Surgical Infection Society Guidelines for Vaccination after Traumatic Injury

Vaccine coverage for recommended vaccines among splenectomised patients in Apulia, South Italy: a retrospective cohort study

OBJECTIVE

Splenectomised/asplenic patients have a 10-50 fold higher risk than the general population of developing overwhelming postsplenectomy infection. To control this risk, these patients have to receive a specific immunisation schedule, before or in the 2 weeks after the surgical intervention. The study aims to estimate vaccine coverage (VC) for recommended vaccines among splenectomised patients in Apulia (South Italy), and to define the determinants of vaccination uptake in this population.

DESIGN

Retrospective cohort study.

SETTING

Apulia, Southern Italy.

PARTICIPANTS

1576 splenectomised patients.

METHODS

The Apulian regional archive of hospital discharge forms (SDOs) was used to define the splenectomised Apulian inhabitants. The study period went from 2015 to 2020. The vaccination status for Streptococcus pneumoniae (13-valent conjugate anti-pneumococcal vaccine+PPSV23), Haemophilus influenzae type b (Hib; one dose), Neisseria meningitidis ACYW135 (two doses), Neisseria meningitidis B (two doses) and influenza (at least one dose of influenza vaccine before an influenza season after splenectomy) was assessed via data collected from the Regional Immunisation Database (GIAVA). In order to define a subject as fully immunised, we considered the Centers for Diseases Control and Prevention guidelines to define the optimal immunisation status.

RESULTS

Since 2015, 1576 Apulian inhabitants have undergone splenectomy; the VC for anti-Neisseria meningitidis B vaccine was 30.9%, for anti-Neisseria meningitidis ACYW135 was 27.7%, for anti-Streptococcus pneumoniae was 27.0%, for anti-Hib was 30.1%, and 49.2% received at least one dose of influenza vaccine before an influenza season after splenectomy. None of the patients splenectomised in 2015 and 2016 had received the recommended MenACYW₁₃₅ and PPSV23 booster doses 5 years after completing the basal cycles.

CONCLUSIONS

The results of our study highlight low VC values among Apulian splenectomised patients. The task of public health institutions is to implement new strategies aimed at increasing VC in this population, implementing educational measures for patients and families, training for general practitioners and specialists, and ad hoc communication campaigns.

Implantation of a neoantigen-targeted hydrogel vaccine prevents recurrence of pancreatic adenocarcinoma after incomplete resection

Tumor involvement of major vascular structures limits surgical options in pancreatic adenocarcinoma (PDAC), which in turn limits opportunities for cure. Despite advances in locoregional approaches, there is currently no role for incomplete resection. This study evaluated a gelatinized neoantigen-targeted vaccine applied to a grossly positive resection margin in preventing local recurrence. Incomplete surgical resection was performed in mice bearing syngeneic flank Panc02 tumors, leaving a 1 mm rim adherent to the muscle bed. A previously validated vaccine consisting of neoantigen peptides, a stimulator of interferon genes (STING) agonist and AddaVax^TM (termed PancVax) was embedded in a hyaluronic acid hydrogel and applied to the tumor bed. Tumor remnants, regional lymph nodes, and spleens were analyzed using histology, flow cytometry, gene expression profiling, and ELISPOT assays. The immune microenvironment at the tumor margin after surgery alone was characterized by a transient influx of myeloid-derived suppressor cells (MDSCs), prolonged neutrophil influx, and near complete loss of cytotoxic T cells. Application of PancVax gel was associated with enhanced T cell activation in the draining lymph node and expansion of neoantigen-specific T cells in the spleen. Mice implanted with PancVax gel demonstrated no evidence of residual tumor at two weeks postoperatively and healed incisions at two months postoperatively without local recurrence. In summary, application of PancVax gel at a grossly positive tumor margin led to systemic expansion of neoantigen-specific T cells and effectively prevented local recurrence. These findings support further work into locoregional adjuncts to immune modulation in PDAC.

