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Guri A, Ben-Ami T. Updated Recommendations on the Prevention and Treatment of Infections in Children With Asplenia/Hyposplenism. J Pediatr Hematol Oncol 2024; 46:225-232. [PMID: 38691084 DOI: 10.1097/mph.0000000000002855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 03/05/2024] [Indexed: 05/03/2024]
Abstract
Children with congenital or acquired asplenia or hyposplenism have an increased risk for severe and even life-threatening infections mainly due to encapsulated bacteria. Current practice focuses on preventing severe infections with timely administration of vaccinations, antibacterial prophylaxis when indicated, and urgent evaluation and treatment of febrile events. As new vaccines are now available for both children and adults with asplenia/hyposplenism, we present an up-to-date recommendation on the prevention and management of acute infections in children with asplenia/hyposplenism.
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Affiliation(s)
- Alex Guri
- Division of Pediatrics, Kaplan Medical Center, Hadassah-Hebrew University Medical School, Jerusalem
- Infectious Diseases Unit, Kaplan Medical Center, Rehovot, Israel
- Pediatric Hematology-Oncology Unit, Kaplan Medical Center, Rehovot, Israel
| | - Tal Ben-Ami
- Division of Pediatrics, Kaplan Medical Center, Hadassah-Hebrew University Medical School, Jerusalem
- Pediatric Hematology-Oncology Unit, Kaplan Medical Center, Rehovot, Israel
- The Hebrew University Hadassah Medical School, Jerusalem, Israel
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Bram R, Bram J, Beaman A, Lee A, Lu M, Yheulon C, Tabak B, Woo R. High Rates of Pediatric Venous Thromboembolism After Elective Laparoscopic Splenectomy Suggest Need for Perioperative Prophylaxis. J Surg Res 2023; 289:135-140. [PMID: 37119614 DOI: 10.1016/j.jss.2023.03.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/20/2023] [Accepted: 03/26/2023] [Indexed: 05/01/2023]
Abstract
INTRODUCTION In adult populations, postoperative venous thromboembolism (VTE) is a reported complication of up to 8% of elective laparoscopic splenectomy (LS) cases. VTE is a rare event in the pediatric population, affecting less than 1% of all pediatric surgical patients. We hypothesized that pediatric patients are at a higher risk of postoperative VTE after undergoing elective LS relative to other laparoscopic procedures and may warrant prophylactic treatment. MATERIALS AND METHODS We queried the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database from 2012 to 2020. Patients were identified using the Current Procedural Terminology code 38120 and only elective cases were analyzed. RESULTS The incidence of VTE in all pediatric patients undergoing surgery in the American College of Surgeons NSQIP-P database was 0.13%. The incidence of VTE in pediatric patients undergoing elective laparoscopic abdominopelvic procedures was 0.17%. There were seven total cases of VTE (0.41%) in pediatric patients undergoing elective LS, more than twice the rate of the general population (P = 0.001). Eighty percent of pediatric patients undergoing elective LS had an underlying hematological disorder. CONCLUSIONS By analyzing the NSQIP-P database, we evaluated the largest cohort of pediatric patients undergoing elective LS to date. We identified a higher incidence of VTE following this procedure relative to the rate of VTE in the overall population in the NSQIP-P database, as well as those undergoing elective laparoscopic abdominopelvic operations. The relatively higher incidence of VTE after elective LS is likely due to the presence of underlying hematological conditions. Given the low incidence of complications associated with pharmacologic VTE prophylaxis, the results of this study suggest that further research is warranted to establish the efficacy of perioperative pharmacological VTE prophylaxis in pediatric patients undergoing elective LS.
