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

Adherence to vaccination guidelines of patients with complete splenectomy in Norway, 2008-2020

The spleen is responsible for blood filtration and mounting an immune response against pathogens. In some people the spleen must be surgically removed because of traumatic events or oncological and hematological conditions. These patients are at higher risk of developing diseases caused by encapsulated bacteria throughout their lives. Thus, immunisations are advised for splenectomised persons to prevent infection caused by Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae type b (Hib). This study assessed vaccination coverage (VC) among Norwegian patients with surgical asplenia. Using the Nomesco Classification of Surgical Procedures codes, patient information (age, sex, date of initial diagnosis and date of surgery) was acquired from the Norwegian Patient Registry. The National Immunization Register provided information on vaccination status and data of any subsequent invasive bacterial infections were obtained from the Norwegian Surveillance System for Communicable Diseases. From the total population of Norway, 3155 patients who had undergone complete splenectomy were identified. Of these, 914 (29.0%) had received at least one dose of pneumococcal conjugate vaccine (PCV), 1324 (42.0%) at least one dose of pneumococcal polysaccharide vaccine and 589 (18.7%) had received both. Only 4.2% of the patients had received two doses of a meningococcal ACWY conjugate vaccine, while 8.0% of 1467 patients splenectomised after 2014 had received at least two doses of a serogroup B meningococcal vaccine. The VC for Hib was 18.7%. Nearly all splenectomised children under the age of 10 were vaccinated with Hib and PCV as these vaccines are included in the childhood immunisation program. For all vaccines, VC decreased with age. Twenty-nine invasive bacterial infections were registered post-splenectomy in 25 patients. Vaccination according to national recommendations could have prevented at least 8 (28%) of these infections. Our study showed that efforts are required to increase VC of splenectomised individuals in Norway.

Patients' with asplenia and doctors' experiences in implementing preventative measures following a novel educational intervention: a qualitative analysis

OBJECTIVE

To explore patients' with asplenia and general practitioners' (GPs) (1) perceptions of a novel, Health Action Process Approach (HAPA)-based, educational intervention which targets to increase adherence to post-splenectomy sepsis (PSS) prevention measures and (2) their experience in implementing prevention measures following this intervention.

DESIGN

A process evaluation conducted on average 3.5 (for patients) and 3.8 (for GPs) months after the intervention between January 2020 and April 2021 individually by means of semi-structured guideline-based telephone interviews. Data was analysed using qualitative content analysis.

PARTICIPANTS

Volunteer subsample of N=25 patients with asplenia and N=8 GPs who received the intervention. Inclusion criteria were met by prior participation in the intervention (German-speaking, of full age and insured by the cooperating health insurance). Patient selection was done by purposeful selection aiming at maximum variability in terms of adherence to preventative measures prior to intervention participation. Participating GPs are a non-purposeful selected convenience sample. For reasons of data protection, no personal data was collected.

RESULTS

The intervention was positively evaluated and its personal relevancy for patients and for the GPs' professional work became apparent. The intervention promoted risk awareness, intention to action, action planning and subsequently, improved adherence to preventative measures. Helpful factors for implementation among the patients were social support by relatives and GPs. Barriers to adherence identified in both groups can be divided into patient-attributed (eg, comorbidities), doctor-related (eg, lack of knowledge or support) as well as contextual factors (eg, vaccine supply constraints).

CONCLUSIONS

Our findings indicate a patient and GP perceived benefit of the intervention, but still identify prevailing barriers to implementation. In a further step, a quantitative evaluation of the intervention will be conducted and recommendations for integrating the intervention in usual care will be made.

TRIAL REGISTRATION NUMBER

DRKS00015238.

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.

Meningococcal vaccination in patients with newly diagnosed asplenia in the United States

BACKGROUND

Patients with asplenia are recommended to receive meningococcal ACWY (MenACWY) and B (MenB) vaccines in the United States (US).

OBJECTIVES

To examine uptake and time to receipt of meningococcal vaccines in newly diagnosed asplenia patients, and identify factors associated with vaccination.

METHODS

For this retrospective database analysis, patients were identified from 1/1/2010 (MenACWY) or 1/1/2015 (MenB) through 3/31/2018 from an administrative claims database including commercially insured US patients with ≥1 inpatient or ≥2 outpatient claims with evidence of a new asplenia diagnosis (sickle cell disease was excluded); continuous enrollment for ≥12 months before and ≥6 months after the index date; and age ≥2 (MenACWY) or ≥10 (MenB) years. Co-primary outcomes were uptake and time to receipt of ≥1 dose, separately for MenACWY and MenB, by Kaplan-Meier analysis. Cox proportional hazards regression models were used to identify characteristics associated with vaccination.

