Sepsis in the Setting of

Asplenia
A Patient Case Presentation

Grace Carpenter, PharmD

 2

Objectives
1. Evaluate history of present illness and past medical history as well as
initial labs, imaging, and therapy in a patient diagnosed with sepsis.

2. Analyze the patient’s course of admission to conclude if therapy was

appropriate and create recommendations for discharge.
Patient
Introduction

About W.S.
About W,S. 4

W.S.: 35-year-old female, wt 94.8 kg, ht 170.2 cm

CC: Presented to the ED on 7/23 with lightheadedness, fatigue,

N/V/D, fever, chills, and headache. Pt also had SOB that has worsened
over the past month and back pain that’s worsened over the past 2
months.

HPI: Hospitalized two years ago for similar symptoms. According to

the patient, she was treated with IV ABX and blood transfusions and
symptoms resolved.

PMH: Beta thalassemia (follows with hematology) s/p splenectomy,

chronic ankle wound, chronic headaches, chronic back pain

Home Meds: Epoetin alfa 40,000 units twice weekly, gabapentin 300
mg qhs, naproxen 220 mg qd prn
 About W.S. 5

Initial Presentation: 7/23

Vitals Radiology
- Temperature: 103.4°F - CXR: “No large eusions or focal
- HR: 126 beats per minute infiltrates”
- BP: 94/44 mmHg - Ankle X-ray: Mild edema, no fracture or
- RR: 43 breaths per minute soft tissue gas
- CT Angiography: Cardiomegaly, no PE
Pertinent Labs seen
- Abdominal CT: No acute abnormalities
WBCs 20.8 LFTs WNL Hgb 6.8

SCr 0.64 Procal 4.5 Other pertinent Information

NT-ProBNP
CRP 170.5 - W.S. is an immigrant from Sudan
Lactate 2.6 - ID consulted was consulted early on in
604
admission
About W.S. 6

What are your

differential diagnoses?
Bacterial pneumonia Meningitis

Skin & soft tissue infection of the

Bacteremia
ankle

C. diicile Viral infection

Pulmonary embolism (ruled out) Malignancy

Vertebral osteomyelitis Tuberculosis

Background on
Sepsis and Asplenia
Background on Sepsis 8

De nitions
Sepsis: “Life-threatening organ dysfunction caused by a dysregulated host
response to infection” (Evans, 2021).

Septic Shock: “Hemodynamic instability despite intravascular volume

repletion…” (Chakraborty, 2023).
 Background on Sepsis 9

Sepsis Diagnostics
Early diagnosis of sepsis is vital to ensuring timely intervention and improved outcomes (Evans, 2021).

Systemic Inflammatory Response Quick Sequential Organ Failure

Syndrome (SIRS) Criteria Assessment (qSOFA) Criteria

Temp > 100.4℉ or < 96.8℉ Glasgow Coma Score < 15

HR > 90 beats per minute Respiratory Rate ≥ 22 breaths per minute

RR > 20 or PaCO2 < 32 mmHg Systolic blood pressure ≤ 100 mmHg

WBC > 12,000/mm3, < 4,000/mm3, or >

10% banded neutrophils
≥ 2 criteria met = qSOFA positive
Score of ≥ 2 meets SIRS criteria

(Chakraborty, 2023)
Background on Sepsis 10

Sepsis Diagnostics
Systemic Inflammatory Response Quick Sequential Organ Failure
Syndrome (SIRS) Criteria Assessment (qSOFA) Criteria

Temp > 100.4℉ or < 96.8℉ Glasgow Coma Score < 15

HR > 90 beats per minute Respiratory Rate ≥ 22 breaths per minute

RR > 20 or PaCO2 < 32 mmHg Systolic blood pressure ≤ 100 mmHg

WBC > 12,000/mm3, < 4,000/mm3, or >

10% banded neutrophils
≥ 2 criteria met = qSOFA positive
Score of ≥ 2 meets SIRS criteria

SIRS Criteria: Temp (103.4℉), HR (126 bpm), RR (43 rpm), WBCs (20.8) → 4
qSOFA Criteria: Unsure of Glasgow Coma Score, RR (43 rpm), SBP (94 mmHg) → 2/3
Background on Sepsis 11

Hemodynamic Management
1. Fluid resuscitation: 30 mL/kg of an IV crystalloid fluid
a. Balanced crystalloids are preferred
b. Goal mean arterial pressure (MAP): 65 mmHg
c. MAP Equation: ⅓(SBP) + ⅔ (DBP)

