Time lapse and comorbidities influence patient knowledge and pursuit of medical care after traumatic splenectomy

Impact of a spleen registry on optimal post-splenectomy vaccination and care

Objective: To evaluate quality of patient knowledge and rates of adherence to guidelines amongst splenectomised patients registered to the Spleen Australia registry. Method: Registrants recruited for assessment of residual splenic function post-splenectomy also underwent an assessment of quality of knowledge and a review of their long-term management. Eligible patients were ≥ 18 years of age, registered to the Spleen Australia clinical registry and had been splenectomised at least 1 year prior to their visit. Quality of knowledge was assessed using a validated questionnaire used in similar studies. Receipt of immunisations was validated by record review. Chemoprophylaxis use was self-reported by patients. Adherence was evaluated using Australian guidelines. Results: 77 patients were evaluated for education and adherence. 58% were female, mean age was 58 years, and median duration since splenectomy was 14 years. Most common indications for splenectomy were trauma and haematological conditions. 77% had good knowledge of key educational points to reduce chances of infection. Adherence to immunisations varied with poor adherence to vaccines introduced after 2010. Only 6 patients were adherent to all recommended immunisations. Increasing duration since registration was associated with poorer 13vPCV (p = 0.008) and 4vMenCV adherence (p = 0.001). Over 70% either currently or had previously used daily chemoprophylaxis and 66% had a supply of emergency antibiotics. Conclusions: Although registrants are receiving initial and booster vaccinations, they do not receive newly recommended vaccines. In order to maintain long-term adherence, we recommend streamlining health information systems, improving awareness strategies and improving financial access to vaccinations in the community with additional awareness of the activities of the registry.

Immunization coverage against capsular bacteria in splenectomized patients

Splenectomy significantly increases the risk of severe invasive infections caused by capsular bacteria, such as sepsis and meningitis. Immunizations before and after splenectomy reduce the risk and are routinely recommended. Little is known about compliance with actual immunization guidelines in Poland. The aim of this study was to analyze the vaccination rate and the knowledge of splenectomized patients concerning immunizations in Poland. We applied a questionnaire to survey 85 adult patients (F/M 49/36) splenectomized in 2009-2010 and analyzed the patients' medical files and immunization certificates. Patients were also questioned over the phone. We found that the patients were most commonly immunized against Streptococcus pneumoniae (17/85, 20 %), less often against Haemophilus influenzae b (8/85, 9.4 %), and rarely against Niesseria meningitidis C (3/85, 3.5 %). In contrast, hepatitis B immunization coverage rate was as high as 67 % (57/85). The majority of respondents (59/85, 69.4 %) regarded information about the recommended immunizations as insufficient and rated their doctor's reasoning as inconsistent, a smaller number (20/85, 23.5 %) confirmed they received sound information before splenectomy. Both surgeons and primary care physicians did not offer immunizations to the majority of patients (59/85, 69.4 %); as a result, only 30.6 % of patients (26/85) were immunized against any capsular bacteria before splenectomy. In conclusion, the majority of splenectomized patients are not immunized despite current guidelines and do show an inadequate level of knowledge concerning the consequences of splenectomy. It is important that both surgeons and primary care doctors give patients clear instructions about immunizations and antibiotics recommended before and after their splenectomy.

Adherence to preventive measures after splenectomy in the hospital setting and in the community

Overwhelming post-splenectomy infection (OPSI) remains a long-term risk in asplenic patients, which may be reduced by appropriate preventive measures. Specific guidelines have been developed to lower its incidence.

AIMS

To assess the implementation of guidelines by specialized physicians of a university hospital and primary care physicians.

METHODS

A retrospective review of splenectomized patients' medical files over a six year period was carried out. Patients' general practitioners were contacted and a questionnaire was sent to them.

RESULTS

154 individuals who underwent splenectomy between 2000 and 2005 were eligible (62 children and 92 adults): 70.8% received pneumococcal vaccine, 44% received vaccine against Haemophilus influenzae type b with a good cover of children population (88.7%), 24% received meningococcal vaccine. Prophylactic antibiotics were prescribed in 74% of patients. Septic events were found in 8.4%, and global mortality was 11.7% during a mean follow-up period of 4.5 years.

