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

Post-Splenectomy Immunizations

Core Vaccination Requirements

All patients undergoing splenectomy must receive three essential vaccines against encapsulated bacteria: pneumococcal, meningococcal (both ACWY and B serotypes), and Haemophilus influenzae type B (Hib), plus annual influenza vaccination. 1, 2

These vaccines are critical because asplenic patients face a lifelong risk of overwhelming post-splenectomy infection (OPSI), which presents as fulminant sepsis, meningitis, or pneumonia with mortality rates of 30-70%, with most deaths occurring within the first 24 hours. 1, 3

Optimal Timing of Vaccination

For Elective Splenectomy

• Administer all vaccines at least 2 weeks before surgery to allow optimal antibody response while the patient still has splenic function. 1, 2
• This pre-surgical timing is particularly important for pneumococcal vaccines, as it results in higher antibody concentrations compared to post-operative vaccination. 2

For Emergency Splenectomy

• Wait at least 14 days after surgery before vaccinating, as antibody response is suboptimal before this time. 1, 2
• If the patient's condition is unstable, administer vaccines as soon as the patient stabilizes. 2

Specific Vaccine Protocols

Pneumococcal Vaccination

• For vaccine-naïve patients: Give PCV13 (or newer PCV15/PCV20) first, followed by PPSV23 at least 8 weeks later. 2
• Booster schedule: Administer a second dose of PPSV23 five years after the first dose. 2
• Long-term: Consider reimmunization every 5-10 years. 1

Meningococcal Vaccination

• Both quadrivalent conjugate vaccine (MenACWY) and serogroup B vaccine are required. 2
• Booster schedule: Revaccinate with MenACWY every 5 years. 2

Haemophilus Influenzae Type B

• One dose of Hib conjugate vaccine is recommended for unvaccinated asplenic adults. 2
• The conjugate vaccine produces superior antibody responses compared to pure polysaccharide vaccines in splenectomized patients. 4

Influenza Vaccination

• Annual influenza vaccine is required for all asplenic patients over 6 months of age to reduce the risk of secondary bacterial infections. 1, 2

Critical Timing Considerations and Pitfalls

Recent Rituximab Exposure

• Patients who received rituximab within the previous 6 months may have suboptimal vaccine responses. 5, 2
• Reassess and potentially revaccinate once B-cell recovery has occurred. 5, 2

Children Under 5 Years

• This age group has significantly higher risk of OPSI with increased mortality compared to adults. 1, 3
• Neonates have particularly elevated risk exceeding 30%. 3
• Most children under 10 are already vaccinated with Hib and PCV through routine childhood immunization programs. 6

Additional Preventive Measures Beyond Vaccination

Antibiotic Prophylaxis

• Offer lifelong prophylactic antibiotics, especially in the first two years post-splenectomy (typically phenoxymethylpenicillin 250-500 mg twice daily or erythromycin 500 mg twice daily). 5, 1, 2
• While the benefit of lifelong prophylaxis remains unproven, the risk is highest in the first two years but persists lifelong. 5, 1

Emergency Standby Antibiotics

• All patients must have a home supply of antibiotics (penicillin VK, erythromycin, or levofloxacin) for immediate use at the first sign of fever, malaise, or chills. 5, 1, 3

Patient Education

• Educate patients to seek emergency care immediately for any fever above 101°F (38°C). 5, 2
• Provide alert cards or recommend medical alert bracelets identifying asplenic status. 5
• Inform primary care providers of the patient's asplenic status. 1, 3

Special Travel Considerations

• Malaria prophylaxis is strongly recommended for asplenic travelers to endemic areas. 1, 3
• Asplenic patients are particularly susceptible to Capnocytophaga canimorsus from dog bites and should receive a 5-day course of co-amoxiclav if bitten. 1

Timeline of Infection Risk

• Highest risk occurs in the first year post-splenectomy, but up to one-third of infections occur at least 5 years later. 1, 3
• The risk remains elevated for more than 10 years and likely for life. 3
• Streptococcus pneumoniae accounts for approximately 50% of OPSI cases. 3

Important Limitations

• Current vaccines do not provide complete coverage against all serotypes of encapsulated bacteria, necessitating additional preventive measures beyond vaccination alone. 1, 3
• Real-world vaccination compliance is poor, with studies showing only 18-30% of splenectomized patients receiving recommended vaccines and virtually no patients receiving appropriate booster doses. 7, 6