c
c iiprofloxacin is not indicated for children;
d
vancom ycin shou ld be add ed when pneum ococcus with high- level penicillin
resistance is likely.

initial empiric regimen, with consideration of an antibiotic such as ceftriaxone or

cefotaxime active against penicillin-resistant pneumococci, as well as betalactamase-producing organisms. Unfortunately, some penicillin-resistant
pneum ococcal iso lates are also resis tant or only in termed iately sensitive to
cephalosporins. If such resistance is suspected, the use of vancomycin will have
to be con sidered. H igh-level p enicillin-resistan t pneum ococci w ill definitely

require van comy cin treatme nt with or w ithout rifam pin. Exp ert opinion should
always be sought in this instance. Fo r patients wh o are allergic to both pe nicillin
and cephalosporins, vancomycin with or without rifampin or chloramphenicol
may be utilized after appropriate infectious disease consultation [34] . Once the
patient has been admitted to the hospital, appropriate diagnostic investigation
should be undertaken. Examination of the peripheral blood smear and b uffy coat
for the presence of bacteria should be performed. Cultures and Gram stains
should be obtained from any site of obvious tissue involvement. Specimens
should include blood, urine, and sputum. Ideally, blood cultures should be
immediately drawn before giving antibiotics, but treatment should not be
delayed when this is not possible. If present, ascitic fluid should be examined. If
indicated, lumbar puncture should be performed, particularly in infants or
children due to the high incidence of meningococcal meningitis in this population.
Standard laboratory tests, a hemotology profile, and serum chemistry, as well as
appropriate radiological studies including chest radiograph should be obtained.
Possible disseminated intravascular coagulation should be anticipated and
managed appropriately. Septic shock should be managed via standard protocol
and will req uire adm ission to the intensive care u nit. The use o f corticostero ids in
this instance has been debated [4] . Additional specialized testing, including the
specific exam ination of a p eripheral blo od film fo r malaria or b abesiosis, s hould
be guided by the clinical history. Optimal antimicrobial therapy for babesiosis has
not been well delineated. A recently described clindamycin-quinine regimen has
shown promise [11] . Exchang e transfusion has also be en success fully utilized in
cases with high grad e parasitemia.

TABLE 3 -- Principal Guidelines

Education
Patients should be inform ed about risks and typ es of infection, and told to w ear a
MediAlert bracelet or necklace and carry a wallet card. Patients s hould b e advised to
seek prompt m edical attention if unwell, when planning travel to a malaria or
babesiosis endemic area, or if bitten by ticks or any animals.
Patients should be encouraged to alert all new healthcare professionals, including
dentists, regarding their asplenic or hyposplenic status.
Individual patient medical records should be prominently labeled that the patient has
had a splenectomy or is functionally hyposplenic.
Imm unopro phylaxis
Pneum ococcal, mening ococcal, and Haemophilus influenzae type B vaccination s hould
be given at least 14 days before splenectomy or as soon as possible postsurgery.
Booster injections every 5 to 6 yrs should be considered in the case of pneumococcal
vaccine. The me asurem ent of antib ody levels may serve as a guide to the need for
revaccination, but such testing is not widely available and interpretation may be
difficult.
Annual influenza immunization is advisable.
Ongo ing doc umen tation and co mm unication o f imm unization statu s is impo rtant.
Immunization should never produce a false sense of complacency.

Chem oprop hylaxis

Failures of prophylaxis have been reported, as well as infections caused by penicillinresistant strains of pneumococcus.
Traditional oral penicillin prophylaxis has been replaced by drugs such
amoxicillin/clavulanic acid, trimethoprim/sulfamethoxazole (SXT) or cefuroxime.

as

Lifelong prophylaxis may be considered in the case of immunocompromised patients

but there exists no consensus among experts in this regard.
If a decision is made to provide "standby" antibiotics, patients should have a supply
of antipneum ococcal an tibiotic availab le to take if febrile illness deve lops, esp ecially
if immediate medical attention is not available.
Patients developing infection despite prophylactic measures (antibiotics, vaccination)
should be given systemic antibiotics (ceftriaxone, cefotaxime) and promptly admitted
to hospita l.

PREVENTIVE STRATEGIES
Preventive strategies fall into three major categories: education,
immunop rophylaxis, and chemoprophy laxis [5] [7] [8] ( Table 3 ).