RESULTS

Among 2,273 and 741 patients eligible for the MenACWY and MenB analyses, respectively, 28.1% and 9.7% received MenACWY and MenB in the first 3 years after a new asplenia diagnosis. Patients were more likely to receive meningococcal vaccines if they had received pneumococcal vaccines (MenACWY: hazard ratio [HR] 26.02; 95% confidence interval [CI] 21.01-32.22; MenB: HR 3.89; 95% CI 2.07-7.29) or attended ≥1 well-care visit (MenACWY: HR 6.63; 95% CI 4.84-9.09; MenB: HR 11.17; 95% CI 3.02-41.26).

CONCLUSIONS

Meningococcal vaccination rates among newly diagnosed asplenia patients were low, highlighting the need to educate providers about the recommendations for high-risk conditions and ensure healthcare access for vulnerable patients.

Prevention of infection in asplenic adult patients by general practitioners in France between 2013 and 2016 : Care for the asplenic patient in general practice

Background

Guidelines that detail preventive measures against Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b, and influenza are published annually in France to decrease the risk of severe infections in immunocompromised patients. We aimed at describing adherence to these guidelines by GPs in the management of their asplenic patients in France between 2013 and 2016.

Method

We conducted a multicenter retrospective study between January 2013 and December 2016 in three French hospitals: asplenic adults were identified and their GPs were questioned. A descriptive analysis was performed to identify the immunization coverage, type and length of antibiotic prophylaxis, number of infectious episodes, and education of patients.

Results

103 patients were finally included in this study: only 57% were adequately vaccinated against Streptococcus pneumoniae or Neisseria meningitidis, 74% against Haemophilus influenzae type b, and 59% against influenza. Only 24% of patients received a combination of all four vaccinations. Two-thirds of patients received prophylactic antibiotics for at least 2 years. Overall, this study found that 50% of splenectomized patients experienced at least one pulmonary or otorhinolaryngological infection, or contracted influenza.

Conclusions

These data match those reported in other countries, including Australia and the United Kingdom, meaning a still insufficient coverage of preventive measures in asplenic patients. Improved medical data sharing strategies between healthcare professionals, along with educational measures to keep patients and physicians up to date in the prevention of infections after splenectomy would improve health outcomes of asplenic patients.

Pneumococcal vaccination coverage in France by general practitioners in adults with a high risk of pneumococcal disease

Streptococcus pneumoniae, the main cause of community-acquired pneumonia (CAP), also leads to exacerbations, hospitalizations, and mortality in chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). The risk of CAP is increased in patients with diabetes mellitus (DM), and the risk of invasive pneumococcal disease is increased in HIV-infected patients. Pneumococcal vaccination is recommended for these patients in France. The objective was a large survey of pneumococcal vaccination coverage (PVC) by general practitioners (GPs) in these patients in France. Diagnosis and treatment forms were extracted from the database of 2000 GPs. The GPs and population panels were representative of the metropolitan populations. The primary endpoint was the comparison of PVC in the adult patients diagnosed with COPD, CHF, DM, or HIV infection during the study (April 2013-April 2017) and the control (March 2012-March 2013) periods. Of the 17,865 and 4,690 patients identified, 756 (4%) and 267 (6%) were vaccinated, respectively. During the study period, the PVC was significantly higher (35/282, 12%) in HIV-infected patients and lower in patients with DM (95/5994, 2%) than in other patients. Even though French pneumococcal vaccine recommendations in adults were updated in 2013, the PVC did not increase according to the years of the study period and slightly increased according to time after diagnosis. S. pneumoniae is responsible only for some CAP and meningitis, and incomplete protection by vaccine, hesitancy from practitioners and patients, and the moving schedule of vaccination could explain the results. New tools and/or strategies must be implemented to increase PVC in France. Abbreviations: CAP: community-acquired pneumonia; COPD: chronic obstructive pulmonary diseases; CHF: congestive heart failure; DM: diabetes mellitus; IPD: invasive pneumococcal disease; HIV: human immunodeficiency virus; PVC: pneumococcal vaccination coverage; PCV7: 7-valent pneumococcal conjugate vaccine; PCV13: 13-valent pneumococcal conjugate vaccine; PPSV23: 23-valent pneumococcal polysaccharide vaccine; GPs: general practitioners; CLM: Cegedim Logiciels Médicaux; MLM: monLogicielMedical; ICD-10: International Classification of Diseases; CNIL: Commission nationale de l'informatique et des libertés; HPV: human papillomavirus; HBV: hepatitis B virus.

A Single-Center Prospective Cohort Study on Postsplenectomy Sepsis and its Prevention

Background

This study evaluated the impact of a dedicated outpatient service on vaccination uptake after splenectomy and on the incidence of postsplenectomy sepsis.

Methods

From 2009 to 2016 at the University Hospital Freiburg (Germany), asplenic patients were referred to a dedicated outpatient service, provided with comprehensive preventive care including vaccinations, and enrolled in a prospective cohort study. The impact of the service on vaccination uptake and the occurrence of severe sepsis/septic shock was compared between patients who had splenectomy (or were asplenic) within 3 months of study entry (“early study entry”) and those who had splenectomy (or were asplenic) >3 months before study entry (“delayed study entry”).

Results

A total of 459 asplenic patients were enrolled, and 426 patients were followed prospectively over a median period of 2.9 years. Pneumococcal vaccine uptake within 3 months of splenectomy or first diagnosis of asplenia was 27% vs 71% among delayed study entry and early study entry patients, respectively (P < .001). Forty-four episodes of severe sepsis or septic shock occurred in study patients: 22 after study entry and 22 before study entry. Streptococcus pneumoniae was more frequent among sepsis episodes that occurred before study entry (8/22) than after study entry (1/22 episodes). For episodes occurring after study entry, only a higher Charlson comorbidity index score was significantly associated with severe sepsis/septic shock postsplenectomy.

Conclusions

With dedicated outpatient care, high uptake of pneumococcal vaccination postsplenectomy was achieved. Sepsis episodes were largely of nonpneumococcal etiology in patients who had received dedicated postsplenectomy care.

A Registry for Patients With Asplenia/Hyposplenism Reduces the Risk of Infections With Encapsulated Organisms

Background

Overwhelming post-splenectomy infection (OPSI) is a serious complication of asplenia. Clinical guidelines recommend numerous measures to reduce the risk of OPSI, but awareness and adherence to preventative measures are generally poor. We aimed to determine whether a registry for asplenic/hyposplenic patients was associated with a reduction in the incidence of infection with encapsulated bacteria.

Methods

We performed a retrospective cohort study of asplenic/hyposplenic patients in the state of Victoria, Australia, who registered with Spleen Australia from 2003 through 2014. Spleen Australia provides education, clinical guidance, and annual vaccination reminders to registrants and their healthcare providers. We compared the incidence of infection with Streptococcus pneumoniae, Haemophilus influenzae type B (Hib), and Neisseria meningitidis before and after registration. Registry data were linked with Victorian notifiable disease data on invasive pneumococcal disease (IPD), invasive meningococcal disease (IMD), and Hib between 2000 and 2014.

Results

Twenty-seven cases of IPD and 1 of IMD occurred among 3221 registrants. No cases of Hib were reported. The rate of IPD/IMD was 150 per 100000 patient-years prior to registration and 36 per 100000 patient-years after registration; registration was associated with a 69% reduction in the risk of infection (incidence rate ratio, 0.31; 95% confidence interval, 0.12 to 0.83; P = .019). Based on the absolute reduction in incidence, we estimate that Spleen Australia prevents 5-6 invasive infections with encapsulated organisms annually among registrants.

Conclusions

Systematic, long-term approaches to post-splenectomy care can significantly reduce the risk of infection with encapsulated organisms among individuals with asplenia/hyposplenism.

Vaccination and splenectomy in Olmsted County

OBJECTIVES

To determine the long-term impact of vaccination on any postoperative infection in adults who underwent splenectomy.

METHODS

All adults (≥18 years) who underwent splenectomy from 1965 to 2011 in Olmsted County, MN were identified using the Rochester Epidemiology Project. Descriptive statistics, Kaplan-Meier estimates, and Cox proportional hazard ratios were performed.

RESULTS

There were 724 patients who underwent splenectomy; 47% were female with a median age of 55 (35-69) years. Overall vaccination rate (pneumococcal, H influenza, meningococcal) was 62% (n = 449). There were 268 (36%) patients who developed a post-splenectomy infection; most presented with sepsis 148 (55%). The 3 most common infections included pneumonia (124, 17%), bloodstream (67, 9%), and urinary tract infection (49, 7%). Median time to infection was quicker in non-vaccinated compared with vaccinated patients (1.5 [0.1-4.3] vs 3.3 [1.9-9.8] years, P = .01).

CONCLUSION

In this population-based study, the highest risk of infection after splenectomy was in patients who did not receive complete vaccination. Lack of complete vaccination was associated with a reduced time to infection and increased rates of bloodstream infections at 5 years. Infectious complication risk reduced as vaccination protocols improved for all indications except for malignancy. Adults who underwent a splenectomy should continue to receive booster vaccines.

Dutch healthcare professionals' opinion on vaccination and education to prevent infections in immunocompromised patients: A mixed-method study with recommendations for daily practice

BACKGROUND

The fast-growing population of immunocompromised patients (ICP) is more vulnerable to infectious diseases, demanding strategies to protect them. These strategies seem inconsistent in available guidelines and in practices. We aim to evaluate healthcare professionals' (HCP) opinions on vaccination to reduce the number and severity of infections in ICP.

METHODS

A mixed-method study, with an exploratory sequential design, was performed. Medical specialists from various departments in a tertiary care center in the Netherlands were invited for semi-structured interviews to explore their perspective on preventive care of ICP. Topics that play a substantial role in daily practice for ICP were translated into a survey to gain insight into what extent opinions were generalizable to Erasmus Medical Center.

RESULTS

Surveys were completed by 689 HCP (43% of the invitees), 269 of them treated at least two ICP weekly on average and were considered eligible for further analysis. Quantitative data showed that according to 80 percent of HCP, preventive care for ICP can be improved. Education was chosen by 40 percent as the most important intervention to reduce the number and severity of infections. Vaccinations were valued as important by seventeen percent of HCP. Except for influenza, vaccinations were not regularly discussed during routine consultations. Difficulties to administer vaccinations were experienced by 75 percent of HCP.

CONCLUSION

According to our respondents, education is the most promising intervention to reduce the number and severity of infections in ICP. To reach a higher vaccine uptake, we recommend HCP to address vaccinations more frequently during consultations and to search for solutions to alleviate barriers to vaccinate.

[Influenzae and pneumococcal vaccination rate in an internal medicine ward]

INTRODUCTION

Vaccination against influenza virus and Streptococcus pneumoniae is a global health priority and authorities, on the basis of recent publications, have recently updated French recommendations. The aim of this study was to describe the influenzae and pneumococcal vaccination's rate in an internal medicine ward.

MATERIAL AND METHODS

All patients consecutively hospitalized during a 10 week-period in an internal medicine ward were included. The reasons for non-vaccination and the impact of an educational program for corrective measures were reported.

RESULTS

Overall, 198 consecutive patients were included; 93 (47%) were immunocompromised; 142 (71.2%) had an indication for pneumococcal vaccination and 171 (86.4%) for influenza vaccination but only 16.2% and 55% of them were vaccinated against these microorganisms, respectively. Prior pneumococcal vaccination was more frequently observed in immunocompromised patients than in non-immunocompromised patients (21.1 versus 6.4%; P=0.029), but no significant difference was observed for influenza vaccine. Corrective measures were initiated in 46 patients (39%), non-immunized against S. pneumoniae.

CONCLUSION

These results underline the very low prevalence of pneumococcal vaccination rate in at-risk hospitalized patients, as compared with influenza, despite recent recommendations.

Vaccination coverage and mortality after splenectomy: results from an Italian single-centre study

Splenectomy is a well-recognised risk factor for life-threatening overwhelming post-splenectomy infection (OPSI). To prevent OPSI, immunisations against encapsulated bacteria (S. pneumoniae, N. meningitidis, H. influenzae) and influenza virus are recommended. However, there is still a lack of uniformity and poor compliance with these recommendations. Following a local physicians' awareness campaign regarding the importance of vaccine prophylaxis of splenectomised patients, we aimed to register vaccination coverage, mortality and infection rates in all patients who underwent splenectomy at our hospital, over a six-year time span. Reasons for splenectomy, patients' compliance with vaccinations, mortality and infectious events were recorded. The reasons for splenectomy in the 216 identified patients (mean age 58.2 ± 14; M:F ratio 1.4:1) were haematologic disorders (38.8%), solid tumours (28.7%), traumatic rupture (22.7%) and other causes (9.7%). A total of 146 patients (67.6%) received at least one of the four vaccines. Overall, the mortality rate was significantly greater in unvaccinated compared to vaccinated patients (p < 0.001), although after the adjustment for the cause of splenectomy the statistical significance was lost (p = 0.085) due to the burden of solid tumour-related mortality. Among the 21 reported cases of OPSI, eight were fatal and five were potentially vaccine-preventable. Our results show that two-thirds of splenectomised patients comply with vaccine prophylaxis. Future interventional studies or ad hoc registries might overcome barriers to vaccination or intentional non-compliance.

Distal pancreatectomy for benign and low grade malignant tumors: Short-term postoperative outcomes of spleen preservation-A systematic review and update meta-analysis

BACKGROUND

The value of spleen preservation with distal pancreatectomy (DP) for benign and low grade malignant tumors remains unclear. The aim of this study was to evaluate the short-term postoperative clinical outcomes in patients undergoing DP with splenectomy (DPS) or spleen preservation (SPDP).

METHODS

Online database search was performed (2000 to present); key bibliographies were reviewed. Studies comparing patients undergoing DP with either DPS or SPDP, and assessing postoperative complications were included.

RESULTS

Meta-analysis of included data showed SPDP patients had significantly less operative blood loss, shorter duration of hospitalization, lower incidence of fluid collection and abscess, lower incidence of postoperative splenic and portal vein thrombosis, and lower incidence of new onset postoperative diabetes. For the whole group, there was no difference in incidence of postoperative pancreatic fistula (POPF) (RR = 0.95; 95%CI 0.65-1.40, P = 0.80), however, subgroup analysis of studies using ISGPF criteria showed that DPS patients had increased rates of Grade B/C POPF (RR = 1.35; 95%CI 1.08-1.70, P = 0.01).

CONCLUSIONS

SPDP for benign and low grade malignant tumors is associated with shorter hospital stay and decreased morbidity compared to DPS. J. Surg. Oncol. 2017;115:137-143. © 2017 Wiley Periodicals, Inc.

[Long-term infectious risks after splenectomy: A retrospective cohort study with up to 10 years follow-up]

INTRODUCTION

Although most infections occur within the first 2 years after splenectomy, the relatively short follow-up reported in many studies may underestimate the frequency of infections. The objective of the study was to determine the incidence of infective outcomes and factors associated with infection after splenectomy by studying a group of patients who underwent splenectomy over a 10-year period.

METHODS

A retrospective and monocentric study of patients who underwent splenectomy between January 1st, 1997 and December 31st, 2004 in a French university hospital. Age, sex, indication for splenectomy, infectious events, death, vaccination and antibiotic prophylaxis were collected in January 2015.

RESULTS

One hundred and sixty-five patients were included. The most common reasons for splenectomy were therapeutic hematological indications (37.5%). Ninety-seven per cent received pneumococcal vaccine. Prophylactic antibiotics were prescribed in 78% of patients. Thirty-seven patients had 42 severe infections with a median incidence rate of 4 years after splenectomy (2 days-12 years). The rate of infection after splenectomy declined over time but 57% occurred after 2 years and 14.3% after 10 years. Respiratory infections were the most common sites of infections. The incidence of infection differed according to age was highest among the elderly (HR=6.2; 95%CI: 1.4-27.1; after 65 years old) and underlying reason for splenectomy (P=0.02). There is no difference with or without prophylactic antibiotics.

CONCLUSION

After splenectomy, the incidence of severe infection declined over time but can occur after 10 years. The onset of infection is linked to age and reason for splenectomy.

Adherence to vaccination guidelines post splenectomy: A five year follow up study

Following a splenectomy patients are at increased risk of significant infections. In its most severe form, overwhelming post-splenectomy infection (OPSI) has a mortality rate of up to 80%. In this study we aim to establish the adherence to vaccination and antibiotic national guidelines in splenectomised patients. A retrospective study of 100 patients who underwent splenectomy (21 emergency, 79 elective), in two teaching hospitals was undertaken over a five-year period. Patients were followed up for five years. Hospital and GP records were reviewed for adherence to pre, intra and postoperative vaccination, thromboprophylaxis and antibiotic guidance. Eighty-six eligible patients (91.5%) received their Haemophilus influenzae B, meningococcal C and pneumococcus vaccinations peri-operatively. Eighty-one (86%) received post-operative antibiotics. Ninety-nine percent of patients received thromboprophylaxis treatment. Eighty-nine (95%) were treated with long-term antibiotic prophylaxis. Only 20 patients (23%) had an emergency supply of antibiotics. Ninety-five percent of patients were administered an annual influenza vaccination and 84% of eligible patients received a five-year pneumococcal booster vaccination. Improvement in the management of this patient cohort can be achieved by a multidisciplinary approach involving adherence to national guidelines, standardised trust protocols, patient information leaflets and advice detailing risk of infection, standardised GP letters and a splenectomy register to monitor and manage this vulnerable group of patients.

Overwhelming post-splenectomy sepsis in patients with asplenia and hyposplenia: a retrospective cohort study

Overwhelming post-splenectomy infection (OPSI) is a serious complication of asplenia and is associated with encapsulated organisms, most commonly Streptococcus pneumoniae, but also Haemophilus influenzae and Neisseria meningitidis. We aimed to estimate the risk of infection in this patient group. We reviewed data collected by the Victorian Spleen Registry in Australia. On registration, all patients are asked about significant infections requiring admission to hospital for intravenous antibiotics; those requiring admission to ICU were defined as OPSI. In the 3274 asplenic patients registered 492 patients reported at least one episode of infection. There were 47 episodes of OPSI requiring intensive care (incidence rate 1·11/1000 patient-years). The risk of OPSI was highest in older patients, and there were no statistically significant differences in incidence by reason for splenectomy except for a higher rate in patients with medical hyposplenia. This study reinforces that post-splenectomy infection is a clinically significant but uncommon complication, and that fulminant infection requiring intensive care is a minority of all infections.

Immunization coverage among splenectomized patients: Results of an ad hoc survey in Puglia Region (South of Italy)

Patients with anatomic or functional asplenia have a 10-50 times higher risk than general population to develop Overwhelming Post-Splenectomy Infection. Evidences are unanimous in recommending splenectomised patients to receive meningococcal, antipneumococcal and Haemophilus influenzae type B vaccinations according to a specific timing. In Italy there are no current data on the immunisation coverage in these patients. This study aims to investigate immunisation coverage in patients undergoing elective or urgent splenectomy for 2012-2013 in the 3 Apulian hospitals. The patients discharged with the code ICD-9-CM 41.5 - "Total splenectomy" were enrolled. The administration of vaccines was verified through consultation of medical records, archives of general practitioners and vaccination offices. In the study period, 166 subjects underwent splenectomy and none of them received vaccinations during hospitalization. 25 splenectomised patients (15.1%) received at least one of the recommended vaccinations. 21 patients (12.6%) received vaccine against Streptococcus pneumonia, 13 (7.8%) meningococcal vaccine, 10 patients (6%) Haemophilus influenzae type B vaccine. The low vaccination coverage could be due both to poor perception of the risk of infection and to a lack of knowledge on vaccinations by surgeons. For this reason it is necessary to draw up and share operational protocols that establish the administration of vaccines.

Howell-Jolly bodies on peripheral smear leading to the diagnosis of congenital hyposplenism in a patient with septic shock

We present a case of isolated congenital hyposplenism that was discovered after the peripheral smear revealed Howell-Jolly bodies. This case serves as the basis for a review of hyposplenism for the general practitioner.

Need for an improved vaccination rate in primary immune thrombocytopenia patients exposed to rituximab or splenectomy. A nationwide population-based study in France

International guidelines on immune thrombocytopenia (ITP) management recommend vaccination against Streptococcus pneumoniae (S.p.), Haemophilus influenza b (Hib) and Neisseiria meningitidis (N.m.) before splenectomy. French guidelines also recommend these vaccinations before rituximab. The aim of this study was to assess the application of these recommendations. The French Adult ITP: a French pHarmacoepidemiological study (FAITH, n°ENCEPP 4574) is aimed at following in the French national health insurance system database (SNIIRAM) the cohort of all incident and persistent or chronic primary ITP adults treated in France. We assessed vaccine exposure in the 1,106 patients who entered the FAITH cohort between 2009 and 2011. Vaccination was said "recommended" if performed at least 2 weeks before rituximab or splenectomy accordingly with French guidelines. Among the 423 non-splenectomized patients exposed to rituximab, vaccination rates against S.p., Hib and N.m. were respectively 32.4%, 18.9%, and 3.8%. It was recommended in 12.8%, 6.6%, and 1.2% of the patients, respectively. Among the 178 splenectomized patients, vaccination rates were 70.2%, 47.0%, and 11.9%, respectively (recommended: 60.1%, 35.7%, and 9.5%). Among the splenectomized patients previously exposed to rituximab (n = 67), 53.3% of the vaccinations occurred during the semester following a rituximab infusion that is during the maximal B-cell depletion period. In multivariate analyses, a disease duration exceeding 3 months was the sole factor associated to recommended vaccination in rituximab-treated patients as well as in splenectomized patients. This study stresses the need of better and earlier vaccination of ITP patients.

Vaccination status and immune response to 13-valent pneumococcal conjugate vaccine in asplenic individuals

Overwhelming post-splenectomy infection (OPSI) is immediately life-threatening and vaccination against encapsulated bacteria, in particular pneumococci, decreases its incidence. First, we investigated the adherence to vaccination guidelines in a retrospective study of the hospital records of splenectomised patients. Second, patients were asked to complete a questionnaire and invited to participate in a study where 12-valent pneumococcal serotype-specific IgG concentrations were determined before and 4 to 6 weeks after vaccination with PCV13. Of 79 individuals who underwent splenectomy between 2000 and 2012: 81.0% received pneumococcal vaccine, 51.9% received vaccine against Haemophilus influenzae type B and 22.8% received meningococcal vaccine. 31 individuals were deceased. 33 individuals completed questionnaires and accepted participation in the second part of the study. The participants consisted of two groups: (1) prior PPV23 (n=24) and (2) prior PPV23+PCV13 (n=9). In group 1, pre-PCV13 GMC's≥0.35μg/mL were observed for serotypes 1, 4, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F, and GMC's<0.35μg/mL for serotypes 3 and 5, significant increases pre- to post-PCV13 were found for serotypes 1, 3, 4, 5, 7F, 18C, 19A, 23F (p≤0.001) and 19F (p=0.01) and all 12 serotypes-specific GMC were above 0.35μg/mL after vaccination. Group 2 did not receive vaccine in this study, but blood tests showed all 12 serotype-specific GMC>0.35μg/mL. Adherence to guidelines regarding primary pneumococcal vaccination was adequate but only a minority received the recommended meningococcal vaccination. High levels of pneumococcal serotype-specific antibodies were observed in the previous PPV23 vaccinated group, and more pronounced in the previous PCV13 group, and our data suggests that PCV13 is immunogenic for serotypes 1, 3, 4, 5, 7F, 18C, 19A, 19F and 23F, if used as a booster dose in asplenic patients with previous PPV23 vaccination.

Assessment of immune cells and function of the residual spleen after subtotal splenectomy due to splenomegaly in cirrhotic patients

Background

The spleen is thought to be central in regulating the immune system, a metabolic asset involved in endocrine function. Overwhelming postsplenectomy infection leads to a mortality rate of up to 50%. However, there is still controversy on performing subtotal splenectomy as treatment of splenomegaly due to portal hypertension in cirrhotic patients. In the present study, immunocytes and the indexes of splenic size, hemodynamics, hematology and immunology in the residual spleen were analyzed to support subtotal splenectomy due to splenomegaly.

Results

In residual spleen, T lymphocytes mainly were focal aggregation in the periarterial lymphatic sheath. While B lymphocytes densely distributed in splenic corpuscle. In red pulp, macrophages were equally distributed in the xsplenic cord and adhered to the wall of splenic sinus with high density. The number of unit area T and B lymphocytes of splenic corpuscle and marginal zone as well as macrophages of red pulp were obviously increased in the residual spleen, while the number of macrophages didn’t be changed among the three groups in white pulp. While there were some beneficial changes (i.e., Counts of platelet and leucocyte as well as serum proportion of CD3+ T cells, CD4+ T cells, CD8+ T cells were increased markedly; serum levels of M-CSF and GM-CSF were decreased significantly; The proportion of granulocyte, erythrocyte, megakaryocyte in bone marrow were changed obviously; But serum IgA, IgM, IgG, Tuftsin level, there was no significant difference; splenic artery flow volume, portal venous diameter and portal venous flow volume, a significant difference was observed in residual spleen) in the clinical indices.

Conclusion

After subtotal splenectomy with splenomegaly due to portal hypertension in cirrhotic patients, the number of unit area T and B lymphocytes, and MØ in red pulp of residual spleen increased significantly. However, whether increase of T, B lymphocytes and MØs in residual splenic tissue can enhance the immune function of the spleen, still need further research to confirm.

Clinical value of spleen-preserving distal pancreatectomy: a case-matched analysis with a special emphasis on the postoperative systemic inflammatory response

BACKGROUND

The impact of splenectomy on outcomes after distal pancreatectomy was assessed in the present study, with a special emphasis on the postoperative systemic inflammatory response.

METHODS

Thirty-three patients with spleen-preserving distal pancreatectomy-Kimura technique (SPDP group) were compared with a group of distal pancreatectomies with splenectomy (DPS group). The two groups were 1:1 matched for age, gender, co-morbidities and pathology.

RESULTS

No differences between the groups were observed regarding the overall/severe/infectious morbidity, pancreatic fistulae and postoperative diabetes rates (P-values ≥ 0.475). An increased blood loss (P = 0.031) and need for intraoperative transfusions (P = 0.004) was observed in the DPS group. Postoperative platelet count and platelet-to-lymphocyte ratio were significantly higher in the DPS group (P < 0.001).

CONCLUSION

Spleen removal during DP is not associated with a higher morbidity but with an increased blood loss and need for intraoperative transfusions. Although the postoperative systemic inflammatory response is higher when the splenectomy is performed, the number of postoperative infectious complications is not influenced. Preservation of the spleen during DP for benign and low-grade malignant tumor of the distal pancreas appears to be worthy and should be the first option whenever is technically feasible and it can be safely achieved.

[Overwhelming postsplenectomy infection syndrome]

The overwhelming postsplenectomy infection syndrome (OPSI) is a fulminant sepsis that is mainly caused by Streptococcus pneumoniae and is characterized by a particular high mortality. Patients whose spleen was removed due to a hematological disease are at special risk. Even after the recommended immunization against Streptococcus pneumoniae 20-30 % of these patients do not develop an adequate level of antibody response. Therefore, this particular group of patients must be trained how to behave in case of fever and need to obtain immediate specific sepsis therapy with antibiotic prophylaxis.

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.

[Post-splenectomy complications in primary immune thrombocytopenia. Literature review and preventive measures]

Management of primary immune thrombocytopenia (ITP) has changed, and clinical practice broadens the use of thrombopoietin receptor agonists and anti-CD20 antibody as options for second-line therapy, as alternative to splenectomy. Splenectomy remains a successful, definitive curative treatment. The purpose of this review about the complications of the splenectomy, in the context of ITP, is to increase the awareness of clinicians towards the preventive measures, which are often not correctly applied.

Is non-operative management safe and effective for all splenic blunt trauma? A systematic review

Introduction

The goal of non-operative management (NOM) for blunt splenic trauma (BST) is to preserve the spleen. The advantages of NOM for minor splenic trauma have been extensively reported, whereas its value for the more severe splenic injuries is still debated. The aim of this systematic review was to evaluate the available published evidence on NOM in patients with splenic trauma and to compare it with the operative management (OM) in terms of mortality, morbidity and duration of hospital stay.

Methods

For this systematic review we followed the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" statement. A systematic search was performed on PubMed for studies published from January 2000 to December 2011, without language restrictions, which compared NOM vs. OM for splenic trauma injuries and which at least 10 patients with BST.

Results

We identified 21 non randomized studies: 1 Clinical Controlled Trial and 20 retrospective cohort studies analyzing a total of 16,940 patients with BST. NOM represents the gold standard treatment for minor splenic trauma and is associated with decreased mortality in severe splenic trauma (4.78% vs. 13.5% in NOM and OM, respectively), according to the literature. Of note, in BST treated operatively, concurrent injuries accounted for the higher mortality. In addition, it was not possible to determine post-treatment morbidity in major splenic trauma. The definition of hemodynamic stability varied greatly in the literature depending on the surgeon and the trauma team, representing a further bias. Moreover, data on the remaining analyzed outcomes (hospital stay, number of blood transfusions, abdominal abscesses, overwhelming post-splenectomy infection) were not reported in all included studies or were not comparable, precluding the possibility to perform a meaningful cumulative analysis and comparison.

Conclusions

NOM of BST, preserving the spleen, is the treatment of choice for the American Association for the Surgery of Trauma grades I and II. Conclusions are more difficult to outline for higher grades of splenic injury, because of the substantial heterogeneity of expertise among different hospitals, and potentially inappropriate comparison groups.

Preserved antibody levels and loss of memory B cells against pneumococcus and tetanus after splenectomy: tailoring better vaccination strategies

Splenectomized patients are exposed to an increased risk of septicemia caused by encapsulated bacteria. Defense against infection is ensured by preformed serum antibodies produced by long-lived plasma cells and by memory B cells that secrete immunoglobulin in response to specific antigenic stimuli. Studying a group of asplenic individuals (57 adults and 21 children) without additional immunologic defects, we found that spleen removal does not alter serum anti-pneumococcal polysaccharide (PnPS) IgG concentration, but reduces the number of PnPS-specific memory B cells, of both IgM and IgG isotypes. The number of specific memory B cells was low in splenectomized adults and children that had received the PnPS vaccine either before or after splenectomy. Seven children were given the 13-valent pneumococcal conjugated vaccine after splenectomy. In this group, the number of PnPS-specific IgG memory B cells was similar to that of eusplenic children, suggesting that pneumococcal conjugated vaccine administered after splenectomy is able to restore the pool of anti-PnPS IgG memory B cells. Our data further elucidate the crucial role of the spleen in the immunological response to infections caused by encapsulated bacteria and suggest that glycoconjugated vaccines may be the most suitable choice to generate IgG-mediated protection in these patients.

Laparoscopic splenectomy: a single center experience. Unusual cases and expanded inclusion criteria for laparoscopic approach

Laparoscopic splenectomy (LS) is nowadays considered as the gold standard for most hematological diseases where splenectomy is necessary, but many questions still remain. The aim of this study was to analyze our 5-years experiences consisting of 48 consecutive LS cases in order to assess the optimal approach and the feasibility of the procedure also in malignant diseases and unusual cases such as a primary spleen lymphoma, a big splenic artery aneurism, or a spleen infarct due to a huge pancreatic pseudo-cyst. Forty-eight consecutive patients underwent LS from January 2006 to January 2011 with at least 1-year follow-up. Clinical data and immediate outcome were retrospectively recorded; age, diagnosis, operation time, perioperative transfusion requirement, conversion rate, accessory incision, hospital stay, and complications were analyzed. We had 14 cases of malignant splenic disease, the most frequent malignant diagnosis was non-Hodgkin's lymphoma (12/14, 85.7 %). Splenomegaly (interpole diameter (ID) >20 cm) was observed in 12 cases (25 %) and massive splenomegaly (ID >25 cm) in 3 cases (6.25 %). Conversion to laparotomy occurred in two patients (4.16 %), both associated to uncontrollable bleeding in patients with splenomegaly. Mean operative time was 138 ± 22 min. Mean hospital stay was 4.5 days. Postoperative morbidity rate was 8.8 % for the benign group and 35.7 % in the malignant group. Mortality occurred in 1/48 patients (2.08 %), as a result of overwhelming post-splenectomy infection (OPSI). LS can be performed safely for malignant splenic disease and splenomegaly without any statistically significant increase of morbidity and mortality rate. Conversion rate is increased for massive splenomegaly. LS should be considered as the preferential approach even in patients with malignant disease, splenomegaly, or unusual cases. Massive splenomegaly should be considered as relative contraindication to LS even at experienced centers.