Weekly blog - Overwhelming Post Splenectomy Infection (OPSI)

I couldn't do better than to refer you to the great "Care of the Asplenic Patient" NEJM article from July 24... Get that here.

What was discussed was this (?false!) belief that ceftriaxone ought not be used in patients with sickle cell anemia due to a fear of antibiotic associated hemolysis.  I do believe that rare drug adverse events do exist -- but I'm uncertain we should en masse change our practices over the fear of rare events.

There certainly is a literature on ceftriaxone induced hemolytic anemia (drug induced hemolytic anemia, DIHA), occuring in sickle cell anemia patients as well as other patients (see here).  In this reference lab, of 169 cases of drug induced hemolysis reported there were 15% of them due to CTX -- the proportion due to CTX increasing as the rates of CEFOTETAN use went down.  In fact, CTX was the number two reported agent for DIHA!

PIP-TAZO has also been linked to drug induced severe and acute hemolysis... (see here) ... oh, and in the report of ceftriaxone I referenced above -- Guess who was number one cause?  PIPERACILLIN.

... also there are case reports for the FLUOROQUINOLONES as well... (see here)

The key is that these are RARE events given the frequency in which these agents are used. The keen clinician is mindful that they exist but does not knee-jerk avoid very useful agents for potential fatal infections out of a fear of rare events.

People can die from adverse reactions to CT contrast (example).  This doesn't mean that we shouldn't use CT contrast.  Rather it means that CT contrast should be used when the expected benefit of contrast exceeds the risks.

***

As discussed, fluoroquinolones carry they own risks -- particularly in sickle patients who may be receiving QTc prolonging medications (think torsades) like methadone or other narcotics.  They may also (in our setting) be associated with an increased risk of C. difficile.

Piperacillin-Tazobactam seemingly would cover most S. pneumoniae but I really cannot say how effective it would be against AMPICILLIN resistant Neiserria species or beta-lactamase negative ampilillin resistant (BLNAR) H. infuenzae, which would likely be resistant. Ceftriaxone has been used in Neiserrial and BLNAR infections.

So, I would agree with the uptodate article on the issue (link) -- ceftriaxone should proabably be the "go to drug" in asplenic patients with sickle-cell anemia and probable infection in the asplenic host.  

With a careful observation for worsening hemolysis and consideration of an early change in the face of the rare, but severe, side effect of intravascular hemolysis.  And an attention to proper dosing in the very young or very underweight individuals.