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Affiliation(s)
- Ryan Bram
- Tripler Army Medical Center, Honolulu Hawaii.
| | - Jason Bram
- The Fu Foundational School of Engineering, Columbia University, New York, New York
| | | | - Anson Lee
- John A. Burns School of Medicine, Honolulu, Hawaii
| | - Michelle Lu
- John A. Burns School of Medicine, Honolulu, Hawaii
| | - Christopher Yheulon
- Tripler Army Medical Center, Honolulu Hawaii; Emory University School of Medicine, Atlanta, Georgia
| | | | - Russell Woo
- Kapi'olani Medical Center for Women & Children, Honolulu, Hawaii
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Surgical and anaesthetic outcomes of paediatric splenectomies at a tertiary care institution in South India: a retrospective cohort. Pediatr Surg Int 2022; 38:1405-1412. [PMID: 35906350 DOI: 10.1007/s00383-022-05182-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2022] [Indexed: 10/16/2022]
Abstract
PURPOSE Splenectomies though well-established in the successful management of several resistant haemoglobinopathies, have not been studied in detail in the paediatric population to assess the outcomes. We conducted this review to primarily assess the surgical and anaesthetic outcomes of paediatric splenectomies and secondarily highlight factors predictive for a high-risk splenectomy. METHODS A 5 year retrospective chart review was made, and patient follow-up was done jointly using the hospital electronic medical records and telephonic calls. A p value of < 0.05 was considered significant. RESULTS Among the 69 splenectomised children, 61% were male and the overall mean age was 10.2 years. The cohort consisted of patients with thalassemia (46%), ITP (30%), haemolytic anemia (19%) and 1 child each with lymphoma, splenic cyst and Kassabach Meritt syndrome. Most (96%) were electively operated and 23% were performed laparoscopically. 61% received intravenous analgesia and the mean volume of fluid administered intra-operatively was 21 ml/kg. There was no documented OPSI, and there was one mortality. The mean follow-up period was 43 months and the overall survival rate was 98.5%. CONCLUSIONS Splenectomy was associated with a promising overall outcome. A greater pre-operative transfusion requirement, a larger sized spleen and increased fluid administration intra-operatively, were associated with a worse outcome.
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Peretz S, Livshits L, Pretorius E, Makhro A, Bogdanova A, Gassmann M, Koren A, Levin C. The protective effect of the spleen in sickle cell patients. A comparative study between patients with asplenia/hyposplenism and hypersplenism. Front Physiol 2022; 13:796837. [PMID: 36105295 PMCID: PMC9465245 DOI: 10.3389/fphys.2022.796837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 08/02/2022] [Indexed: 11/23/2022] Open
Abstract
Sickle cell disease (SCD) is caused by a point mutation in the beta-globin gene. SCD is characterized by chronic hemolytic anemia, vaso-occlusive events leading to tissue ischemia, and progressive organ failure. Chronic inflammatory state is part of the pathophysiology of SCD. Patients with SCD have extremely variable phenotypes, from mild disease to severe complications including early age death. The spleen is commonly injured in SCD. Early splenic dysfunction and progressive spleen atrophy are common. Splenomegaly and hypersplenism can also occur with the loss of the crucial splenic function. Acute, life-threatening spleen-related complications in SCD are well studied. The association of laboratory parameters with the spleen status including hyposplenism, asplenia, and splenomegaly/hypersplenism, and their implication in vaso-occlusive crisis and long-term complications in SCD remain to be determined. We evaluated the association between the spleen status with clinical and laboratory parameters in 31 SCD patients: Group a) Patients with asplenia/hyposplenism (N = 22) (including auto-splenectomy and splenectomized patients) vs. Group b) patients with splenomegaly and or hypersplenism (N = 9). Laboratory studies included: Complete Blood Count, reticulocyte count, iron metabolism parameters, C Reactive Protein (CRP), Hb variant distribution, and D-dimer. Metabolic and morphological red blood cell (RBC) studies included: density gradient (by Percoll), glucose consumption, lactate release, and K+ leakage, fetal RBC (F-Cells) and F-Reticulocytes, annexinV+, CD71+, oxidative stress measured by GSH presence in RBC and finally Howell Jolly Bodies count were all analyzed by Flow Cytometry. Scanning electron microscopy analysis of RBC was also performed. Patients with asplenia/hyposplenism showed significantly higher WBC, platelet, Hematocrit, hemoglobin S, CRP, D-dimer, Gamma Glutamyl Transferase (GGT), cholesterol, transferrin, annexin V+ RBCs, CD71+ RBCs, together with a markedly lower F Reticulocyte levels in comparison with splenomegaly/hypersplenism patients. In summary, important differences were also found between the groups in the studied RBCs parameters. Further studies are required to elucidate the effect of the spleen including hyper and hypo-splenia on laboratory parameters and in clinical manifestations, vascular pathology, and long-term complications of SCD. The benefits and risks of splenectomy compared to chronic transfusion need to be evaluated in clinical trials and the standard approach managing hypersplenism in SCD patients should be re-evaluated.
