1. Pneumococcal. Streptococcus pneumoniae is a bacterial pathogen that affects children and adults world-wide. The organism colonises the upper respiratory tract, but severe infection can result from dissemination of the bacteria into the bloodstream and the central nervous system. Asplenic individuals are at the highest risk from pneumococcal infection due to reduced clearance of encapsulated bacteria from the bloodstream. Children in this group are at particular risk of fulminant pnemococcal sepsis and subsequent high mortality. Where possible, the vaccine should be given, together with advice about the increased risk of pneumococcal infection, four to six weeks (but at least two weeks) before splenectomy or the initiation of chemotherapy or other immunosuppressive treatment. In the case of splenectomy following trauma there is evidence that better functional antibody responses seems to occur if vaccination is delayed for 14 days after surgery. ¹²

   Revaccination: Antibody levels are likely to decline rapidly in individuals who have asplenia or splenic dysfunction and therefore revaccination with 23-valent PPV is recommended every five years. Testing of antibodies prior to vaccination is not required.¹³

2. Hib and meningococcal. Asplenic/hyposplenic children and adults may be at increased risk of invasive disease caused by Haemophilus influenzae type b, and meningococci, and require appropriate immunisation, as per summary table below.

3. Influenza. In asplenic/hyposplenic patients, influenza vaccination is associated with a 54% reduced risk of death compared to unimmunised asplenic persons¹⁴. Annual vaccination against influenza is recommended, preferably in September. Asplenic/hyposplenic individuals are not thought to be at more risk of catching influenza but vaccination may reduce the risk of secondary bacterial infection.

In practice it is difficult to know whether some individuals (e.g. those with coeliac syndrome) are hyposplenic, as there is no readily available diagnostic test, and to some extent it therefore depends on clinical judgement.

In the absence of evidence of hyposplenia, only influenza and pneumococcal vaccines are recommended for those with coeliac syndrome.

*Patients on Eculizumab (Soliris) therapy are not at increased risk of pneumococcal disease and do not require PPV23 or additional doses of PCV13
** Patients with splenic dysfunction should receive boosters of PPV at five yearly intervals

Guidance on the use of zanamivir, oseltamivir and amantadine for the treatment of influenza produced by the National Institute for Clinical Excellence (NICE) and endorsed by Health Improvement Scotland should be followed¹⁵. This advises that when there is evidence that influenza is circulating in the community at levels above the baseline, antiviral medication for the treatment of influenza in the community may be prescribed for those at risk, provided that treatment can be started within 48 hours of the onset of symptoms. The Scottish Government Health Department issues advice when prescribing of antivirals in general practice becomes appropriate.

The 1996 Guidelines⁸ recommended that prophylactic antibiotics should be offered in all cases. There are no data to support or refute the previously published recommendations for antibiotic prophylaxis and treatment of infection in asplenic individuals¹⁰. However, it is recognised that compliance may be a problem, (and there has also been more recent discussion concerning the increase in penicillin resistance of pneumococci). Overall pneumococcal resistance to penicillins remains low in the UK¹⁰. Though not common in the UK, rates of up to 43% of isolates with some degree of resistance have been reported in Spain¹⁶ and travel will bring about increased exposure to resistant strains. The reluctance of some people to take antibiotics on a lifelong basis must also be taken into consideration. Given these factors, people in the following groups should be strongly recommended to receive prophylaxis:

• All people in the first three years after splenectomy⁵
• All children up to the age of 16 and those over 50 years⁶
• Individuals in whom there is underlying impaired immune function, (malignancy or haematological condition)
• Individuals who have suffered one severe infection

 Regardless of whether prophylaxis is used, patient education is of paramount importance regarding:

• The fact that immunisation and antibiotic prophylaxis does not guarantee protection against invasive disease.
• The need for rapid medical assessment of suspected infections
• The requirement to keep a course of antibiotics at home in order to commence treatment prior to medical assessment when this is delayed.