Immunization coverage among asplenic patients and strategies to increase vaccination compliance: a systematic review and meta-analysis

BACKGROUND

Asplenic or splenectomized patients have a higher risk (ranging from 10 to 50-fold) than the general population of developing an overwhelming post-splenectomy infection (OPSI). Thus, they should receive specific vaccinations to prevent bacterial infections and influenza. The aim of this meta-analysis was to estimate vaccination coverage (VC) with the recommended vaccines among splenectomized patients; strategies recommended in those studies to improve VC worldwide are considered as well.

RESEARCH DESIGN AND METHODS

Scopus, MEDLINE/PubMed, Google Scholar and ISI Web of Knowledge databases were searched. Research papers, short reports, reviews, and meta-analyses published between January 1, 2010 and July 18, 2020 were included; no geographic restrictions were included. Twenty-four studies were included in the meta-analysis.

RESULTS

For anti-pneumococcal vaccination, coverage was 55.1% (95%CI = 41.0-69.2%), for anti-Hib 48.3% (95%CI = 34.3-52.3%), for anti-meningococcal C/ACYW135 33.7% (95%CI = 23.6-43.9%), for anti-meningococcal B 13.3% (95%CI = 7.0-19.5%) and for anti-influenza 53.2% (95%CI = 22.0-84.4%). Most studies determined a lack of adherence to international guidelines by healthcare workers and suggested the need to better educate health professionals in the management of post-splenectomy patients.

CONCLUSIONS

The meta-analysis showed the suboptimal immunization coverage for the vaccines recommended for asplenic patients. Greater efforts must be made by public health professionals to increase VC in this group of patients at risk. Introducing specific prophylaxis protocols in the clinical routine seems to guarantee better immunization compliance in those patients.

Complement After Trauma: Suturing Innate and Adaptive Immunity

The overpowering effect of trauma on the immune system is undisputed. Severe trauma is characterized by systemic cytokine generation, activation and dysregulation of systemic inflammatory response complementopathy and coagulopathy, has been immensely instrumental in understanding the underlying mechanisms of the innate immune system during systemic inflammation. The compartmentalized functions of the innate and adaptive immune systems are being gradually recognized as an overlapping, interactive and dynamic system of responsive elements. Nonetheless the current knowledge of the complement cascade and its interaction with adaptive immune response mediators and cells, including T- and B-cells, is limited. In this review, we discuss what is known about the bridging effects of the complement system on the adaptive immune system and which unexplored areas could be crucial in understanding how the complement and adaptive immune systems interact following trauma.

Wound management in disaster settings

BACKGROUND

Few guidelines exist for the initial management of wounds in disaster settings. As wounds sustained are often contaminated, there is a high risk of further complications from infection, both local and systemic. Healthcare workers with little to no surgical training often provide early wound care, and where resources and facilities are also often limited, and clear appropriate guidance is needed for early wound management.

METHODS

We undertook a systematic review focusing on the nature of wounds in disaster situations, and the outcomes of wound management in recent disasters. We then presented the findings to an international consensus panel with a view to formulating a guideline for the initial management of wounds by first responders and subsequent healthcare personnel as they deploy.

RESULTS

We included 62 studies in the review that described wound care challenges in a diverse range of disasters, and reported high rates of wound infection with multiple causative organisms. The panel defined a guideline in which the emphasis is on not closing wounds primarily but rather directing efforts toward cleaning, debridement, and dressing wounds in preparation for delayed primary closure, or further exploration and management by skilled surgeons.

CONCLUSION

Good wound care in disaster settings, as outlined in this article, can be achieved with relatively simple measures, and have important mortality and morbidity benefits.

Possible infectious causes of spontaneous splenic rupture: a case report

Introduction

Spontaneous atraumatic splenic rupture is a rare but dramatic occurrence that is most commonly attributed to infection or neoplasia. Deciphering the etiology can be challenging with many cases remaining unclear despite full investigation.

