Postsplenectomy care. Strategies to decrease the risk of infection

Labyrinthitis Ossificans in a Post-Splenectomy Patient With Meningitis: A Case Report and Review of Literature

This report describes a case of cochlear implantation to treat profound deafness three months after a diagnosis of bacterial meningitis in a patient with a remote history of splenectomy. A 71-year-old woman with a remote history of a splenectomy over 20 years before presented with bilateral profound deafness that occurred as sequela from pneumococcal meningitis three months prior. The patient had been vaccinated against the 23-valent polysaccharide pneumococcal vaccine (PPV-23). The audiometric evaluation revealed no response in either ear. Imaging was suggestive of complete ossification of the right cochlea with partial ossification of the basal turn of the left cochlea. She underwent successful left-sided cochlear implantation. Standard post-implantation speech outcomes include consonant-nucleus-consonant (CNC) word and phoneme scores and Az-Bio in quiet and noise. The patient noted subjective improvement in her hearing. Performance measures markedly improved when compared to her pre-operative evaluation, which showed no aided sound detection. This case report highlights the possibility of meningitis many years after splenectomy that can result in profound deafness with labyrinthitis ossificans and the potential for hearing rehabilitation for cochlear implantation.

Bacterial Etiology of Fever Episodes of Splenectomized Patients in Three Medical Centers in the City of Mashhad in Northeastern Iran

Background: Many medical and surgical conditions may need to be treated with splenectomy. As this lymphoid tissue plays an important role in controlling various infections, and many life-threatening infections can occur in the absence of the spleen, any episode of fever should be taken seriously. Objectives: This study aims to assess the bacterial etiology of fever episodes in splenectomized patients in three medical centers in Mashhad, a city in northeastern Iran. Methods: Between 2006 and 2017, splenectomized patients in Imam Reza, Ghaem, and Dr. Sheikh hospitals were included in a cross-sectional study. Data collected included, age at splenectomy, hospitalization duration, indications for admission to the intensive care unit, vital signs at admission, bacterial species responsible for sepsis, times of hospitalization due to fever episodes, clinical signs and symptoms, antibiotic prophylaxis, and outcomes at six and one years. The data were analyzed using SPSS Statistics 20. Results: A total of 280 splenectomized patients were reviewed, and 23 of them had episodes of fever. The most common causes of splenectomy were spleen masses and idiopathic thrombocytopenic purpura (ITP), each accounting for 17.4% of cases. The mean age of the patients was 24.2 ± 1.6 years. 47.8% of the patients were male, and 52.2% were female. The median admission duration was seven days. A majority of admissions were due to intra-abdominal infections (26.7%), pneumonia (13.3%), and bacteremia (10.0%). There were 30 episodes of fever recorded, of which 2 (6.7%) resulted in death. Blood culture was positive in four cases (13.3%) for Streptococcus pneumoniae, Staphylococcus aureus, Citrobacter, and Brucella. A suitable antibiotic coverage was obtained in 13.3% of cases (i.e., ceftriaxone + vancomycin or fluoroquinolone + vancomycin), and a minimum suitable empiric coverage was obtained in 10.0% of cases, and no appropriate antibiotic coverage was obtained in 76.7% of cases. Conclusions: The present study highlights widespread inappropriate empiric therapy of fever episodes in splenectomized patients, as well as a lack of due attention to timely sample collection before antibiotic administration. Despite this, the isolated organisms were varied and included S. pneumoniae, S. aureus, coagulase negative staphylococci, P. aeruginosa, Brucella, and Citrobacter.