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Affiliation(s)
- Sari Peretz
- Pediatric Hematology Unit, Emek Medical Center, Afula, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Leonid Livshits
- Pediatric Hematology Unit, Emek Medical Center, Afula, Israel
- Red Blood Cell Research Group, Vetsuisse Faculty, Institute of Veterinary Physiology, University of Zurich, Zürich, Switzerland
| | - Etheresia Pretorius
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch, South Africa
| | - Asya Makhro
- Red Blood Cell Research Group, Vetsuisse Faculty, Institute of Veterinary Physiology, University of Zurich, Zürich, Switzerland
| | - Anna Bogdanova
- Red Blood Cell Research Group, Vetsuisse Faculty, Institute of Veterinary Physiology, University of Zurich, Zürich, Switzerland
- The Zurich Center for Integrative Human Physiology (ZIHP), Zürich, Switzerland
| | - Max Gassmann
- Red Blood Cell Research Group, Vetsuisse Faculty, Institute of Veterinary Physiology, University of Zurich, Zürich, Switzerland
| | - Ariel Koren
- Pediatric Hematology Unit, Emek Medical Center, Afula, Israel
| | - Carina Levin
- Pediatric Hematology Unit, Emek Medical Center, Afula, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
- *Correspondence: Carina Levin, ,
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Liu Y, Jin S, Xu R, Ding C, Pang W, Li Y, Chen Y. Hereditary spherocytosis before and after splenectomy and risk of hospitalization for infection. Pediatr Res 2022; 93:1336-1341. [PMID: 35915237 DOI: 10.1038/s41390-022-02229-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/12/2022] [Accepted: 07/15/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND The infectious burden in hereditary spherocytosis (HS) children before splenectomy has rarely been reported and the risk of severe postsplenectomy infection is controversial. METHODS We conducted a retrospective study of pediatric patients with HS to evaluate the risk of infection presplenectomy and postsplenectomy. The primary outcome was any bacterial, Mycoplasma, or fungal infection that required hospitalization. The secondary outcomes were sepsis and septic shock. Appendectomized children were matched on age at surgery and enrolled as controls. RESULTS In all, 232 patients were included. Before splenectomy, the primary outcome was identified in 51 (22.0%) patients, and the secondary outcome was identified in 1 (0.4%) patient. After splenectomy, the primary and secondary outcomes were detected in 8 (4.1%) and 1 (0.5%) patients, respectively. The risk of infection was higher presplenectomy than postsplenectomy (OR, 6.6; 95% CI, 3.0-14.2). HS patients had a higher risk of infection than the controls before surgery (OR, 3.7; 95% CI, 2.3-5.9) but not after surgery (OR, 1.4; 95% CI, 0.6-3.6). CONCLUSIONS HS patients who require splenectomy later in life had a high incidence of hospitalization for infections. In contrast, postsplenectomy risk of hospitalization involving infection or severe infection was low. IMPACT Patients with hereditary spherocytosis who require splenectomy later in life have a high risk of hospital admission for infections, especially those with severe hereditary spherocytosis. With vaccines or postoperative antibiotics, splenectomy does not increase the risk of infection or severe infections. Splenectomy may reduce the risk of hospitalization for infections by alleviating the complications of hereditary spherocytosis. With vaccines, prophylaxis, or advanced antibiotics, the benefits of splenectomy in children with hereditary spherocytosis and a heavy disease burden may outweigh the risks.