CONCLUSIONS

Management of the infectious risk in asplenic patient has to be improved: some of the patients are not correctly identified as at risk of OPSI, and vaccination against Neisseria meningitidis is insufficient. Hospital specialists should improve the implementation of guidelines and give better information to general practitioners involved.

Information on the internet for asplenic patients: a systematic review

BACKGROUND

Asplenic patients in general have poor knowledge about their condition. Patients are increasingly turning to the Internet for their health care information, therefore this is a resource that many asplenic patients will use. The aim of our study was to determine the quality of information on the Internet for asplenic patients.

METHODS

We identified websites by entering "splenectomy OR spleen removal" into 3 Internet search engines on July 28, 2008. The top 50 English-language websites from each search engine were included in our analysis. We evaluated the websites with our own 21-point content scale as well as 4 commonly used quality-assessment tools. All websites were analyzed independently by 2 reviewers. Correlations were made between the quality assessment instruments, content, readability and target audience.

RESULTS

We included 89 websites in the study. The mean content score percentage for all websites was 49% (95% confidence interval 44%-54%). The long-term risk of infection was mentioned in 84% of websites, and the need for vaccination was mentioned in 79%. The mean quality assessment tool score was 61%, and the mean reading grade level was 11.

CONCLUSION

Whereas websites on average did not cover most of the information that asplenic patients should receive, the long-term risk of serious infection and the need for vaccination was consistently mentioned. Websites were inconsistent with respect to adhering to standards advocated by the quality assessment instruments we used, and the mean reading grade level was far above what is recommended for patient literature.

Pneumococcal and influenza immunization in asplenic persons: a retrospective population-based cohort study 1990-2002

Background

Splenectomy is associated with increased risk for bacteremia, due to impaired clearance of bloodborne agents and to altered phagocytosis and humoral immunity. We conducted a retrospective cohort study of patients at risk for splenectomy for a 13-year period to determine immunization coverage, and outcomes of those with and without splenectomy, and with or without receipt of influenza or pneumococcal vaccine.

Methods

Data were extracted from the provincial Medical Services Insurance database for insured services rendered by a physician for 1990-2002, and from the Vital Statistics Death database. The eligible cohort was selected based on diagnostic codes for hematologic conditions for which splenectomy might be considered, such as immune thrombocytopenia. Each patient was followed longitudinally from the date of first diagnosis until 31Dec2002, or death, or relocation out-of province. In addition, persons with splenectomy and no hematologic condition were identified and followed for 6 months post-surgery. Infectious illness rates per 100 person-years of observation and death rates were calculated with and without splenectomy. Death rates were determined using splenectomy status as a time-dependent covariate. The relationship between splenectomy and death according to immunization status was examined using Cox proportional hazard ratios.

Results

Of 38,812 persons in the cohort 427 subjects with a hematologic diagnosis had splenectomy and another 452 subjects without a hematologic diagnosis had this surgery. 72% were > 18 years of age. Pneumococcal immunization was recorded in 16.5% of asplenic patients overall, and was not associated with reduced risk of death in these persons (adjusted Hazard Ratio [HR] = 1.07, 95% CI 0.70 - 1.65). Influenza immunization was recorded in 53.1% of asplenic patients overall, and was associated with reduced risk of death (adjusted HR = 0.46, 0.33-0.62). No pneumococcal or influenza immunization was recorded in patients with a hematologic diagnosis without splenectomy. Infectious illness visits were higher among all patients who had a splenectomy than among those without a splenectomy (151 visits/100 person-years of observation in the post-splenectomy period vs. 120 visits/100 person-years; p < 0.0001).

Conclusions

In asplenic patients, influenza immunization is associated with a 54% reduced risk of death compared to unimmunized asplenic persons; no reduction in risk was demonstrated with (polysaccharide) pneumococcal vaccine. Vaccine coverage in the entire cohort was less than routinely recommended. Improved delivery of infection prevention programs to this population is warranted. Conjugate pneumococcal vaccines should be urgently studied in this immunocompromised population.