What vaccinations are recommended after a splenectomy (removal of the spleen)?

Recommended Vaccines After Splenectomy

After a splenectomy, patients must receive immunizations against encapsulated bacteria (Streptococcus pneumoniae, Haemophilus influenzae type B, and Neisseria meningitidis) to prevent potentially fatal overwhelming post-splenectomy infection (OPSI). 1

Core Vaccinations Required

Timing of Vaccination

• Ideally, vaccinations should be administered at least 2 weeks before elective splenectomy 1
• For emergency splenectomy, vaccinations should be started no sooner than 14 days after surgery 1
• If discharge occurs before 15 days post-splenectomy and risk of missing vaccination is high, vaccinate before discharge 1

Essential Vaccines

1. Streptococcus pneumoniae

   • Both conjugate (PCV13) and polysaccharide (PPSV23) vaccines recommended 2
   • S. pneumoniae causes approximately 50% of OPSI cases 1

2. Haemophilus influenzae type B (Hib)

   • Single dose required 2

3. Neisseria meningitidis

   • Both meningococcal ACYW135 (two doses) and meningococcal B (two doses) vaccines 2

4. Annual influenza vaccine

   • Recommended for all asplenic patients over 6 months of age 1
   • Helps prevent secondary bacterial infections, including pneumococcal infection 1

Clinical Significance and Rationale

The risk of OPSI is highest in the first year after splenectomy but remains elevated for life 1. OPSI has a mortality rate of 30-70%, with most deaths occurring within the first 24 hours 1. This underscores the critical importance of proper vaccination.

Key facts about OPSI:

• Incidence: 0.5-2% in asplenic patients 1
• Mortality: 30-70% 1
• Highest risk: First year post-splenectomy, but remains elevated for more than 10 years 1
• Children under 5 years have greater overall risk compared to adults 1

Common Pitfalls and Caveats

1. Inadequate vaccination coverage

   • Studies show poor vaccination rates among splenectomized patients, with coverage ranging from only 27-42% for recommended vaccines 2, 3

2. Timing errors

   • Vaccinating too soon after splenectomy (before 14 days) may result in suboptimal antibody response 1

3. Incomplete vaccination series

   • Many patients receive only some of the recommended vaccines 3
   • Only 18.7% of patients in one study received both pneumococcal vaccines 3

4. Lack of revaccination

   • Booster doses are often missed 2
   • Consider revaccination every 1-5 years 4

5. Failure to recognize hyposplenic status

   • Patients with partial splenic embolization should also receive vaccinations 1

Additional Preventive Measures

• Malaria prophylaxis is strongly recommended for travelers to endemic areas 1

• Emergency antibiotics

  • Patients should have an antibiotic supply for use with any sudden onset of fever, malaise, or chills 1
  • Adult options: Amoxicillin 3g starting dose followed by 1g every 8h, or levofloxacin/moxifloxacin for penicillin-allergic patients 1
  • Children: Amoxicillin 50mg/kg in three divided daily doses 1

• Patient education

  • Primary care providers must be aware of the patient's asplenic status 1
  • Patients should be informed that vaccination reduces but does not eliminate OPSI risk 1

Proper vaccination and preventive measures are essential for reducing the significant morbidity and mortality associated with asplenia, with vaccination being the cornerstone of prevention.