Post-Splenectomy Sepsis ======================= Causes: encapsulated organism (pneumococcus, H.Flu, meningococcus, DF-2) 1.Cullingford GL; Watkins DN; Watts AD; Mallon DF Severe late postsplenectomy infection. Department of Surgery, University of Western Australia, Nedlands. Language: Eng Source: Br J Surg 1991 Jun;78(6):716-21 Unique Identifier: 91300296 Abstract: In all, 1490 patients underwent splenectomy in Western Australia between 1971 and 1983, giving 7825 person years exposure. Thirty-three patients developed severe late postsplenectomy infection (septicaemia, meningitis or pneumococcal pneumonia requiring hospitalization) and three developed overwhelming postsplenectomy infection. The incidence and mortality rates of severe late postsplenectomy infection were 0.42 and 0.08 per 100 person years exposure respectively and for overwhelming postsplenectomy infection the incidence and mortality rates were 0.04 per 100 person years exposure. There were 628 splenectomies after trauma, giving 3922 person years exposure. Eight patients developed severe late postsplenectomy infection of whom one had overwhelming postsplenectomy infection. Following trauma, the incidence of severe late postsplenectomy infection was 0.21 per 100 person years exposure, with the incidence and mortality rates of overwhelming postsplenectomy infection being 0.03 per 100 person years exposure. Patients undergoing splenectomy have a 12.6-fold increased risk of developing late septicaemia compared with the general population. Splenectomy following trauma gives an 8.6-fold increased risk of late septicaemia. The majority of severe late postsplenectomy infections did not occur within the first 2 years and 42 per cent of severe late postsplenectomy infections occurred greater than 5 years after splenectomy. The low incidence of severe late postsplenectomy infection and overwhelming postsplenectomy infection makes statistical evaluation of the effectiveness of prophylactic antibiotics, vaccination and splenic repair most difficult. 2. Pimpl W; Dapunt O; Kaindl H; Thalhamer J Incidence of septic and thromboembolic-related deaths after splenectomy in adults. Ludwig-Boltzmann Institute for Experimental and Gastroenterological Surgery, Landeskrankenanstalten Salzburg, Austria. Language: Eng Source: Br J Surg 1989 May;76(5):517-21 Unique Identifier: 89287677 Abstract: In a review of 37,012 autopsies over the last 20 years 202 deceased adults who had had a splenectomy were investigated. The incidence of infections and thromboembolic complications related to death in these patients was compared with that of a matched deceased population (n = 403) who had not undergone splenectomy. Death-related pneumonia was diagnosed frequently in the splenectomy group and to a lesser extent in the control group (57.9 versus 24.1 per cent, P less than 0.001). Lethal sepsis with multiple organ failure occurred in 6.9 per cent of the splenectomy group and in 1.5 per cent of the controls (P less than 0.001). Purulent pyelonephritis was observed in 7.9 per cent of the splenectomy group and was significantly more frequent than in the control group with its rate of 2.2 per cent (P less than 0.001). Finally, pulmonary embolism was the major or a contributory cause of death more often in the splenectomy group than in the control group (35.6 versus 9.7 per cent, P less than 0.001). We conclude that splenectomy generates a considerable life-long risk of severe infection and of thromboembolism. 3. Stryker RM; Orton DW Overwhelming postsplenectomy infection. Emergency Department, Methodist Hospital, Omaha, Nebraska 68114. Language: Eng Source: Ann Emerg Med 1988 Feb;17(2):161-4 Unique Identifier: 88104849 Abstract: A characteristic case of overwhelming postsplenectomy infection in a previously healthy, 25-year-old man is presented. The patient progressed from influenza-like symptoms to irreversible septic shock and death within 24 hours. His spleen had been removed nine years earlier because of abdominal trauma. Aggressive therapy, including IV fluids, antibiotics, vasopressers, steroids, heparin, packed red blood cells, platelets, cryoprecipitates, and fresh frozen plasma, failed to alter the course of this fulminant septic syndrome. The cause, treatment, and certain prevention options are presented. 