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Affiliation(s)
- Yakun Liu
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Shaobin Jin
- Department of Pediatric Surgery, Qilu Hospital of Shandong University, No. 107 West Wenhua Street, Jinan, Shandong, 250000, China
| | - Ruone Xu
- Shanghai Medical College, Fudan University, No. 138 Yixueyuan Street, Shanghai, 200032, China
| | - Cailin Ding
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Wenbo Pang
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Yang Li
- Department of Pediatric Surgery, Qilu Hospital of Shandong University, No. 107 West Wenhua Street, Jinan, Shandong, 250000, China.
| | - Yajun Chen
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.
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Vercellati C, Zaninoni A, Marcello AP, Fermo E, Fattizzo B, Giannotta JA, Bianchi P, Zanella A, Barcellini W. Changing trends of splenectomy in hereditary spherocytosis: The experience of a reference Centre in the last 40 years. Br J Haematol 2022; 198:912-915. [DOI: 10.1111/bjh.18106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/11/2022] [Accepted: 02/11/2022] [Indexed: 01/19/2023]
Affiliation(s)
- Cristina Vercellati
- Hematology Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Anna Zaninoni
- Hematology Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Anna P. Marcello
- Hematology Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Elisa Fermo
- Hematology Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Bruno Fattizzo
- Hematology Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Juri A. Giannotta
- Hematology Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Paola Bianchi
- Hematology Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Alberto Zanella
- Hematology Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Wilma Barcellini
- Hematology Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
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Kalff H, Cario H, Holzhauer S. Iron deficiency anemia and thrombosis risk in children-revisiting an old hypothesis. Front Pediatr 2022; 10:926925. [PMID: 35979407 PMCID: PMC9376258 DOI: 10.3389/fped.2022.926925] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 07/11/2022] [Indexed: 11/13/2022] Open
Abstract
Iron deficiency anemia has a high prevalence in children and has repeatedly been implicated as a risk factor for arterial and venous thrombosis. As an effective therapy for iron deficiency anemia is available, understanding the association between this form of anemia and the potentially severe thrombosis phenotype is of major clinical interest. Recent findings shed light on pathophysiology of hypercoagulability resulting from iron-restricted erythropoiesis. Specifically, an animal model of induced iron deficiency allowed identifying multiple mechanisms, by which iron deficiency anemia results in increased thrombus formation and thrombus progression both in arterial and venous thrombosis. These findings complement and support conclusions derived from clinical data. The purpose of this mini review is to summarize current evidence on the association of iron deficiency anemia and thrombosis. We want to increase the awareness of iron deficiency as a risk factor for thrombosis in the pediatric population. We discuss how novel pathophysiological concepts can be translated into the clinical settings and suggest clinical studies on prevention and treatment strategies in high-risk patient groups.
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Affiliation(s)
- Hannah Kalff
- Department of Pediatric Hematology and Oncology, Charité University Medicine, Berlin, Germany
| | - Holger Cario
- Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | - Susanne Holzhauer
- Department of Pediatric Hematology and Oncology, Charité University Medicine, Berlin, Germany
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Arunagiri N, Kelly SM, Dunlea C, Dixon O, Cantwell J, Bhudia P, Boterberg T, Janssens GO, Gains JE, Chang YC, Gaze MN. The spleen as an organ at risk in paediatric radiotherapy: A SIOP-Europe Radiation Oncology Working Group report. Eur J Cancer 2021; 143:1-10. [PMID: 33271483 DOI: 10.1016/j.ejca.2020.10.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 09/29/2020] [Accepted: 10/20/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Radiation may cause long-term splenic dysfunction, risking potentially fatal late sepsis. We aimed to review this complication's magnitude in paediatric radiotherapy and gauge the level of awareness of the spleen as an organ at risk. METHODS Clinical trial protocols and radiotherapy guidelines, patient/parent information sheets, and professional guidance documents were reviewed to assess the perceived risk of radiotherapy-related splenic dysfunction. Paediatric oncologists and paediatric radiation oncologists across Europe were surveyed to estimate the level of understanding of this risk and to ascertain current practice. Spleen doses received in practice were examined. A systematic review of relevant publications was undertaken. RESULTS The risk is not mentioned in most clinical trials, patient information leaflets, or professional guidance documents. When mentioned, a threshold dose of 40 Gy is cited. The survey showed only limited awareness. More than half of patients assessed received spleen doses in excess of 10 Gy. The systematic review identified one paper reporting a relative mortality risk of 5.5 with spleen doses in the 10-20 Gy range. CONCLUSIONS The risk of mortality from overwhelming infection is poorly recognised. We therefore recommend routine delineation of the spleen. Protocols and guidelines should give a spleen dose objective as low as reasonably achievable, ideally mean <10 Gy without compromise to target volumes. Revised evidence-based guidelines and continuing professional development activities should inform oncologists. Patient/parent information should mention the risk and the dose received be communicated to colleagues. Antibiotic prophylaxis and/or (re)vaccination should be considered if the mean spleen dose is ≥10 Gy.
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Affiliation(s)
- Niruthiga Arunagiri
- Department of Oncology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, United Kingdom.
| | - Sarah M Kelly
- SIOP Europe, Clos Chapelle-aux-Champs 30, 1200 Brussels, Belgium; EORTC Headquarters, Avenue Emmanuel Mounier 83, 1200 Brussels, Belgium.
| | - Cathy Dunlea
- Department of Oncology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, United Kingdom.
| | - Olivia Dixon
- Department of Oncology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, United Kingdom.
| | - Jessica Cantwell
- Department of Oncology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, United Kingdom.
| | - Pravesh Bhudia
- Department of Oncology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, United Kingdom.
| | - Tom Boterberg
- Department of Radiation Oncology, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium.
| | - Geert O Janssens
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; Princess Máxima Centre for Paediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands.
| | - Jennifer E Gains
- Department of Oncology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, United Kingdom.
| | - Yen-Ch'ing Chang
- Department of Oncology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, United Kingdom.
| | - Mark N Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, United Kingdom.
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Lee GM. Preventing infections in children and adults with asplenia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:328-335. [PMID: 33275684 PMCID: PMC7727556 DOI: 10.1182/hematology.2020000117] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
An estimated 1 million people in the United States have functional or anatomic asplenia or hyposplenia. Infectious complications due to encapsulated organisms such as Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae can lead to fulminant sepsis and death, particularly in young children, in the period shortly after splenectomy, and in immunocompromised patients. Patients with asplenia are also at risk for less common infections due to Capnocytophaga, Babesia, and malaria. Antibiotic prophylaxis, vaccines, and patient and family education are the mainstays of prevention in these at-risk patients. Recommendations for antibiotic prophylaxis typically target high-risk periods, such as 1 to 3 years after splenectomy, children ≤5 years of age, or patients with concomitant immunocompromise. However, the risk for sepsis is lifelong, with infections occurring as late as 40 years after splenectomy. Currently available vaccines recommended for patients with asplenia include pneumococcal vaccines (13-valent pneumococcal conjugate vaccine followed by the 23-valent pneumococcal polysaccharide vaccine), meningococcal vaccines (meningococcal conjugate vaccines for serogroups A, C, Y and W-135 and serogroup B meningococcal vaccines), H. influenzae type b vaccines, and inactivated influenza vaccines. Ongoing booster doses are also recommended for pneumococcal and meningococcal vaccines to maintain protection. Despite the availability of prevention tools, adherence is often a challenge. Dedicated teams or clinics focused on patient education and monitoring have demonstrated substantial improvements in vaccine coverage rates for individuals with asplenia and reduced risk of infection. Future efforts to monitor the quality of care in patients with asplenia may be important to bridge the know-do gap in this high-risk population.
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Affiliation(s)
- Grace M Lee
- Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
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