Education.
Patient education represents a mandatory strategy in attempting to prevent
OPSI. Studies [35] [36] have shown that from 11% to 50% of postsplenectomy
patients remain unaware of their increased risk for serious infection or the
appropriate health precautions that should be undertaken. In one study [36] ,
100% of the surgeons felt that they had adequately explained the immunological
conseq uences o f splenecto my and approp riately stressed infectious risks , while
only 16 to 40% of the patients involved were aware of any health precautions.
Asplenic patients should be encouraged to wear a Medi-Alert bracelet or necklace
and carry a wallet card explaining their lack of spleen and other clinical details [7]
[8]
. Patients sho uld und erstand the p otential seriou sness of O PSI and the rapid
possible time cou rse of prog ression. Th ey should be aware o f the need to notify
their physician in the event of any acute febrile illness, especially if associated
with rigors or system ic symptom s. They should inform any new healthcare
professio nals, includin g dentists, o f their asplenic o r hyposp lenic status. Pa tients
also need to be informed of an increased risk for travel-related infections such as
babesiosis and malaria [5] . Specifically with regard to malaria, patients should be
advised about chemoprophylaxis relevant to any local pattern of infestation, and
simple measures to reduce exposure to m osquitoes [7] [8] . They should be
warned regarding the prompt treatment of even minor dog or other animal bites
with adeq uate antibio tic coverag e in view of th e increased susceptib ility to
infection by the DF-2 bacillus [10] .

Immunoprophylaxis.
An important factor in preventing OPSI is an appropriate vaccination strategy [7]
[8] [27]
. This strategy has been b est defined for S. pneumoniae. Howe ver, it is
impo rtant to realize that th e overall efficacy of pneum ococcal va ccination in
preventing OPSI has never been adequately determined by objective study.
Physicians must always maintain vigilance for serious infection, even amongst
fully immunized patients. The pneumococcal vaccine is a polysaccharide vaccine
that com prises the 23 bacterial type s respons ible for 90% of bacterem ic
pneumococcal disease seen in North Am erica [37] . Unfortunately, the most
virulent pne umoc occal seroty pes tend to be the least im muno genic, and there is
also evidence that the efficacy of the vaccine is poorest in younger patients who
would be at highest risk [37] [38] . However, under ideal conditions in a healthy
imm unocom petent ho st, the vaccine has a 70% protection rate. This rate is
related to the fact that ~10% of possible antibody responses to individual
antigens do no t occur [38] . Unfortunately, studies performed in North America
and Europe [35] [36] continue to indicate that from 30% to 60% o f eligible
postsplenectom y patients never receive the pne umoco ccal vaccine.
Pneumococcal vaccination should be performed at least 2 wks before an elective
splenectomy [39] . If this timeframe is not practical, the patient should be
immunized as soon as possible after surgical recovery and before discharge from
the hospital. Newly recognized unimmunized patients splenectomized at an
earlier date should be im munized at the first opp ortunity. The vaccine's
immunogenicity may be reduced if it is given after splenectomy or while the
patient is receiving chemotherapy [37] . In the case of H odgkin 's disease, if
vaccination is delayed until after treatment has begun, inadequate antibody
responses are observed for as long as 3 yrs [39] . For this reason, the
manufacturer recommends that immunization be delayed for at least 6 mos
following imm unosup pressive ch emoth erapy or rad iotherapy . Proph ylactic
antibiotics should probably be utilized during this time [37] . There are cur rently
no adeq uate data in the literature on the efficacy of vaccin ation in functio nally
hyposplenic populations. Re-vaccination is recommended for asplenic or
functionally hyposplenic individuals after 5 to 6 yrs. Patients should be revaccinated sooner if there is reason to believe that antibody titres may
experience an early decline. For instance, re-immunization may b e required as
early as 3 yrs in lymphoproliferative disorders or sickle cell anemia [7] . Since
children <2 yrs have a poor immune respo nse to polysaccharide vaccines, it may
be better to initially rely on prophylactic antibiotics and immunize after the
second birthday [5] .
Thirty percent of vaccinated patients may have minor side effects, including
erythema or myalgia with localized pain at the injection site; 3% to 7% of
patients may experience mild pyrexia for 24 to 48 hrs after vaccination [37] .
Severe sy stemic rea ctions with p hotoph obia, chills, an d fever occ ur in only 1 in
1,000 vaccinations and usually resolve spontaneously. Vaccination should not be
performed during a febrile illness and may be deferred in pregnant women [8] .
The occasional patient with chronic immune thrombocytop enic purpura may
experience a transient relapse postimmunization [40] .

Haemophilus Influenzae Type B Immunization.