4. Green JB; Shackford SR; Sise MJ; Fridlund P Late septic complications in adults following splenectomy for trauma: a prospective analysis in 144 patients. Language: Eng Source: J Trauma 1986 Nov;26(11):999-1004 Unique Identifier: 87061122 Abstract: One hundred forty-four patients were prospectively followed through our Asplenic Registry for the development of late septic complications following splenectomy for trauma. There were 114 males and 30 females with a mean age of 28.6 years. The total time of followup was 8,810 patient months with a mean followup of 61 months (range, 12-144 months). Indications for splenectomy were blunt trauma, 111 patients; penetrating trauma, six patients; and intra-operative injury, 27 patients. During the followup to date, 15 late major septic complications requiring hospitalization have occurred in 13 patients (9%). Fulminant pneumococcal sepsis resulted in the death of a 27-year-old male, 3 years after splenectomy. Septicemia occurred in four patients, pneumonia in five, abscess in two, infection of a prosthetic heart valve in one, meningitis in one, and fever of unknown origin in one. All but two of these infections were due to encapsulated organisms. Minor septic complications occurred in 44 patients (30%), and consisted of infections which required outpatient medical care. Major late septic complications occurred more frequently following incidental splenectomy than following splenectomy for blunt or penetrating trauma (18.5% and 5.9% respectively; p less than 0.05). The mortality from major septic complications in this series (7%) is lower than previously reported by other investigators (30-80%). Our data suggest that adults undergoing splenectomy for trauma are at an increased risk of developing late major septic complications. This risk is significant enough to warrant attempts at splenic salvage, especially when injury is incidental to an elective operative procedure.(ABSTRACT TRUNCATED AT 250 WORDS) 5. Brigden ML Postsplenectomy sepsis syndrome. How to identify and manage patients at risk. Language: Eng Source: Postgrad Med 1985 Jun;77(8):215-8, 221, 224-6 Unique Identifier: 85216142 Abstract: Established postsplenectomy sepsis syndrome, although infrequent, may carry a mortality rate of over 90%. Pneumococcus (Streptococcus pneumoniae) has been the infective organism in more than 50% of published cases. Certain groups, such as infants, patients with hematologic malignancy, and those with compromised humoral immunity, may be especially susceptible. However, even healthy individuals who have been splenectomized because of trauma may be affected. Within the general population there is a significant pool of asplenic or functionally hyposplenic patients who are not aware of their condition. Efforts must be made to identify any such individual at risk for the postsplenectomy sepsis syndrome. The new 23-valent polysaccharide pneumococcal vaccine should be made available to any asplenic or functionally hyposplenic individual. A high index of suspicion must be maintained for febrile illness in asplenic patients, and if such an illness occurs, a vigorous investigation is mandatory. 6. Ruben FL; Norden CW; Korica Y Pneumococcal bacteremia at a medical/surgical hospital for adults between 1975 and 1980. Language: Eng Source: Am J Med 1984 Dec;77(6):1091-4 Unique Identifier: 85069532 Abstract: All 72 episodes of pneumococcal bacteremia from 1975 through 1980 at Montefiore Hospital, Pittsburgh, a medical/surgical hospital for adults, were reviewed. There were 10 to 14 episodes per year, accounting for 4 to 5 percent of all bacteremias; it was estimated that one episode occurred for every thousand patients discharged. Patients' ages ranged from 16 to 94 years (mean 61 years); 65 percent were male. There was an underlying disease in 87 percent of all patients, and 78 percent of the infections were community-acquired. Treatment with antimicrobial drugs was given to all but six patients. Overall mortality was 43 percent, but it was higher for asplenic patients (five of six died). In 44 percent of patients, one to four complications occurred. Outcome correlated with presence of coexisting disease (p less than 0.03), development of one or more complications (p less than 0.04), presence of asplenia (p = 0.04), and the type of antimicrobial treatment used (p less than 0.001; patients treated with penicillin alone fared better). Typing of isolates in the last two study years revealed that 67 percent of isolates were pneumococcal types present in 14-valent pneumococcal vaccine available at the time of the study. It is concluded that pneumococcal bacteremia occurs primarily in patients with underlying disease, and that pneumococcal vaccine should be offered to such patients.