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Antibiotics Asplenia


Asplenia Prophylaxis Antibiotics - Antibiotics Asplenic Patients - Asplenia Antibiotic Prophylaxis - Asplenia Antibiotic Treatments

Asplenia refers to the absence of normal spleen function and is associated with some serious infection risks. Hyposplenism is used to describe reduced ‘hypo-’) splenic functioning, but not as severely affected as with asplenism.

Asplenia refers to the absence ('a-') of normal spleen function and is associated with some serious infection risks.

Hyposplenism is used to describe reduced ('hypo-') splenic functioning, but not as severely affected as with asplenism.

"Asplenia" means absence of spleen or splenic functioning. This condition can be congenital or occur at birth, or it may happen later in life if spleen functioning somehow fails or if the spleen needs to be removed. The challenge of this situation at any time in life is that it makes people much more vulnerable to infection. In order to manage this, preventative antibiotics are usually needed and must be taken on a daily basis. Special protocol might also exist if the person with asplenia is exposed to serious illnesses or requires surgery.

Congenital asplenia is usually present with heart defects. Though rare, a condition called heterotaxy is one of the main causes. Heterotaxy is further separated into right and left atrial isomerism. In left atrial isomerism, the body may have many small spleens, and these may function well enough to confer some immunity. Surgery is usually still needed in early childhood to repair conditions such as holes between the ventricles (ventricular septal defects), or narrowing of the pulmonary valve.

Right atrial isomerism is more severe, with more significant heart defects and complete asplenia. Heart defects associated with this condition include atrioventricular canal, though others can be present. With both forms of heterotaxy the heart has looped in the wrong direction when forming, and is abnormally placed. Other organs can be misarranged too, in addition to the body missing a spleen or having too many of them. It should be noted that asplenia may occasionally be congenital without heart defects.

There are a few reasons why people might acquire asplenia. The more obvious is that the spleen needs to be removed at some point in life, due to accident or trauma, or occasionally due to an elected treatment to deal with certain blood disorders like thalassemia. Some serious illnesses can also destroy the spleen, and though it may be present, it may no longer function properly. One example of this is sickle cell anemia, which can target the spleen and basically cause its death.

The degree to which a missing spleen alone provides problems is not always possible to predict. In many cases people do quite well by taking simple antibiotics like amoxicillin each day. It’s usually highly advised that people with asplenia get vaccinations, though it might inadvisable for them to use live active forms of vaccines. Doctors may also recommend additional antibiotics for use when colds or flus occur, and people with heterotaxy will especially need antibiotic prophylaxis prior to dental work.

The main concern with taking so many antibiotics is that they may cease to be effective and people could then get infections that are harder to treat. At the same that asplenia’s main treatment is usually antibiotics, it’s still important to use antibiotics wisely. It can be said, though, that many people with this condition have healthy lives and very few limits on their behavior.

Treatment Asplenia

Antibiotic prophylaxis
Because of the increased risk of infection, physicians administer oral antibiotics as a prophylaxis after a surgical splenectomy. The duration suggested varies: one suggestion is that antibiotics be taken for two years or until the age of sixteen years old is reached, whichever is longer.

Patients are also cautioned to start a full-dose course of antibiotics at the first onset of an upper or lower respiratory tract infection (for example, sore throat or cough), or at the onset of any fever.

Vaccinations
It is suggested that splenectomized persons receive the following vaccinations, and ideally prior to planned splenectomy surgery:

• pneumococcus every 6 years (a conjugated form is used for children under 2 years)

• Haemophilus influenzae - whilst in many countries now routinely given to all children, a single booster is advised following the development of asplenia, but for those adults who have not been previously vaccinated, two doses given two months apart were advised in the new 2006 UK vaccination guidelines (in the UK may be given as a combined Hib/MenC vaccine).

• meningococcus-'C' conjugate vaccine - again routinely given to children in many countries, previously vaccinated adults require a single booster and non-immunised adults advised, in UK since 2006, to have two doses given two months apart.

• annual flu vaccinations - to help prevent getting secondary bacterial infection.

Pediatric Asplenia Treatment

Once the diagnosis of anatomic or functional asplenia is confirmed, aggressive management is the key to decreasing the morbidity and mortality associated with this condition. Newborn diagnosis of sickle cell disease is essential because the first manifestation of the hemoglobinopathy in these infants may be an asplenia-related fatal bacteremia. Any episode of fever or signs of infection should be promptly and aggressively treated.

Medical care involves 4 key components: antibiotic prophylaxis, appropriate immunization, aggressive management of suspected infection, and parent education.

