II. Epidemiology

  1. Risk in Asplenic or Hyposplenic patients
    1. Hospitalization for infection in 33% within 10 years
  2. Highest riskin first 2 years after splenectomy

III. Causes

  1. Most common
    1. Streptococcus Pneumoniae (57%)
    2. HaemophilusInfluenzae (6%)
    3. Neisseria Meningitidis (3.7%)
    4. Salmonella (esp. in Sickle Cell Anemia)
  2. Other causes
    1. Capnocytophaga canimorsus (dog exposure)
    2. Group B Streptococcus
    3. Bartonella Bacilliformis
    4. Eikenella corrodens
  3. Region specific (tick-borne illness)
    1. Babesia (Babesiosis)
    2. Ehrlichia

IV. Risk Factors in Asplenic or Hyposplenic patients

  1. Splenectomy within last 2 years (highest risk)
  2. Hodgkin's Disease
  3. Hypogammaglobulinemia
  4. Chemotherapy
  5. Radiation Therapy
  6. Bone Marrow Transplantation

V. Symptoms

  1. Source of infection may be difficult to identify
  2. Short, often mild Influenza-like prodrome
    1. Fever
    2. Malaise
    3. Myalgias
    4. Headache
    5. Vomiting
    6. Diarrhea
    7. Abdominal Pain

VI. Signs

  1. Septic Shock
  2. Disseminated Intravascular Coagulation
  3. May be rapidly fatal within 48 hours

VII. Labs (do not delay antibiotics)

  1. Chemistry panel (Chem7 or SMA7)
  2. Complete Blood Count with platelets and differential
    1. White Blood Cell Count will be abnormal (too high or too low)
    2. Toxic granulation
    3. Thrombocytopenia
  3. Peripheral Blood Smear with buffy coat preparation
    1. Observe for Bacteria
  4. Blood Culture

VIII. Imaging

IX. Management: Antibiotics

  1. Empirically cover Penicillin-resistant pneumococcus and HaemophilusInfluenzae
  2. First Line Antibiotics (usually used in combination with Vancomycin)
    1. Cefotaxime (Claforan)
      1. Adults: 2 g IV q8 hours
      2. Children: 25 to 50 mg/kg IV q6 hours
    2. Ceftriaxone (Rocephin)
      1. Adults: 2 g IV q12 to 24 hours
      2. Children: 50 mg/kg IV q12 hours
    3. Levofloxacin (Use as alternative only if Anaphylaxis to Penicillin or Cephalosporins)
      1. Adults: 750 mg IV q24 hours
  3. Added Antibiotics in Special Circumstances
    1. Penicillin Resistant Pneumococcus suspected (add in most cases)
      1. Vancomycin
        1. Adults: 1 to 1.5 g IV q12 hours
        2. Children: 30 mg/kg IV q12 hours
    2. Gastrointestinal or Urinary Source
      1. Gentamicin
        1. Adults: 5 to 7 mg/kg IV q24 hours
        2. Children: 2.5 mg/kg IV q8 hours
      2. Ciprofloxacin (adults only) 400 mg IV q12 hours

X. Prognosis

  1. Mortality
    1. Immediate treatment: 10% mortality
    2. Delayed treatment: 50-80% mortality

XI. Prevention

  1. See Asplenic

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