Overwhelming post splenectomy infection syndrome - review study

The spleen has an abundance of lymphoid tissue, including splenic macrophages that attack encapsulated organisms. Overwhelming post-splenectomy infection (OPSI) is a serious disease that can progress from a mild flu-like illness to fulminant sepsis in a short time period. However, recognition and clinical management of OPSI is not well established. Patients who are asplenic or hyposplenic are at an increased risk for infection and death from encapsulated organisms and other dangerous pathogens. Although relatively rare, it has a high mortality rate with delayed or inadequate treatment, and therefore it is important for Emergency Physicians to be familiar with it. Durations between Splenectomy and onset of OPSI ranged from less than 1 wk to more than 20 years. Although the mortality rate from OPSI has been reduced by appropriate vaccination and education. The precise pathogenesis and a suitable therapeutic strategy remain to be elucidated. Overwhelming postsplenectomy infection (OPSI) is a serious fulminant process that carries a high mortality rate.

User-held personalised information for routine care of people with severe mental illness

BACKGROUND

It is important to seek cost-effective methods of improving the care and outcome of those with serious mental illnesses. User-held records, where the person with the illness holds all or some personal information relating to the course and care of their illness, are now the norm in some clinical settings. Their value for those with severe mental illnesses is unknown.

OBJECTIVES

To evaluate the effects of personalised, accessible, user-held clinical information for people with a severe mental illness (defined as psychotic illnesses).

SEARCH METHODS

We updated previous searches by searching the Cochrane Schizophrenia Group Trials Register in August 2011. This register is compiled by systematic searches of major databases, and handsearches of journals and conference proceedings.

SELECTION CRITERIA

We included all relevant randomised controlled trials (RCTs) that:i. have recruited adult participants with a diagnosis of a severe mental illness (specifically psychotic illnesses and severe mood disorders such as bipolar and depression with psychotic features); andii. compared any personalised and accessible clinical information held by the user beyond standard care to standard information routinely held such as appointment cards and generic information on diagnosis, treatment or services available.

DATA COLLECTION AND ANALYSIS

Study selection and data extraction were undertaken independently by two authors and confirmed and checked by a third. We contacted authors of trials for additional and missing data. Where possible, we calculated risk ratios (RR) and 95% confidence intervals (CI). We used a random-effects model. We assessed risk of bias for included studies and created a 'Summary of findings' table using GRADE.

MAIN RESULTS

Four RCTs (n = 607) of user-held records versus treatment as usual met the inclusion criteria. When the effect of user-held records on psychiatric hospital admissions was compared with treatment as usual in four studies, the pooled treatment effect showed no significant impact of the intervention and was of very low magnitude (n = 597, 4 RCTs, RR 0.99 CI 0.71 to 1.38, moderate quality evidence). Similarly, there was no significant effect of the intervention in three studies which investigated compulsory psychiatric hospital admissions (n = 507, 4 RCTs, RR 0.64 CI 0.37 to 1.10, moderate quality evidence). Other outcomes including satisfaction and mental state were investigated but pooled estimates were not obtainable due to skewed or poorly reported data, or only being investigated by one study. Two outcomes (violence and death) were not investigated by the included studies. Two important randomised studies are ongoing.

AUTHORS' CONCLUSIONS

The evidence gap remains regarding user-held, personalised, accessible clinical information for people with psychotic illnesses for many of the outcomes of interest. However, based on moderate quality evidence, this review suggests that there is no effect of the intervention on hospital or outpatient appointment use for individuals with psychotic disorders. The number of studies is low, however, and further evidence is required to ascertain whether these results are mediated by the type of intervention, such as involvement of a clinical team or the type of information included.

Termografia infravermelha em tempo real como método de avaliação da viabilidade do baço em modelo de esplenectomia parcial em porcos

OBJETIVO: Determinar se a termografia infravermelha é capaz de detectar com precisão a perda de perfusão tecidual em áreas de parênquima esplênico. MÉTODOS: Cinco porcos Landrace pesando entre 12 a 15 kg, após medicação pré-anestésica intramuscular e anestesia por infusão endovenosa, foram submetidos a quatro etapas de ligaduras sequenciais, dos vasos arteriais para o pólo inferior do baço: 1-vasos do ligamento esplênico; 2-ramo da artéria esplênica para o pólo inferior; 3-ramo arterial para o pólo inferior na face visceral do órgão; 4-parênquima esplênico dividindo o órgão. As imagens foram captadas por câmera Therma CAM SC500 instalada a 50 centímetros da superfície do órgão. As temperaturas foram medidas na região proximal (vascularizada) e na região distal (isquêmica), em três áreas circulares distintas de cada região através do software SAT Report, antes e após cada etapa de ligaduras, constituindo cinco grupos de medidas: tempo 0 = antes da etapa 1; tempo 1 = após etapa 1; tempo 2 = após etapa 2; tempo 3 = após etapa 3; tempo 4 = após etapa 4. RESULTADOS: Houve manutenção da temperatura da região proximal (vascularização preservada) durante todos os tempos de desvascularização. A temperatura da região distal (desvascularizada) iniciou queda a partir da primeira ligadura e tornou-se estatisticamente menor que a da região proximal a partir da ligadura 3 (Etapa 3). Houve diferença estatisticamente significativa entre as temperaturas proximais e distais do órgão na medida em que foram sendo realizadas as ligaduras vasculares. CONCLUSÃO: A termografia infravermelha foi capaz de distinguir com precisão áreas de parênquima esplênico com vascularização preservada de áreas isquêmicas e pode contribuir para a avaliação da viabilidade de órgãos sólidos.

Immune response to the 7-valent pneumococcal conjugate vaccine in 30 asplenic children

The aim of the study was to determine the concentration of pneumococcal antibodies after a dose of 7-valent pneumococcal conjugate vaccine (PCV7) in 30 asplenic children between 4 months and 19 years of age. Fifteen children had received pneumococcal polysaccharide vaccine (PPV) approximately 5 years prior to vaccination with PCV7. The antibody concentrations against serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F were measured by ELISA before and after the PCV7 vaccination. Before vaccination with PCV7, the antibody concentrations were similar in children who had or had not received PPV previously. A dose of PCV7 stimulated a good immune response in asplenic patients. Prior immunization with PPV did not affect the antibody concentration after the vaccination with PCV7. In conclusion, asplenic children vaccinated with PPV may need revaccination with PPV earlier than the recommended 3-5 years after the first dose. PCV7 induces a satisfactory immune response in asplenic patients and should be considered as an alternative vaccine in that patient group.

Overwhelming postsplenectomy infection syndrome in adults - A clinically preventable disease

Overwhelming postsplenectomy infection (OPSI) syndrome is a rare condition, but is associated with high mortality. However, recognition and clinical management of OPSI is not well established. The prevalence of splenectomy increased recently because it was a clinically effective treatment for hepatitis C virus-associated thrombocytopenia before the introduction of the interferon/ribavirin combination therapy. We reviewed the literature characterizing the clinicopathological features of OPSI and assessed the most effective and feasible administration of the condition. A Medline search was performed using the keywords 'overwhelming', 'postsplenectomy infection', 'postsplenectomy sepsis', 'chronic liver disease', and/or 'splenectomy'. Additional articles were obtained from references within the papers identified by the Medline search. Durations between splenectomy and onset of OPSI ranged from less than 1 wk to more than 20 years. Autopsy showed that many patients with OPSI also had Waterhouse-Friderichsen syndrome. Although the mortality rate from OPSI has been reduced by appropriate vaccination and education, the precise pathogenesis and a suitable therapeutic strategy remain to be elucidated. Protein energy malnutrition (PEM) is commonly observed in cirrhotic patients. Since the immune response in patients with PEM is compromised, a more careful management for OPSI should therefore be applied for cirrhotic patients after splenectomy. In addition, strict long-term follow up of OPSI patients including informed consent will lead to a better prognosis.