Antibiotic prophylaxis

  • Antibiotic prophylaxis should be initiated immediately upon the diagnosis of asplenia because these patients are at significant risk of pneumococcal infections. For children younger than 2 years, oral penicillin V may be given twice a day. Amoxicillin has also been recommended as an appropriate prophylactic antibiotic. Erythromycin is an alternate choice in patients who are allergic to penicillin.

  • In general, antimicrobial prophylaxis should be considered for all children with asplenia or splenic dysfunction until age 5 years and for at least 1 year after surgical splenectomy. Some experts recommend continuing prophylaxis into adulthood, particularly for high-risk patients.

  • Numerous controversies surround when to discontinue antimicrobial prophylaxis in asplenia and hyposplenia (if it should be discontinued at all). Arguments for cessation of prophylaxis include poor patient compliance and the development of resistant bacterial strains in patients on daily antibiotics. Those in favor of lifelong prophylaxis cite case reports of overwhelming postsplenectomy sepsis that occurs years after removal of the spleen. Currently, most guidelines leave the option open to continue lifelong prophylaxis based on the clinical circumstances of the individual patient.

Immunization
  • All patients should receive all standard childhood and adolescent immunizations at the recommended age. Most importantly, vaccinations against encapsulated organisms, including pneumococcal conjugate and/or polysaccharide, H influenzae type b conjugate, and meningococcal conjugate and/or polysaccharide vaccines, should be administered on the standard schedule.

  • Approximately 80% of the pediatric pneumococcal bacteremias in the United States are caused by the 7 serotypes covered in the conjugate vaccine: 4, 6B, 9V, 14, 18C, 19F, and 23F. The conjugate vaccine has been effective in dramatically reducing the occurrence of invasive pneumococcal disease. In children younger than 2 years, the incidence of all invasive pneumococcal infections has decreased by 80% after conjugate vaccine was recommended in the routine childhood immunization schedule. Infections caused by vaccine and vaccine-related serotypes have decreased by 90% in older children and adults.

  • The immunization schedule for pneumococcal conjugate vaccine (PCV7) consists of a primary series of 4 doses (0.5 mL each) at age 2, 4, 6, and 12-15 months. Catch-up immunization schedules are published regarding appropriate dosing schedules for children aged 5 years or younger.

  • In February, 2010 the FDA approved a pneumococcal conjugate vaccine covering 13 serotypes (PCV13) for children from 6 weeks to 5 years of age. This will likely replace the 7 serotype vaccine and provide broader coverage against pneumococcus.

  • The pneumococcal polysaccharide vaccine against 23 serotypes (PPV23) should be given after age 24 months for supplemental protection. Children older than 5 years should receive a dose of either PCV7 or PPV23. If both vaccine types are given, PCV7 should be administered first, with administration of PPV23 at least 8 weeks after the last dose of PCV7. A booster dose of PPV23 is appropriate 3-5 years after the first dose.

  • Patients should also receive quadrivalent meningococcal vaccine. Two licensed meningococcal vaccines are available in the United States against serotypes A, C, Y, and W-135, and another vaccine against serotype C is available in Europe. Meningococcal conjugate vaccine (MCV4) is indicated for children aged 2 years or older with increased risk of invasive meningococcal disease. Patients who were previously vaccinated at 7 years old or older should be revaccinated 5 years after their previous meningococcal vaccine. Patients who were previously vaccinated at ages 2-6 years should be revaccinated 3 years after their previous meningococcal vaccine. Patients with asplenia should continue to be revaccinated at 5 year intervals indefinitely.

  • The recommended vaccination schedule for H influenzae type b is a primary series of 3 doses given at age 2, 4, and 6 months or 2 doses given at age 2 and 4 months, depending on the particular conjugate vaccine product administered. A booster dose at age 12 months is recommended for all vaccine products. Children who are undergoing scheduled splenectomy after completion of their primary series and booster dose may benefit from an additional dose of conjugate vaccine at least 7-10 days before surgery. Catch-up immunization schedules regarding H influenzae type b vaccine are published. Patients 5 years or older who never received Hib immunization should receive 1 dose.

  • Yearly influenza vaccine is also recommended to minimize the likelihood of secondary bacterial infections.

  • Children 2 years of age or older undergoing elective splenectomy should receive 1 or both pneumococcal vaccines and the meningococcal vaccine at least 2 weeks prior to surgery. Children younger than 2 years should receive PCV7 (or PCV13) prior to elective splenectomy. Ensure the Hib vaccination series is completed.

Histoplasmosis and asplenia, Syndromes of Asplenia and Polysplenia, Asplenic Patients
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