...and may be ineffectiveBMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6921.132 (Published 08 January 1994) Cite this as: BMJ 1994;308:132
- R G Finch,
- R Read
EDITOR, - We agree with Mary McMullin and George Johnston that splenectomy causes a slight but important long term susceptibility to (Predominantly pneumococcal) sepsis, but we cannot agree with their recommendation for lifelong chemoprophylaxis with phenoxymethylpenicillin or their devaluation of pneumococcal vaccine.1 A rigid regimen of lifelong chemoprophylaxis is of uncertain value for several reasons, the most pertinent being that the patients do not comply.
Pneumococcal vaccine is the most important component of prophylaxis for people after a splenectomy. There are few data, but the 23 valent vaccine seems to be highly effective,2 with rare reports of failure of the vaccine. The only clinical situation in which chemoprophylaxis is unavoidable is for infants who have had a splenectomy who are too young to mount a serological response to the vaccine; they should receive formal chemoprophylaxis until capable of mounting a response. With regard to chemoprophylaxis, Streptococcus pneumoniae can no longer be regarded as a pathogen with uniformly predictable sensitivities. Pneumococci with reduced susceptibility or resistance to penicillin remain relatively rare in Britain but have been reported to account for 43% of isolates in Spain.3 Fortunately, 80% of Spanish isolates resistant to penicillin are of serotypes included in the currently licensed 23 valent vaccine. With the expansion of tourism British residents will probably increasingly encounter resistant strains. There has already been a report of invasive disease (meningitis) caused by a pneumococcus resistant to penicillin in a patient taking regular prophylactic ampicillin.4
We believe that education of patients or their carers is a far superior prophylaxis to oral medication. In a recent survey of patients' awareness of health precautions after splenectomy only 11% were aware of their increased susceptibility to serious infection.5
The important points are as follows. Firstly, pneumococcal vaccine should be given two weeks before splenectomy (if no splenic tissue can be conserved) or postoperatively to patients with trauma. Secondly, patients or parents, or both should be counselled to encourage rapid medical assessment for suspect infections and, when appropriate, self treatment with antibiotics. Thirdly, prophylactic phenoxymethylpenicillin should be given to children less than 2 years old until a logical response to the vaccines is assured. Finally, Haemophilus influenzae type b vaccine should be given to all patients who have not already received it. Improved conjugate pneumococcal vaccines are expected to provide greater protection and make the requirement for reimmunisation clearer.