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    Fever in Patients with Impaired Spleen Function

    Cardinal Presentations / Presenting Problems, Infections

    Last Reviewed on Feb 08, 2023
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    By James Reid,Andrew Au


    • Patients with impaired splenic function are particularly vulnerable to sepsis caused by bacteria. These infections can become fulminant and fatal within hours of symptoms onset and as such, should be treated as a medical emergency.
    • Asplenic patients are at risk of overwhelming post-splenectomy infection (OPSI), a serious bacterial infection that carries a mortality of 38-39%.
    • Common foci of infection accompanying sepsis in asplenic and hyposplenic patients are pneumonia, primary bacteremia and meningitis.
    • Encapsulated bacteria:
      • pneumoniae (40-60%): most common, present with nonspecific features and often with pneumonia
      • influenzae
      • meningitidis
    • Less common encapsulated bacteria: canimorsus, Bordetella holmesii, K. pneumoniae.
    • Bloodborne parasites: Babesia spp, Plasmodium spp.

    Diagnostic Process

    1. History

    • New site-specific symptoms
    • Last CD4+ lymphocyte count
    • Current treatment and adherence (e.g., HAART)
    • Recent history of drug intake, travel or unprotected sexual contact
    • Recent antibiotic treatment
    • Surgical history
    • Underlying comorbid conditions
    • Past microbiology records – history of antibiotic resistant organisms or bacteremia

    2. Physical Examination

    • Axillary temperature
    • Presence of indwelling IV catheters
    • Emphasis on:
      • Skin lesions and lymph nodes
      • Oropharynx and sinuses
      • Chest and lungs
      • Abdomen
      • Genital and perianal/rectal area*
        • * DRE should be avoided in neutropenic or immunocompromised patients
      • Central nervous system

    3. Investigations

    • Peripheral blood smear to assess for Howell-Jolly bodies (evidence of impaired spleen function)
    • CBC with differential
    • Creatinine, electrolytes
    • Liver function tests, coagulation screen
    • CRP
    • Blood cultures: two sets – one peripheral and one from CVC
    • Microbiologic testing from suspected sites of infection:
      • Urinalysis and culture
      • Sputum microscopy and culture
      • Stool microscopy and culture
      • Skin lesion (aspirate, biopsy, swab, culture)
      • Chest radiograph
      • Lumbar puncture
    • SARS-CoV-2 testing
    • Ultrasound to confirm asplenia


    • Take an oral antibiotic (if on hand) AND present to the nearest emergency department immediately.
    • Upon arrival to the ED, prompt administration of IV broad-spectrum antibiotics. Do not delay this to perform diagnostic studies.
      • Standard regimen: vancomycin + either ceftriaxone or cefotaxime.
      • Cephalosporin allergy or intolerance: vancomycin + either moxifloxacin or meropenem.
      • NOTE: due to increased prevalence of meningitis, antibiotics are dosed for CSF penetration.

    Recommended Treatment

    Adults (Standard regimen)

    • Vancomycin 25-30 mg/kg IV loading dose, followed by 15-20 mg/kg IV q8-12h (maximum 2g/dose or daily total of 60 mg/kg initially), PLUS
    • Ceftriaxone 2 g IV q12h OR cefotaxime 2 g IV q4-6h

    Adults (Cephalosporin allergy or intolerance)

    • Vancomycin 25-30 mg/kg IV loading dose, followed by 15-20 mg/kg IV q8-12h (maximum 2g/dose or daily total of 60 mg/kg initially), PLUS
    • Moxifloxacin 400 mg IV q24h OR meropenem 2 g IV q8h

    Children (Standard regimen)

    • Vancomycin 15 mg/kg IV q6h (maximum 2 g per dose), PLUS
    • Ceftriaxone 50 mg/kg IV q12h (maximum 2 g per dose) OR cefotaxime 75 mg/kg IV q4h (maximum 2 g per dose and 12 g per day)

    Children (Cephalosporin allergy or intolerance)

    • Vancomycin 15 mg/kg IV q6h (maximum 2 g per dose), PLUS (one of):
    • Levofloxacin 10 mg/kg IV q12h (maximum 375 mg per dose) if ≥ 6 months old and < 50 kg;
    • Levofloxacin 750 mg IV q24h (maximum 750 mg per day) if > 50 kg; OR
    • Meropenem 40 mg/kg IV q8h (maximum 2 g/dose)

    Unusual Exposures

    Animal bites

    • If antecedent dog bite (or other animal bite), treat with:
    • Vancomycin + piperacillin-tazobactam (4.5g q6h) or meropenem (2g q8h) to target Capnocyophaga spp.

    Bloodborne parasites

    • If at risk for babesiosis (e.g., tick bite, transfusion in an endemic area) and compatible features (e.g. fever, myalgias, arthralgias, hemolytic anemia), include targeted treatment for the relevant parasite in the initial antibiotic regime.


    • Because progression to septic shock and respiratory distress can occur rapidly, preparations for fluid resuscitation, vasopressor support, and airway management should be made.
    • Admit asplenic and hyposplenic patients with fever and/or sepsis to the hospital for at least 72 hours for close monitoring, supportive care, and empiric antibiotic treatment while diagnostic evaluation is pending.

    Related Information

    Reference List

    1. Morgan, T. L., & Tomich, E. B. (2012). Overwhelming post-splenectomy infection (OPSI): A case report and review of the literature. The Journal of emergency medicine, 43(4), 758-763.

    2. Davies, J. M., Lewis, M. P., Wimperis, J., Rafi, I., Ladhani, S., & Bolton‐Maggs, P. H. (2011). 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. British journal of haematology, 155(3), 308-317.

    3. Kanhutu, K., Jones, P., Cheng, A. C., Grannell, L., Best, E., & Spelman, D. (2017). Spleen Australia guidelines for the prevention of sepsis in patients with asplenia and hyposplenism in Australia and New Zealand. Internal Medicine Journal, 47(8), 848-855.

    4. Davidson, R. N., & Wall, R. A. (2001). Prevention and management of infections in patients without a spleen. Clinical Microbiology and Infection, 7(12), 657-660.

    5. Theilacker, C., Ludewig, K., Serr, A., Schimpf, J., Held, J., Bögelein, M., & Kern, W. V. (2016). Overwhelming postsplenectomy infection: a prospective multicenter cohort study. Clinical Infectious Diseases, 62(7), 871-878.



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