HNY Policy and Pathway Repository - North Yorkshire

Patients without a functioning spleen are at increased risk of severe life-threatening infection but this risk can be reduced by education, vaccination and antibacterial prophylaxis.

Patients may have had their spleen removed surgically or have poor splenic function from a variety of conditions (e.g. sickle cell disease, amyloidosis, tumour infiltration, chronic GVHD, splenic irradiation, coeliac disease, inflammatory bowel disease).

The lack of splenic function may be obvious (e.g. post splenectomy or congenital asplenia) or may be assumed from Howell-Jolly bodies on a blood film (specific but not completely sensitive). The radiological finding of a small spleen does not always indicate poor function so a blood film should also be examined.

The risk of severe infection comes from encapsulated bacteria (pneumococcus, haemophilus, meningococcus) as well as more unusual infections such as malaria, babesia (tick borne infection mainly seen in north-eastern USA and southern Europe) and capnocytophaga (dog or cat bites).

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Patient Education

• Patients should be aware that they have an increased risk of severe infection.
• They should know about the need for vaccination and antibacterial prophylaxis.
• They should know what actions to take if they suspect infection. They may wish to wear a Medic Alert bracelet and should carry a card with written information about their condition, relevant clinical details and contact telephone details.
• They should be aware of the risks from animal bites, mosquito bites and from tick bites. Travel advice should include appropriate malaria chemoprophylaxis and strategies to reduce mosquito bites.

Vaccination (age 10 and above, assuming completed childhood vaccination programme)

[for younger patients see details in Green Book, referenced]

Vaccines should preferably be given at least 2 weeks before splenectomy (or at least two weeks post-splenectomy if not done previously). Patients on a short course of chemotherapy or immunosuppressants may get a better response if vaccines are given at least 3 months after completion.

Pre-splenectomy:

• Pneumococcal polysaccharide vaccine: Pneumovax-23 0.5ml i.m. or s.c.
• Conjugate meningococcus A, C, W125 and Y vaccine: Menveo 0.5ml i.m.
• Meningitis B vaccine: Bexsaro 0.5ml i.m.

Four weeks later:

• Meningitis B vaccine: Bexsaro 0.5ml i.m.

Long-term:

• Annual influenza vaccine
• Booster pneumococcal vaccine (PPV-23) 5 yearly
• Booster meningococcal vaccine if travelling to high-risk area (e.g. sub Saharan Africa or Saudi Arabia). Country specific recommendations at www.travax.nhs.uk

Antibacterial prophylaxis

Antibacterial prophylaxis should be offered to all patients. It should be actively encouraged in patients with high-risk features, however patients without these features may decide not to use regular antibiotics after appropriate counselling. Regardless, all patients should have a supply of antibiotics at home to take in an emergency.

High risk features:

• Age less than 16 years or age greater than 50 years
• Inadequate response to pneumococcal vaccination
• Previous invasive pneumococcal infection
• Underlying haematological malignancy or immunosuppression

Patients are also at a higher risk in the immediate post-operative period and for the first two years after splenectomy.

Antibacterial prophylaxis should be with penicillin V 250mg BD (or erythromycin 500mg BD if penicillin allergic).

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Splenectomy: leaflet and card - GOV.UK

Haematology Handbook - South Tees Hospitals NHS Foundation Trust
 

References:

Davies JM, Lewis MPN et al. Review of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen: Prepared on behalf of the British Committee for Standards in Haematology by a Working Party of the Haemato-Oncology Task Force. Br J Haematol 2011; 155: 308-317

Public Health England. Immunisation against infectious disease. Chapter 7: Immunisation of individuals with underlying medical conditions. Update January 2020.

• South Tees Hospitals