Case presentation

We report the case of a previously healthy and immunocompetent 52-year-old Caucasian woman with a remote history of clinically diagnosed infectious mononucleosis who experienced sudden atraumatic splenic rupture after an untreated stray cat bite.

Conclusions

The differential diagnosis for atraumatic splenic rupture, specifically its infectious causes, is reviewed. Key clinical and laboratory findings that differentiate Bartonella henselae infection and Epstein–Barr virus reinfection are reviewed.

A review of postoperative feeding regimens in infantile hypertrophic pyloric stenosis

Infantile hypertrophic pyloric stenosis is a condition well known to pediatric surgeons. Postoperative length of hospital stay is a financial concern and remains a potential target for reduction in hospital costs. Ultimately, these costs are directly affected by the ability to effectively advance postoperative enteral nutrition. This review will serve to: 1) identify clinically relevant postoperative feeding patterns following pyloromyotomy, 2) review the relevant literature to determine an optimal feeding pattern, and 3) identify possible preoperative predictors that may determine the success of postoperative feeding regiments.

Blunt splenic injury

PURPOSE OF REVIEW

To review the current care of the patient with an injured spleen.

RECENT FINDINGS

The initial care of the patient with splenic injury is dictated by their hemodynamic presentation and the institution's resources. Although most high-grade injuries require splenectomy, up to 38% are successfully managed nonoperatively. Angioembolization has increased splenic salvage with a minimum of complications. In the absence of injuries that mandate longer hospital stays, patients with low-grade injuries are successfully discharged in 1-2 days and high-grade injuries in 3-4 days. Delayed splenic hemorrhage remains a feared complication, but fortunately the 180-day readmission rate for splenectomy is low with the majority of those returning within 8 days of injury.

SUMMARY

Nonoperative management (NOM) is the standard of care for the hemodynamically stable patient with an isolated blunt splenic injury. Splenic salvage can be safely increased, even in higher grade injuries, with the use of angioembolization. Patients managed nonoperatively are successfully discharged as early as 1-2 days for low-grade injuries and as early as 3-4 days for higher grade. Safe management of the patient with blunt splenic injury requires careful selection for NOM, meticulous monitoring and follow-up.

Prevention of infections associated with combat-related thoracic and abdominal cavity injuries

Trauma-associated injuries of the thorax and abdomen account for the majority of combat trauma-associated deaths, and infectious complications are common in those who survive the initial injury. This review focuses on the initial surgical and medical management of torso injuries intended to diminish the occurrence of infection. The evidence for recommendations is drawn from published military and civilian data in case reports, clinical trials, meta-analyses, and previously published guidelines, in the interval since publication of the 2008 guidelines. The emphasis of these recommendations is on actions that can be taken in the forward-deployed setting within hours to days of injury. This evidence-based medicine review was produced to support the Guidelines for the Prevention of Infections Associated With Combat-Related Injuries: 2011 Update contained in this supplement of Journal of Trauma.

Primary epithelial splenic cyst with micro-rupture and raised carbohydrate antigen CA 19-9: a paradigm of management

Epithelial splenic cysts are rare entities which surgeons may not have previously encountered. Their management is based on historical studies. A 21-year-old woman presented with a cyst of the spleen that produced a high serum concentration of carbohydrate antigen CA 19-9. A partial splenectomy with removal of the entire cyst and preservation of the splenic parenchyma by laparotomy was performed and the patient made an uneventful recovery. A microscopic rupture of the wall of the cyst and blood degradation products in the fluid of the cyst were confirmed. A functional splenic parenchyma was documented 18 months after surgery. There was no infection during follow-up. Partial surgical splenectomy with resection of the entire cyst prevents recurrence and preserves splenic function.

Antibiotics and appendicitis in the pediatric population: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review

OBJECTIVE

The aim of the study was to review evidence-based data regarding the use of antibiotics for the treatment of appendicitis in children.

DATA SOURCE

Data were obtained from PubMed, MEDLINE, and citation review.

STUDY SELECTION

We conducted a literature search using "appendicitis" combined with "antibiotics" with children as the target patient population. Studies were selected based on relevance for the following questions: (1) What perioperative antibiotics should be used for pediatric patients with nonperforated appendicitis? (2) For patients with perforated appendicitis treated with appendectomy: a. What perioperative intravenous antibiotics should be used? b. How long should perioperative intravenous antibiotics be used? c. Should oral antibiotics be used? (3) For patients with perforated appendicitis treated with initial nonoperative management, what antibiotics should be used in the initial management?

RESULTS

Children with nonperforated appendicitis should receive preoperative, broad-spectrum antibiotics. In children with perforated appendicitis who had undergone appendectomy, intravenous antibiotic duration should be based on clinical criteria. Furthermore, broad-spectrum, single, or double agent therapy is as equally efficacious as but is more cost-effective than triple agent therapy. If intravenous antibiotics are administered for less than 5 days, oral antibiotics should be administered for a total antibiotic course of 7 days. For children with perforated appendicitis who did not initially undergo an appendectomy, the duration of broad-spectrum, intravenous antibiotics should be based on clinical symptoms.

CONCLUSIONS

Current evidence supports the use of guidelines as described above for antibiotic therapy in children with acute and perforated appendicitis.

Primary epithelial splenic cyst with micro-rupture and raised carbohydrate antigen CA 19-9: a paradigm of management

Epithelial splenic cysts are rare entities that surgeons might not have previously encountered and their management is based on historical studies. A 21-year-old female presented with a cyst of the spleen that produced a high serum concentration of carbohydrate antigen CA 19-9. A partial splenectomy with the removal of the entire cyst and preservation of splenic parenchyma by laparotomy was performed and the patient made an uneventful recovery. A microscopic rupture of the wall of the cyst and degradation of blood in the fluid of the cyst were confirmed. Eighteen months following surgery a functional splenic parenchyma was documented. There was no episode of infection during this follow-up time. Partial surgical splenectomy with resection of the entire cyst prevents recurrence and preserves splenic function.

Overview, prevention, and treatment of rabies

Each year, approximately 55,000 individuals worldwide die from an infection due to the rabies virus. Rabies is a life-threatening disease caused by an RNA virus that is usually transmitted to humans through bites from rabid animals. More recently, reports of transmission by means of organ transplantation have been reported. Since human rabies is nearly 100% fatal if prophylactic measures are not followed, an increased awareness of who should receive prophylaxis and when prophylaxis should be administered is necessary. Preexposure prophylaxis entails the administration of the rabies vaccine to individuals at high risk for exposure to rabies viruses (e.g., laboratory workers who handle infected specimens, diagnosticians, veterinarians, animal control workers, rabies researchers, cave explorers). Preexposure prophylaxis involves a three-dose series of the rabies vaccine that may confer some protection from the virus while simplifying postexposure prophylaxis regimens. Postexposure prophylaxis consists of a multimodal approach to decrease an individual's likelihood of developing clinical rabies after a possible exposure to the virus. Regimens depend on the vaccination status of the victim and involve a combination of wound cleansing, administration of the rabies vaccine, and administration of human rabies immune globulin. If used in a timely and accurate fashion, postexposure prophylaxis is nearly 100% effective. Once clinical manifestations of rabies have developed, however, treatment options for rabies are limited, and to date, only seven individuals have survived rabies virus infection. Treatment of clinical rabies consists of medical support in an intensive care unit, using a multifaceted approach that includes supportive care, heavy sedation, analgesics, anticonvulsants, and antivirals. The recently developed Milwaukee Protocol added induction of therapeutic coma to supportive care measures and antivirals; however, its use has shown inconsistent outcomes.