2. In the case of septic shock…

a. First Line: Norepinephrine (Levophed)
b. Second Line: Vasopressin
c. Third Line: Epinephrine
d. Consider using an arterial BP monitor (aka “art line”)
Background on Sepsis 12

Antimicrobials
3. Administer empiric ABX immediately (or within 1 hour of recognition of possible septic shock or likely
sepsis) unless another cause is very likely.
a. Cover MRSA in patients at high risk (below are risk factors provided by SJHS):
i. Central catheter, indwelling hardware, IV drug user
ii. Known colonization with MRSA
iii. Recent (within 90 days) or prolonged (> 2 weeks) hospitalization
iv. Transfer from ECF
b. Use antifungal therapy in patients at high risk for fungal infection
c. If at high risk for infection with MDROs, use two Gram(-) agents until cultures result
d. Duration of antibiotic therapy is still controversial

Gram (-) agents Zosyn OR cefepime

SJHS Antibiotic
Recommendations PLUS
for Empiric
Coverage in Sepsis
MRSA agents Vancomycin (not in combo with Zosyn), linezolid, OR daptomycin
Background on Sepsis 13

(Evans, 2021)
 Background on Sepsis 14

Intervention: Short-course (≤ 7 days) vs. long-course (> 7 days) of consecutive antibiotic therapy
(Takahashi, 2022)

Design: Retrospective observational study in the Japanese population

Patients (N=1,002,818): Sepsis diagnosis (suspected severe infection and acute end-organ dysfunction),
18 years or older, received antibiotics for ≤ 14 days

Primary Endpoint: 28-day mortality

Results: Primary endpoint occurred in 6% of short-course group vs. 7.3% of long-course group (HR 0.94, p<
0.001) although there were slightly higher re-initiation rates; subgroup analyses were completed by
infection

Conclusion: 28-day mortality was significantly lower in short-course antibiotics in the treatment of sepsis.
Background on Sepsis 15

Additional Therapies
6. IV Corticosteroids: For patients with septic shock and ongoing vasopressor
requirements (hydrocortisone 200 mg/day)
7. Stress Ulcer Prophylaxis: Recommended for patients with risk factors for GI bleeding
8. Venous Thromboembolism Prophylaxis: Pharmacologic prophylaxis is recommended
for septic patients unless a contraindication exists (LMWH preferred over UFH)
9. Insulin: Recommended for patients with blood glucose ≥ 180 mg/dL
10. Sodium Bicarbonate: Recommended for patients with septic shock, blood pH ≤ 7.2,
and AKI
11. Enteral Nutrition: If able to be fed enterally and not eating, start EN within 72 hours
Background on Sepsis 16

Monitoring & Other Precautions

6. Determining source of infection - radiology, symptoms,
cultures, etc.
7. Lactate → Can help guide fluid resuscitation
8. Procalcitonin → Can help guide antimicrobial
discontinuation
9. Remove any intravascular devices that could be a source of
infection
Background on Asplenia 17

What is our source or cause of

infection?

Remember: W.S. has beta

thalassemia and is asplenic….
 Background on Asplenia 18

The Spleen’s Role

The spleen serves two functions:
1. White Pulp: Antigen-presenting cells can
activate T cells, triggering a cascade that
results in the production of IgM and IgG
antibodies as well as the activation of B
cells which help phagocytose
encapsulated bacteria.
2. Red Pulp: Processes damaged red blood
cells and also supports phagocytosis
(Lee, 2020).
 Background on Asplenia 19

Beta Thalassemia & Asplenia

Beta thalassemia: Inherited disorder causing a decreased production of hemoglobin
(Thalassaemia, 2022).

- Results in anemia, leading to a possible lifelong blood transfusion requirement.

Importance: W.S. is s/p splenectomy to decrease transfusion requirements and

prevent iron overload.

- Beta thalassemia can lead to splenomegaly and recurrent abdominal pain.

- Asplenia predisposes patients to infection, particularly with encapsulated
organisms like S. pneumoniae, H. influenzae, and N. meningitidis as well as Gram
(-) organisms like E. coli, Klebsiella, and P. aeruginosa (Cappellini, 2008).
Background on Asplenia 20

Antibiotic Prophylaxis in Asplenia

Determining if a patient requires ABX prophylaxis requires evaluation of “...age, time since
splenectomy, degree of immunocompromise, or prior episode of sepsis (Lee, 2020).”
Background on Asplenia 21

ACIP Recommendations - Pneumococcal

ACIP: Advisory Commiee

of Immunization Practices

Important: Defer live

vaccinations due to
immunodeficiency.

