Postsplenectomy sepsis clinical features, management and prevention Report by Ri劉有文/VS韓吟宜 Introduction ● ● PSS(Postsplenectomy sepsis) Fulminant sepsis syndrome – ● usually due to S.pneumoniae Pateint with impaired spleen function or s/p splenectomy both have risk Role of spleen ● ● ● ● The largest lymphoid organ Filter senescent, rigid RBCs Ingesting circulating bacteria Production of antibodies Common causes of theraputic splenectomy ● ● ● ● ● Hemolytic anemia Thrombocytopenia Malignancy Hypersplenism Splenic trauma Common causes of impaired spleen function ● ● ● ● ● Hemoglobinopathy Hemolysis Congenital asplenia Collagen vascular diseases Allogenic bone marrow transplantation Incidence ● ● ● Children: 1/175 patient years Adults: 1/400~500 patient years Highest risk at first few years – – – ● 1/3 at first year 1/2 at first 2 years However, 1/3 after first 5 years Can happen even 20 years after splenectomy Common pathogens ● ● Encapsulated pathogen Streptococcus pneumoniae(50~60 %) – ● ● ● No particular serotype is more common Haemophilus influezae(20~30 %) Neisseria spp.(10~20 %) Other uncommon pathogens: – Capnocytophaga canimorsus ● – Common flora in oral cavity of dogs and cats Bordetella holmesii Clinical manifestations ● Fever – ● ● Bacteremia Coagulopathy – ● Cough, dyspnea, respiratory failure GI symptoms – ● Headache, neck stiffness, seizure Respiratory symptoms – ● Purpura, petechiae Meningitis – ● Any fever must be viewed as possible PSS Nausea, vomiting, diarrhea, GI bleeding Shock LAB ● ● ● ● ● ● CBC Blood smear DIC profile Lumbar puncture CXR Blood culture Management ● Braod-spectrum antibiotics – – Based on expert opinion Must cover: ● ● – General suggestion ● ● ● penicillin-resistant pneucoccus beta-lactamase producing H.influenzae Ceftriaxone + Vancomycin Levofloxacin + Vancomycin Life-support measures – – – – H/D or CVVH for ARF Ventilator Inotropic agents Fluid Prevention ● ● Avoid unnecessary splenectomy Immunization – Timing ● ● – Pneumococcal vaccine ● ● – – – – 14 days before splenectomy 14 days after splenectomy (not immediately) PPV-23 for adults PCPV-7 for children and some adults Haemophilus B vaccine Meningococcal vaccine Re-immunization Other vaccines: influenza vaccine Prevention ● Antibiotic prophylaxis – Daily penicillin ● ● ● ● – Abx for fever ● ● ● – Reduce incidence by half Reduce mortality by 80 percents Life-long or 3~5years? Post PSS patients On hand Empirical: Augmentin, Cefuroxine, fluoroquinolones When fever, Take the drug and go to doctor without delay Abx for dental procedures ● Not recommended for no obvious advantage Summary ● Be aware – ● Treatment in time – – ● Any fever may be possible PSS Empirical abx Supportive care Pervention – – Vaccine Daily and On hand abx