Adult Medical Prophylaxis

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Asplenia / Splenic Dysfunction / Splenectomy Prophylaxis

Vaccination

Patients should be vaccinated ideally 4 weeks before but at least two weeks before or two weeks after splenectomy .  If patient is discharged sooner than 2 weeks post-splenectomy, give first dose of vaccines on day of discharge.  In general, vaccination should take place at least two weeks before or at least three months after immunosuppressive chemotherapy or radiotherapy. Ensure the GP is fully informed about outstanding vaccinations on discharge.

For both adult and paediatric patients, the vaccination schedule in cases of asplenia or hyposplenia is outlined in the National Immunisation Guidelines, available at www.hse.ie .  See the tables below for a summary of the vaccination schedule for ADULT patients.

Vaccine – Full Name

Vaccine – Short Name

Brand(s)

Haemophilus influenzae type b

Hib

Hiberix®

Meningococcal conjugate

MenACWY

Menveo®, Nimenrix®

Meningococcal B

MenB

Bexsero®

Pneumococcal conjugate

PCV

Prevenar-13®

Pneumococcal polysaccharide

PPV

Pneumovax 23®

Influenza

Influenza

Changes annually

Vaccine

Recommended Schedule

Hib

Not previously immunised with Hib:

Two doses given 2 months apart.

Previously immunised with Hib:

One dose.

MenACWY

Regardless of immunisation history:

Two doses given 2 months apart.  Booster dose every 5 years.

MenB

Not previously immunised with MenB:

Two doses given 1 month apart.

PCV

Not previously immunised with PCV or PPV:

Two doses 2 months apart followed by PPV (see below)

Previously immunised with PCV:

One dose followed by PPV (see below).

Previously immunised with PPV:

Wait at least 1 year before giving PCV schedule.

PPV

Not previously immunised with PPV:

First dose at least 2 months after PCV. Booster dose 5 years later.  If < 65 years when booster dose given, final booster dose at least 5 years later at > 65 years.

Previously immunised with PPV when < 65 years:

Booster dose 5 years after previous dose (given at least 2 months after PCV).  If < 65 years when booster dose given, final booster dose at least 5 years later at > 65 years.

Previously immunised with PPV when > 65 years:

No further doses of PPV required.

Influenza

Annual vaccination during the influenza season.  Influenza vaccine also recommended for household contacts of a person with asplenia or hyposplenia.

Antibiotic Prophylaxis ​

  • Phenoxymethylpenicillin (Calvepen®) 666mg BD
  • If penicillin allergic, Erythromycin 250mg BD

Duration of Antibiotic Prophylaxis

​Life-long antibiotic prophylaxis is recommended, particularly for patients at highest risk of pneumococcal infection:

  • Aged less than 16 years or greater than 50 years
  • Inadequate serological response to pneumococcal vaccination
  • History of previous invasive pneumococcal disease
  • Splenectomy for underlying haematological malignancy, particularly in the context of on-going immunosuppression

​

Patients not at high risk may be counselled regarding the risks and benefits of lifelong antibiotic prophylaxis – the review may be conducted by the patient’s GP after 2 years, who should also assess the serological response to vaccination after the first 2 years.  Though most infections occur within the first two years after splenectomy, up to a third may be manifested at least five years later.

Patient Education

A patient information leaflet and splenectomy card is available from https://www.gov.uk/government/publications/splenectomy-leaflet-and-card :

Advise patient to

  • Seek urgent medical attention if they develop a fever or other symptoms of infection, e.g. sore throat, as asplenic patients are immunocompromised and infection can progress very quickly.
  • Consider carrying a card to alert doctors that they do not have a working spleen in case of emergency.
  • Seek medical advice prior to booking an overseas holiday.  It is recommended that patients who plan to travel overseas receive an emergency/standby supply of antimicrobials to take on the trip in the event that they become unwell and there is a potential delay in seeking medical attention.  Prescribe co-amoxiclav 625mg TDS PO or, if penicillin allergy, levofloxacin 500mg once daily PO (Caution with levofloxacin – risk of long-lasting and disabling adverse effects, mainly involving muscles, tendons and bones and the nervous system.  Consider potential to prolong the QT interval. Consider that seizure threshold may be lowered.)

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Endocarditis Prophylaxis

See 2023 European Society of Cardiology Guidelines for the management of infective endocarditis available at https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Endocarditis-Guidelines

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Influenza (Flu) Prophylaxis

Indication

Influenza (Flu) Prophylaxis

First Line Antimicrobials

ALWAYS refer to the latest national influenza management algorithm which is update regularly and available at http://www.hpsc.ie/a-z/respiratory/influenza/seasonalinfluenza/guidance/

Oseltamivir chemoprophylaxis may be prescribed when an individual in a defined “at-risk” group (listed below) is exposed to a confirmed case of influenza infection:

  • Age > 65 years
  • Severe obesity (BMI > 40 kg/m 2 )
  • Chronic respiratory, heart, kidney, liver or neurological disease, diabetes mellitus, haemoglobinopathy
  • Immunosuppression
  • Pregnancy and up to 2 weeks post-partum
  • LTC residents
  • Start chemoprophylaxis within 48 hours of the patient’s most recent exposure to a confirmed case of influenza
  • If duration since last exposure > 48 hours, discuss chemoprophylaxis with Consultant Microbiologist.

Oseltamivir 75mg once daily PO

Comments

Duration of Prophylaxis

10 days

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Meningococcal Prophylaxis for Contacts

N.B. ALWAYS Contact Public Health 046 9282700 and/or Occupational Health 041 6857811 as indicated.

Following each notification of a case of meningococcal meningitis, Public Health, in conjunction with Occupational Health for HCW, is responsible for conducting a risk assessment to determine which individuals require chemoprophylaxis.