Recommended doses for antibiotic prophylaxis:^20,21

Asplenic individuals should receive a supply of stand by antibiotic whether or not they receive prophylactic antibiotics^17,18,19, with clear instructions on when to take. Recommended courses for adults include amoxicillin or levofloxacin for those with penicillin allergy.

Travel

Patients should be made aware of the need to seek travel advice early, even for travel in Europe and the potential risks of overseas travel particularly with regard to malaria and unusual infection such as those from animal bites¹⁰. Those not taking regular antibiotic prophylaxis should be advised to do so on holiday. Asplenics can have live vaccines unless there is an underlying immunosuppressive disorder. 

1. Malaria. All asplenic patients should be made aware of the increased risk of severe falciparum malaria, and the requirement for antimalarial prophylaxis cannot be overemphasised. Travel to areas where malaria is endemic should be discouraged. Depending on sensitivities in the area of intended travel, doxycycline may offer a combination of antibiotic and antimalarial prophylaxis¹⁷. 
2. Tick bites. Babesiosis is a rare potentially severe tick-borne disease caused by infection with a protozoan parasite. Most infections are asymptomatic, though the clinical syndrome can include fever, chills, myalgia, fatigue and jaundice secondary to haemolytic anaemia that may last from a few days to several months. Geographic distribution of the species of ticks that carry the disease is worldwide. Asplenic patients should be educated about the need for protective clothing when walking in areas of forestry or long grass. 
3. Meningococcal disease. There is an increased risk of serogroup A, W135 or Y disease in some countries. Ensure that individuals have been immunised with MenACWY conjugate vaccine as per summary table page 4.

Animal Bites

Capnocytophaga canimorsus can cause febrile illness in patients with impaired immune systems who have been licked, bitten or scratched by dogs or cats. Co-amoxiclav, the antibiotic of choice for these infections, should be given prophylactically to high risk individuals who are bitten by a dog or cat.

General Practitioners attending a known asplenic patient with clinically significant infection should (provided there is no history of anaphylaxis to penicillin) give an immediate dose of intramuscular or intravenous ceftriaxone before transfer to hospital:

If ceftriaxone is not available, give benzylpenicillin as below:

If there is a history of anaphylaxis to penicillin chloramphenicol may be used.

This guidance is provided to assist general practices in providing appropriate treatment and prophylaxis to their patients who have asplenia or functional hyposplenia. As historically management of patients in these categories has been found to be sub-optimal⁷ the Health Protection Team have agreed to assist General Practitioners by notifying them of patients potentially in this category, obtaining data by the following means:

• Patients undergoing elective splenectomy - Clinicians are requested to ensure that the In-patient Report (Appendix 1) is completed and forwarded to the Health Protection Team.
• The Health Protection Team also actively seeks to identify relevant patients using data supplied by the Pathology Department and SMR data from the Health Intelligence & Knowledge team in Public Health. This is undertaken quarterly.

All patients identified as described above will be sent a leaflet, A guide for people without a working spleen which includes an alert card (Appendix 2) to be carried in a purse/wallet.

Some patients may additionally wish to purchase a MedicAlert bracelet and details are available at www.medicalert.org.uk , or by telephoning 01908 951045. Patients may also be encouraged to obtain further information on splenectomy: http://www.patient.co.uk/health/Splenectomy-Ongoing-Prevention-of-Infection.htm

All patients who undergo splenectomy should receive the following vaccines and be advised regarding antibiotic prophylaxis.

Please complete this form prior to discharge and forward to the Health Protection Team, Larch House, Stoneyfield Business Park Inverness. The Health Protection Team will write to the patient’s GP to ensure that they are aware of the relevant guidance.

For detailed guidance regarding protection against sepsis following splenectomy please refer to NHS Highland Guidelines for the Prevention of Sepsis in Patients with Asplenia or Functional Hyposplenia which are available on the Intranet, under Policies and Procedures.

Please note antibiotic prescribed, or reason if not prescribed:

Please sign below to indicate that the ‘information about splenectomy for patients’ leaflet has been given to the patient, and the card on the back of the leaflet has been completed: