Anti-infectious prophylaxis after splenectomy: current practice in an eastern region of Switzerland

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.

Prevention of early infective complications after laparoscopic splenectomy with the Garamycin sponge

Introduction

Surgical site infection (SSI) appear to be more frequent in splenectomized patients than might be expected and its incidence can be explained neither by the extent of surgery nor by the risk of bacterial contamination of the operating field.

Aim

Evaluation the local antibiotic prophylaxis using a gentamicin surgical implant in order to reduce SSI, particularly subphrenic abscesses.

Material and methods

We conducted a prospective, randomized study of two groups of patients undergoing laparoscopic splenectomy who were considered at high risk of infective complications: patients with idiopathic thrombocytopenic purpura (ITP) pre-treated chronically with systemic steroids and patients with non-Hodgkin lymphoma (NHL). Out of 98 laparoscopic splenectomies performed during the study period, 40 patients with ITP and 20 with NHL met the inclusion criteria and were enrolled in the study. In 20 randomly selected patients with ITP and 10 with NHL, a gentamicin-collagen implant was left in the splenic bed.

Results

Infective complications occurred in 4 (6.67%) among 60 patients from the entire study group; 2 in patients with ITP and a gentamicin implant who developed fever of unknown cause which resolved after systemic antibiotics, and 2 in patients with NHL and gentamicin prophylaxis who developed a subphrenic abscess. In all patients operated on without a gentamicin implant, the postoperative course was uncomplicated.

Conclusions

Gentamicin surgical implants not only fail to reduce the risk of subphrenic abscesses in splenectomized patients, but may contribute to the increase in its incidence, which puts into question the possible benefits of this form of prophylaxis.

Screening and prevention in Swiss primary care: a systematic review

BACKGROUND AND OBJECTIVES

Prevention is a challenging area of primary care. In Switzerland, little is known about attitudes to and performance of screening and prevention services in general practice. To implement prevention services in primary care it is important to know about not only potential facilitators but also barriers. Primary care encompasses the activities of general practitioners, including those with particular interest and/or specializations (eg, pediatrics, gynecology). The aim of this study was to review all studies with a focus on prevention services which have been conducted in Switzerland and to reveal barriers and facilitators for physicians to participate in any preventive measures.

METHODS

The Cochrane Library, PubMed, EMBASE and BIOSIS were searched from January 1990 through December 2010. Studies focussing on preventive activities in primary care settings were selected and reviewed. The methodological quality of the identified studies was classified according to the guidelines in the Consolidated Standards of Reporting Trials (CONSORT) statement.

RESULTS

We identified 49 studies including 45 descriptive studies and four randomised controlled trials (RCTs). Twelve studies addressed the prevention of epidemics, eleven out of them vaccinations. Further studies focused on lifestyle changes, physical activity counselling, smoking cessation, cardiovascular prevention and cancer screening. Perceived lack of knowledge/training and lack of time were the most commonly stated barriers. Motivation, feasibility and efficiency were the most frequently reported supporting factors for preventive activities. The methodological quality was weak, only one out of four RCTs met the applied quality criteria.

CONCLUSION

Most studies focussing on screening and prevention activities in primary care addressed vaccination, lifestyle modification or cardiovascular disease prevention. Identified barriers and facilitators indicate a need for primary-care-adapted education and training which are easy to handle, time-saving and reflect the specific needs of general practitioners. If new prevention programs are to be implemented in general practices, RCTs of high methodological quality are needed to assess their impact.

Information on the internet for asplenic patients: a systematic review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Physicians report barriers to deliver best practice care for asplenic patients: a cross-sectional survey

Background

Current management of asplenic patients is not in compliance with best practice standards, such as defined by the British Committee for Standards in Haematology. To improve quality of care, factors inhibiting best practice care delivery need to be identified first. With this study, we aimed to identify and quantify physicians' barriers to adhere to best practice management of asplenic patients in the Netherlands.

Methods and Principal Findings

A cross-sectional survey, preceded by multiple focus group discussions, was performed among Dutch physicians responsible for prevention of infections in asplenic patients, including specialists (of Internal medicine and Surgery) and general practitioners (GPs). Forty seven GPs and seventy three hospital specialists returned the questionnaire, yielding response rates of 47% and 36,5% respectively. Physicians reported several barriers to deliver best practice. For both GPs and specialists, the most frequently listed barriers were: poor patient knowledge (>80% of hospital specialists and GPs) and lack of clarity about which physician is responsible for the management of asplenic patients (50% of Internists, 46% of Surgeons, 55% of GPs). Both GPs and hospital specialists expressed to experience a lack of mutual trust: specialists were uncertain whether the GP would follow their advice given on patient discharge (33–59%), whereas half of GPs was not convinced that specialists' discharge letters contained the correct recommendations. Almost all physicians (>90%) indicated that availability of a national guideline would improve adherence to best practice, especially if accessible online.

Conclusion

This study showed that, in accordance with reports on international performance, care delivery for asplenic patients in the Netherlands is suboptimal. We identified and quantified perceived barriers by physicians that prevent adherence to post-splenectomy guidelines for the first time. Better transmural collaboration and better informed patients are likely to improve the quality of care of the asplenic patient population. A national, online-available guideline is urgently required.