Invasive Cryptococcus neoformans infection in an asplenic patient

Individuals who are asplenic or have impaired splenic function are at increased risk of developing life-threatening infections, especially due to encapsulated bacteria. This risk is higher in children, but adults can also develop fulminant infection or "post splenectomy sepsis" (PSS). Cryptococcus neoformans is an encapsulated yeast usually causing infection in immunocompromised patients. In a recent review of cryptococcal infection in HIV-negative patients, splenectomy was reported to be a risk factor for infection in 3% of cases. Detailed case reports are lacking. Here we report a case of disseminated C. neoformans infection in a patient who had a splenectomy performed for warm autoantibody haemolytic anaemia some months before he presented with signs and symptoms of meningitis. This report aims to raise awareness of the possibility of C. neoformans infection in asplenic patients.

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

BACKGROUND

There is insufficient knowledge of infectious risk in patients after splenectomy; minimal data exists specifically for trauma patients. This study evaluated patient knowledge and practices regarding infection risk after traumatic splenectomy. Our hypothesis was that patients with poor knowledge regarding their asplenic state would be less likely to pursue medical care in the event of an illness than those with good knowledge.

METHODS

Non-randomized, cohort study of all posttraumatic splenectomy patients < or =11 years after injury in 2 rural trauma centers. Patients received a validated questionnaire; weighted responses determined knowledge about infection risks and appropriate follow-up actions.

RESULTS

Fifty-four percent of patients responded to the questionnaire. Overall, 47% of responders were identified as having adequate knowledge regarding infectious risk, and only 28% would pursue appropriate medical care. Of patients with adequate knowledge, 42% were more likely to pursue appropriate care versus 15% of patients with inadequate knowledge (p = 0.06). Patients with adequate knowledge were more likely to receive an annual influenza vaccine (p = 0.03) and contact their provider with fewer symptoms (p = 0.03). Logistic regression revealed significant interactions between knowledge and presence of comorbidities (p = 0.04). Focusing on patients with poor knowledge and absence of comorbidities, none would engage in appropriate action in the event of illness (p < 0.01). A longer time since injury, >3 years, was associated with a diminished likelihood of appropriate action (p = 0.03). The relationship between knowledge and action was not accounted for by other potential confounders.

CONCLUSIONS

Trauma patients retain minimal knowledge about infection risk after splenectomy and are not likely to pursue appropriate medical care. Time since injury negatively influences patient actions. Healthcare providers must be more proactive to develop new strategies in educating these patients, particularly those without comorbidities and those greater than 3 years postsplenectomy.

Impact of splenectomy on the early outcome after oesophagectomy for squamous cell carcinoma of the oesophagus

AIM

Operative procedures for oesophageal malignancies are becoming more extensive and may result in fatal complications. Splenectomy compromises the immune system and can lead to increased susceptibility to infections. The aim of the present study was to report the early outcome of patients who underwent oesophagectomy and simultaneous splenectomy due to oesophageal squamous cell carcinoma (SCC).

METHODS

Pre-operative risks and post-operative morbidity and mortality in 135 patients who had undergone extensive oesophagectomy without simultaneous splenectomy for SCC of the thoracic oesophagus were compared with those of 14 patients who had undergone oesophagectomy associated with splenectomy.

RESULTS

Post-operative pneumonia, intra-abdominal abscess, post-operative sepsis and anastonotic leakage were significantly increased when splenectomy was added to the original operation. The incidence of in-hospital death was significantly higher among splenectomized than non-splenectomized patients (35.7% vs 8.1%, P<0.01). Pulmonary complications and leakage were the main causes of death. Multivariate analysis recognized splenectomy as an independent prognostic factor for in-hospital death following transthoracic oesophagectomy for SCC.

CONCLUSION

The addition of splenectomy to transthoracic oesophagectomy for oesophageal carcinoma can be a fatal combination. Preservation of the spleen should be the primary intention. In circumstances that necessitate splenectomy precautions should be taken to prevent post-operative infectious complications.

Infectious complications in asplenic hosts

Hyposplenism, secondary to splenectomy or disease state, predisposes the host to overwhelming infection with certain bacteria, such as S. pneumoniae. Recognition of the hyposplenic state and preventive measures, including patient education and vaccination, appear to reduce the rate of this highly fatal infection. In addition to considering chemoprophylaxis, a clinician should promptly evaluate or empirically treat all febrile episodes in hyposplenic patients.