Please also refer to HPSC Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis 2012, updated 2016, available from www.hpsc.ie .

Recommendation for chemoprophylaxis among HCW:

  • Chemoprophylaxis is recommended only for those whose mouth or nose is directly exposed to large particle droplets/secretions from the respiratory tract of a probable or confirmed case of meningococcal disease during the acute illness until the case has completed 24 hours of systemic antibiotics. This type of exposure will only occur among staff who are working close to the face of the case without wearing a mask or other mechanical protection.
  • In practice, this implies a clear perception of facial contact with droplets/secretions and is unlikely to occur unless using suction during airway management, inserting an airway, intubating, or if the patient coughs in your face .
  • General medical or nursing care of cases is not an indication for prophylaxis.

Isolation of meningococci from sputum or swabs taken from nasopharynx or genital tract in the absence of clinical evidence of sepsis, is not by itself an indication for public health action as asymptomatic carriage in the respiratory and genital tract is common.

Recommended meningococcal chemoprophylaxis :

Ciprofloxacin, rifampicin and cef-TRI-axone are currently in use in Ireland for meningococcal chemoprophylaxis, depending on the situation.  The HPSC Guidelines outline that ciprofloxacin can be used in all age groups and for the majority of the population (except for those with contra-indications).

CIPROFLOXACIN Dosing Schedule:

Patient Group

CIPROFLOXACIN Chemoprophylaxis Dose

Adults and children aged 12 years or more

CIPROFLOXACIN 500mg stat dose

Children aged 5 to 11 years

CIPROFLOXACIN 250mg stat dose

(see notes below)

Children under 5 years

CIPROFLOXACIN 30mg/kg (max 125mg)

stat dose (see notes below)

Notes:

  • Ciprofloxacin 250mg tablets may be halved to provide a 125mg dose
  • Ciprofloxacin tablets may be dispersed in water for younger children and those that cannot swallow tablets (allow 2 to 5 minutes for the tablet to disperse).
  • Ciprofloxacin liquid is unlicensed.  It should be required only for infants < 4kg based on the dosing recommendations above.

RIFAMPICIN Dosing Schedule:

Patient Group

RIFAMPICIN Chemoprophylaxis Dose

Adults and children aged 12 years or more

RIFAMPICIN 600mg twice daily for 2 days

Children aged 1 to 11 years

RIFAMPICIN 10mg/kg (max 600mg) twice daily for 2 days

Children aged 0 to 11 months

RIFAMPICIN 5mg/kg twice daily for 2 days

CEF-TRI-AXONE Dosing Schedule:

Patient Group

CEF-TRI-AXONE Chemoprophylaxis Dose

Adults

CEF-TRI-AXONE 250mg IM stat dose

Timing of meningococcal chemoprophylaxis :

Antibiotic prophylaxis should be given as soon as possible (ideally within 24 hours) after notification of the index case.

Follow-up of contacts :

Public Health will inform the GP for each contact for whom chemoprophylaxis has been recommended.  The Obstetrician should also be informed in the case of pregnant contacts.  Depending on the serogroup of the index case, vaccination with Meningitis B, Meningitis C or Meningitis ACWY vaccine may be recommended for close contacts.  HCW should be referred to Occupational Health for further follow-up.  Public Health will arrange follow-up for other contacts.

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Variceal Haemorrhage Prophylaxis

Indication

Variceal Haemorrhage Prophylaxis for patients with cirrhosis

First Line Antimicrobials

Cef-TRI-axone 1g once daily IV

NON-immediate-onset and NON-severe Penicillin Hypersensitivity

Cef-TRI-axone 1g once daily IV

IMMEDIATE-onset or SEVERE Penicillin Hypersensitivity

Ciprofloxacin 500mg BD PO (excellent oral bioavailability) or 400mg BD IV only where oral route is not feasible

N.B. Risk of long-lasting and disabling adverse effects with quinolones, mainly involving muscles, tendons and bones and the nervous system.  Consider potential to prolong the QT interval. Consider that seizure threshold may be lowered.

Duration of Treatment

5 days

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References

  • Allison MC, Sandoe JAT, Tighe R et al. Antibiotic prophylaxis in gastrointestinal endoscopy. British Society of Gastroenterology. Gut 2009;58:869–880.

  • Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications. A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation. 2015;132:1435-1486.

  • Beaumont Hospital Antimicrobial Guidelines 2018. Available from RCSI Hospitals Antimicrobial Guidelines Smartphone Application, accessed 12/03/18.Obtained with permission from Consultant Microbiologist.

  • Davies JM, Lewis MP, Wimperis J et al. Review of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen: Prepared on behalf of the British Committee for Standards in Haematology by a Working Party of the Haemato-Oncology Task Force. Br J Haematol 2011;155:308-317.

  • Garcia-Tsao G, Abraldes JG, Berzigotti A, et al. Portal Hypertensive Bleeding in Cirrhosis: Risk Stratification, Diagnosis, and Management: 2016 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2017;65(1):310-335.

  • Gill D, Bates M, Bonner C et al. Immunisation Guidelines for Ireland. Available from www.immunisation.ie , accessed 9/5/16.

  • HSE and HPSC. Guidance on the use of antiviral agents for the treatment and prophylaxis of influenza, 2017-2018. Available from www.hpsc.ie .

  • Occupational Health Department. 2016. On file on OLOL T Drive.

  • Osmon DR, Berbari EF, Berendt AR et al. Diagnosis and Management of Prosthetic Joint Infection: Clinical Practice Guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2013;56(1):e1–25.

  • Scientific Advisory Committee, HPSC. Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis, 2012, revised 2016. Available from www.hpsc.ie .

  • Working Party of the British Committee for Standards in Haematology Clinical Haematology Task Force.