Many children in North America have received the Haemophilus type B vaccine.
Adolescents >18 yrs usually acquire some degree of imm unity via natural
exposure, but this immunity may not provide adequate protection in the face of
an absent or dysfunctional spleen [7] . The Haemophilus vaccine has been shown
[41]
to be im muno genic in p atients with im paired sp lenic function associated w ith
sickle cell anem ia. Howe ver, the spe cific antibod y concen trations requ ired in
patients lacking a spleen remain unknown. Overall, the efficacy and utility of
vaccination against Haemophilus is less clear than for pneumococcal vaccine
since mo st adults already carry antibody for H. influenzae type B, and many
infections involve non-type B strains [42] . The require ment fo r re-imm unization is
also undefined.

Meningococcal Immunization.
The current meningococcal vaccine covers types A, C, W135, and Y, but misses
other pathogenic strains [41] [42] . Imm unity follow ing this vacc ine appea rs to
diminish over a few years, suggesting requirement for frequent boosters. The
efficacy and importance of meningococcal vaccination in splenectomized
individuals is unknown. A conjugated vaccine currently under development m ay
provide longer lasting immunity [7] .

Influenza Immunization.
The annu al admin istration of influe nza virus vacc ine to asplen ic and hyp osplenic
individuals is recommended [7] [8] .

Vaccine Failure.
Sporad ic cases of pn eumo coccal and other vaccine failures have b een repo rted in
appropriately immunized persons [43] [44] . In addition, bacteria other than
pneumococcus accoun t for at least 50% of cases of OPSI. For these reasons,
vaccination by itself shou ld never b e allowed to confer a false sense of sec urity
[44] [45]
.

Chemoprophylaxis.
Most au thorities recom mend antibiotic pro phylaxis fo r asplenic or h yposp lenic
children, especially for the first 2 yrs after splenectomy [5] [7] [8] . Some
investigators [5] advocate continuing chemo prophy laxis in children for at least 5
yrs, or until the age of 21. T he value o f such an app roach in old er children o r in

adults has never b een adeq uately evaluate d in a clinical trial [1] . Although
compliance is a problem with long-term prophylaxis in adults, recent experience
in Europe [27] has yielded more o ptimistic res ults with reg ard to com pliance in
asplenic ch ildren. Ano ther shortco ming o f antibiotic pro phylaxis is th e inevitable
selection for colonization with nonsusceptible pathogens, which of course must
always be considere d when selecting antib iotic treatme nt for appa rent sepsis in
the patient who has been prophylaxed.
Traditionally a single daily dose of penicillin or amoxicillin has constituted the
regimen of choice. However, these antibiotics will not protect against organisms
resistant to penicillin. In this regard, moderately resistant and highly resistant
pneumococci represent an increasing problem. In som e European countries such
as Spain, the incidence of highly resistant isolates approaches 50% [7] . With
increasing concern about resistance, antibiotics with broader activity such as
amoxicillin/clavulanic acid, cefuroxime, or trimethoprim/sulfamethoxazole have
been increasingly utilized for p rophylactic program s. However,
amox icillin/clavulanic acid is not activ e against pe nicillin-resistant p neum ococci,
and m ulti-drug re sistant pneu moco cci may n ot be sens itive to
trimethoprim/sulfamethoxazole. Thus, cefotaxime or ceftriaxone have been
recommended as empiric treatment for symptomatic patients who have been
taking antib iotic prop hylaxis or tho se with strains k nown to show inte rmedia te
resistance to penicillin [7] [8] . Because cases of OPSI involving pneumo coccal
infection hav e been rep orted in p atients who have receive d both p enicillin
prophylaxis and vaccination [45] [46] , the use of p rophylac tic measu res should
never be allowed to engender a false sense o f security.
Another strategy that has been advocated is the provision of "standby"
antipneumococcal antibiotics. In this instance, the patient retains a personal
supply to be taken at the first sign of respiratory illness, fever, or rigors,
especially if the re is likely to be a delay in m edical evalua tion. There is currently
no proof that such early self-treatment will lower the incidence of OPSI [1] . In
fact, the literature series [3] with the low est mortality reported to date
emphasized patient education, close follow-up, and promp t physician
intervention at the earliest sign of even minor infection. Thus, in such situations,
even if patients have their own supply of antibiotics, medical help should be
sought immediately [7] [8] . Howe ver, for patien ts traveling to re mote are as, it
would be wise to take a supply of antibiotics, taking into account any regional
patterns of d rug resistanc e which ex ist.

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