Patient held clinical information for people with psychotic illnesses

BACKGROUND

It is important to seek cost-effective methods of improving the care and outcome of those with serious mental illnesses. Patient-held records, where the person with the illness holds all or some personal information relating to the course and care of their illness, are now the norm in some clinical settings. Their value for those with serious mental illnesses is unknown.

OBJECTIVES

To evaluate the effects of personalised and accessible patient-held clinical information for people with a diagnosis of psychotic illness.

SEARCH STRATEGY

Electronic searches of AMED (1980-1998), Biological Abstracts (1985-1998), British Nursing Index (1994-1998), CAB (1973-1999), CINAHL (1982-1999), The Cochrane Controlled Trials Register (Issue 1, 1999), EMBASE (1980-1999), HEALTHSTAR (1990-1999), HMIC (King's Fund Database 1979-1998 & HELMIS 1984-1998), MEDLINE (1966-1999), PsycLIT (1887-1999), Royal College of Nursing Database (1985-1996), SIGLE (1990-1998), Sociological Abstracts (1963-1998) and the Internet (http://www. controlled-trials.com/) were undertaken. This was supplemented by personal contact with the Executive Board of the European Network for Mental Health Service Evaluation.

SELECTION CRITERIA

The inclusion criteria were that studies should: i. be randomised or quasi-randomised trials; ii. have involved adults with a diagnosis of a psychotic illness; and iii. compare any personalised and accessible clinical information held by the patient beyond standard care to standard information routinely held such as appointment cards and generic information on diagnosis, treatment or services available.

DATA COLLECTION AND ANALYSIS

Study selection and data extraction was reliability undertaken. Analysis was not possible.

MAIN RESULTS

Not one study met the inclusion criteria for the review. One study (Stafford 1997) was found on the use of client held records for people with long term mental illness but the participants had not been randomised. Two important randomised studies (Lester 1999, Papageorgiou 1999) are ongoing.

REVIEWER'S CONCLUSIONS

There is a gap in the evidence regarding patient-held, personalised, accessible clinical information for people with psychotic illnesses. It cannot be assumed that patient-held information is beneficial or cost-effective without evidence from well planned, conducted and reported randomised trials.

Prevention and management of overwhelming postsplenectomy infection--an update

OBJECTIVES

To review the diagnosis and management of overwhelming postsplenectomy infection and to discuss various preventative measures.

DATA SOURCES

Data used to prepare this article were drawn from published articles and work in progress.

STUDY SELECTION

Articles were selected for relevance to the subject after location by a MEDLINE key word search.

DATA EXTRACTION

The literature was reviewed to summarize the etiology and pathophysiology of postsplenectomy sepsis. Preventative strategies were outlined with a particular emphasis on education, immunoprophylaxis, and chemoprophylaxis.

DATA SYNTHESIS

Although physicians have become increasingly aware of overwhelming postsplenectomy infection in children, many remain unaware of the risk to asplenic or hyposplenic adults who may have no underlying medical problems. Recent studies have shown that many patients who have had splenectomies have had neither appropriate vaccinations nor teaching that would explain the lifelong nature of their risk. The increasing incidence of penicillin-resistant pneumococci represents a major area of therapeutic and prophylactic concern. The identification of Howell-Jolly bodies on a peripheral blood smear should alert physicians to the need for follow-up to document possible hyposplenism. Attention has focused on a three-pronged attack to this problem, including education, immunoprophylaxis, and chemoprophylaxis.

CONCLUSIONS

Overwhelming postsplenectomy infection should be largely preventable if appropriate precautions are taken. Physicians need to know of the spectrum of diseases associated with hyposplenism and how patients noted to have Howell-Jolly bodies should be investigated. They should also be aware of appropriate guidelines for management of patients with asplenia or hyposplenism.