A 34-year-old man is being discharged from the hospital after treatment for splenic rupture and intraabdominal bleeding following blunt abdominal trauma. His postoperative course was uncomplicated. The patient has no other chronic medical conditions and previously took no medications. He has no known drug allergies. Vital signs are normal. Abdominal examination shows a well healing incision. Appropriate vaccinations are planned for the first follow-up appointment in 2 weeks. Which of the following antibiotics should be prescribed for this patient to take immediately if he develops a fever?

Question

A 34-year-old man is being discharged from the hospital after treatment for splenic rupture and intraabdominal bleeding following blunt abdominal trauma.  His postoperative course was uncomplicated.  The patient has no other chronic medical conditions and previously took no medications.  He has no known drug allergies.  Vital signs are normal.  Abdominal examination shows a well healing incision.  Appropriate vaccinations are planned for the first follow-up appointment in 2 weeks.  Which of the following antibiotics should be prescribed for this patient to take immediately if he develops a fever?

Quizplus · Accepted Answer

This patient with splenic rupture likely had an emergency splenectomy. Because the spleen plays a vital role in generating antibodies, storing monocytes, and removing antibody-coated bacteria, patients with splenectomy are at significant risk for fulminant bacterial infection. Risk is greatest with encapsulated bacteria (eg, Streptococcus pneumoniae, Hemophilus influenzae, Neisseria meningitidis) because these organisms are destroyed primarily by splenic monocytes following opsonization in the intravascular or reticuloendothelial space. Fulminant bacterial infection can lead to death within hours of symptoms. Therefore, patients who undergo splenectomy are prescribed an antibiotic to take immediately when they develop fever. Amoxicillin-clavulanate is used most often due to its broad spectrum of activity against common encapsulated pathogens, but those with penicillin allergy can take levofloxacin, which has similar broad efficacy. Patients should be instructed to proceed to the nearest emergency department for evaluation of fever after they take the antibiotic. Patients who undergo splenectomy are also generally vaccinated against common encapsulated organisms. Vaccinations are typically administered >2 weeks after urgent splenectomy to ensure adequate humoral response. Most patients receive the 13-valent and 23-valent pneumococcal vaccines, the H influenzae type B vaccine, and the quadrivalent and monovalent meningococcal vaccines. Patients should also be given the yearly seasonal influenza vaccination to reduce the risk of secondary bacterial infection with S pneumoniae following influenza infection. (Choice B) Clindamycin is used to treat some gram-positive aerobic and anaerobic bacteria but has almost no efficacy against gram-negative bacteria such as N meningitidis and H influenzae. (Choice C) Metronidazole effectively covers gram-negative anaerobic bacteria and some protozoans but has minimal efficacy against aerobic and gram-positive organisms (eg, S pneumoniae). (Choice D) Rifampin has activity against intracellular pathogens such as Mycobacterium tuberculosis. Although it is sometimes used for chemoprophylaxis against N meningitidis in high-risk patients, it is not generally used for the treatment of this organism or other common encapsulated pathogens. (Choice E) Trimethoprim-sulfamethoxazole has broad efficacy against many gram-positive and gram-negative bacteria but is not typically used for splenectomy patients with fever due to delayed bactericidal activity and resistance patterns. Educational objective: Patients who undergo splenectomy are at high risk for fulminant sepsis with encapsulated organisms. They should be prescribed amoxicillin-clavulanate to take immediately in the setting of fever and then should be advised to proceed directly to the nearest emergency department.

A 34-Year-Old Man Is Being Discharged from the Hospital After