People with asplenia/hyposplenism are at increased risk of fulminant sepsis, which carries a high mortality rate. A range of preventive measures is recommended although there is ongoing evidence that knowledge of and adherence to these strategies is poor. There have been significant changes in recommended vaccinations since the previously published recommendations in 2008. We provide current recommendations to help Australian and New Zealand clinicians in the prevention of sepsis in patients with asplenia and hyposplenia. The guideline includes Australian epidemiological data, preferred diagnostic techniques and recommendations for optimal antimicrobial prophylaxis and vaccination protocols.

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Iron staining is an unwanted and in some cases permanent adverse effect of intravenous iron administration. Cosmetically unacceptable staining may cause distress and have psychological implications for the patient. There should be a suitable indication for parenteral iron therapy. Patients must be advised of the risk of harm and give their informed consent before receiving parenteral iron. Strategies to minimise the risks of staining with intravenous iron include appropriate cannulation and close monitoring of the infusion. Stop the infusion if there are signs of extravasation. Laser therapy may be a treatment option in cases of persistent discolouration due to iron staining. is limited in practice, 3 but the injection can be given into an unexposed site. However, administration at an unexposed site is not necessarily possible when giving iron intravenously. A rise in reports of iron staining 6-10 may correspond with the increasing use of intravenous iron in clinical practice. 6-13 Minimising harm Specific definitive risk factors for extravasation of intravenous iron have not been published. The principles for minimising the harm associated with intravenous iron preparations have been adapted from those applied to intramuscular iron (Box 1). 5 They include a good infusion technique (Box 2). REFERENCES SELF-TEST QUESTIONS True or false? 1. Extravasation of intravenous iron leads to skin necrosis 2. The skin staining from intravenous iron usually resolves in one week

A 62-year-old man was admitted to hospital for elective revision of a left total hip arthroplasty. His history was significant for human immunodeficiency virus (HIV) infection for which he was taking the following antiretroviral agents (ARVs): etravirine, ritonavir, darunavir, raltegravir and tenofovir/emtricitabine. Rivaroxaban 10 mg daily was commenced on the second postoperative day for venous thromboembolism (VTE) prophylaxis. Approximately 24 h later, the patient developed hypotension and anaemia, accompanied by thigh swelling due to bleeding at the surgical site. Fluid resuscitation was commenced with red cell transfusion. The prothrombin time (PT) was prolonged at 24.3 (10.6–15.3) s, and a rivaroxaban level taken 24 h after administration was 75 ng/mL. Rivaroxaban was ceased, the PT normalised within 24 h of stopping the drug, and the patient made an uneventful recovery. None of the other coadministered drugs are known to interact with rivaroxaban, or are likely to, based on their metabolic pathways. Rivaroxaban, a substrate for cytochrome P450 (CYP) 3A4 and P-glycoprotein (P-gp), is contraindicated in patients concomitantly treated with strong inhibitors of both these systems, e.g. protease inhibitors (PIs) such as ritonavir (based on in vitro data and a pharmacokinetic study in healthy volunteers). No published data are available on the PI darunavir, a moderate inhibitor; however, concomitant use with rivaroxaban should also be avoided. A prolonged PT and a rivaroxaban trough level greater than eight times that predicted from pharmacokinetic modelling suggests that bleeding was due to increased exposure to rivaroxaban, probably due to an interaction with ritonavir and darunavir. This is supported by a Drug Interaction Probability Scale (DIPS) score of 8. An interaction between a single dose of rivaroxaban and ARVs may be clinically significant; therefore, the patient’s medication history should be extensively evaluated to identify any potential interactions.