(Lee, 2020)
Background on Asplenia 22

ACIP Recommendations - Meningitis

(Lee, 2020)
Background on Asplenia 23

ACIP Recommendations - H. influenzae

(Lee, 2020)
Further Patient
Workup
Further Patient Workup 25

ID Consult Summary
W.S. was worked up for…
- Bacterial meningitis → lumbar puncture and encephalitis panel (negative)
- Pneumonia → CT, CXR (supposedly negative for PNA, possible evidence of
transfusion-related acute lung injury)
- Tuberculosis → QuantiFERON-TB Gold and sputum AFB (negative)
- Bacteremia → Blood cultures (negative)
- Osteomyelitis → Ankle X-ray (negative)
- Malignancy (leukemia/lymphoma) → Pending
- UTI → UA (negative)
- Pharyngitis (strep throat) → Rapid strep screen (positive)
- Mononucleosis → Mono screen (negative)
- Hepatitis A, B, & C → Hep A, B, and C antibodies + hepatitis panel (negative)
- HIV → HIV 1&2 antibodies (negative)
Further Patient Workup 26

ID Consult Summary
W.S. was worked up for…
- C. diicile → C. diicile antigen test (negative)
- Pulmonary embolism → CT angiography (negative)
- Intra-abdominal infection → Abdominal CT (negative)
- Influenza → Influenza PCR (negative)
- COVID-19 → COVID-19 PCR (negative)
- Legionella → Urine antigen test (negative)
- Histoplasma → Urine antigen (negative)
- Intestinal parasites → Stool culture (negative)
- West Nile → IgG (positive) and IgM (negative, recent infection unlikely)
 Further Patient Workup 27

Discharge Summary
- W.S. was thoroughly worked up from an ID standpoint, and no definitive answers
were obtained in regard to a cause of sepsis.

- W.S. received broad-spectrum antibiotics (cefepime + vancomycin) for a period of

7 days while fevers slowly came down and continued to spike every couple of days.

- She was transitioned onto PO levofloxacin and doxycycline and was sent home
with a 7 day supply of each.
Conclusions &
Recommendations
Conclusions & Recommendations 29

Recommendations
- While the RCT referenced earlier states that short-course antibiotics are preferential to
long-course antibiotics, this patient continued to have fevers that spiked every couple
days. Because of this, I would not have recommended to stop antibiotics early.

- Antibiotic Prophylaxis: W.S. has already had one episode very similar to this several
years ago, so I feel that the patient is at great enough risk of infection to require
antibiotic prophylaxis.
- Routine Prophylaxis: Penicillin VK 250 mg PO BID
- Emergency Supply before ED Arrival: Amoxicillin/clavulanate 875/125 mg PO BID

- Immunizations: Continue to stay up-to-date with pneumococcal and meningococcal

vaccines, was already vaccinated with pneumococcal, meningococcal (MenACWY and
MenB), and Hib vaccines.
 References
1. Cappellini MD, Cohen A, Eleftheriou A, et al. Splenectomy in β-thalassaemia. In: Guidelines for the Clinical
Management of Thalassaemia. 2nd Ed. Nicosia, CY: Thalassemia International Federation; 2008.
2. Chakraborty RK, Burns B. Systemic inflammatory response syndrome. StatPearls. Accessed August 20,
2023. hps://www.ncbi.nlm.nih.gov/books/NBK547669/
3. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for
management of sepsis and septic shock 2021. Crit Care Med. 2021;49(11):e1063-e1143.
doi:10.1097/CCM.0000000000005337
4. Lee GM. Preventing infections in children and adults with asplenia. Am J Hematol. 2020;2020(1):328-335.
doi:10.1182/hematology.2020000117
5. Takahashi N, Imaeda T, Nakada T, et al. Short- versus long-course antibiotic therapy for sepsis: a post hoc
analysis of the nationwide cohort study. J Intensive Care. 2022;10(49). doi:10.1186/s40560-022-00642-3
6. Thalassaemia. National Health Service. Updated October 17, 2022. Accessed August 21, 2023.
hps://www.nhs.uk/conditions/thalassaemia/