What vaccinations are recommended before undergoing a splenectomy?

Vaccination Before Splenectomy

All patients undergoing elective splenectomy should receive pneumococcal, meningococcal, and Haemophilus influenzae type b (Hib) vaccines at least 2 weeks before surgery to ensure optimal antibody response and protection against overwhelming post-splenectomy infection. 1

Timing of Vaccination

• Administer all vaccines at least 14 days before elective splenectomy to allow adequate time for antibody formation, which typically takes 9 days 2, 1
• For emergency splenectomy, vaccinate at least 14 days after surgery when the patient's condition has stabilized, as antibody response is suboptimal before this timepoint 2, 1
• The 2-week pre-surgery window is critical for achieving higher antibody concentrations compared to vaccination at shorter intervals 1

Required Vaccines

Pneumococcal Vaccination

• Start with PCV13 (or newer PCV15/PCV20) for vaccine-naïve patients, followed by PPSV23 at least 8 weeks later 1
• This prime-boost strategy provides superior protection compared to PPSV23 alone 2
• Administer a second dose of PPSV23 five years after the first dose 1
• Reimmunize with PPSV23 every 5-10 years thereafter for lifelong protection 2, 1, 3

Meningococcal Vaccination

• Administer quadrivalent meningococcal conjugate vaccine (MenACWY) covering serogroups A, C, W, and Y 2, 1
• Also administer meningococcal serogroup B vaccine (MenB) as asplenic patients face 40-70% mortality from meningococcal infections 2, 1
• Revaccinate with MenACWY every 5 years 2, 1, 4

Haemophilus influenzae Type b (Hib) Vaccination

• Give one dose of conjugated Hib vaccine to all unvaccinated asplenic adults 2, 1
• Patients who completed the primary Hib series in childhood (by 6 months with booster at 6-8 months later) or received one dose after 14 months of age do not require revaccination 2
• Conjugated Hib vaccine demonstrates superior immunogenicity compared to polysaccharide vaccines 5

Influenza Vaccination

• Administer annual inactivated influenza vaccine to reduce risk of secondary bacterial pneumonia and sepsis 2, 1, 3, 4
• Use only inactivated vaccine, not live attenuated nasal spray formulation 4
• Annual influenza vaccination is associated with 54% reduced mortality in asplenic patients 4

Administration Strategy

• All vaccines can be administered simultaneously at different injection sites if needed 2
• If preoperative vaccination is not possible, still vaccinate as soon as feasible postoperatively rather than delaying further 1
• Patients who received rituximab within the previous 6 months may have suboptimal vaccine response and should be reassessed once B-cell recovery occurs 1

Critical Pitfalls to Avoid

• Do not delay elective surgery for vaccination—the 2-week minimum is sufficient 2
• Do not vaccinate within 14 days after emergency splenectomy—wait the full 2 weeks for adequate immune response 2, 1
• Do not forget to notify the patient's primary care provider of asplenic status and vaccination history to prevent premature reimmunization reactions 2, 1
• Do not assume childhood vaccination is sufficient—most adults require catch-up vaccination, as only 26% of splenectomized patients receive all recommended vaccines 6

Lifelong Risk Context

• The risk of overwhelming post-splenectomy infection (OPSI) is lifelong, with mortality rates of 30-70% 1, 3
• While most infections occur within the first 2 years, up to one-third manifest at least 5 years later, and cases have been reported more than 20 years post-splenectomy 2, 3
• Streptococcus pneumoniae accounts for approximately 50% of OPSI cases 1
• Proper vaccination could prevent at least 28% of post-splenectomy invasive bacterial infections 7

Additional Preventive Measures

• Prescribe lifelong prophylactic antibiotics (phenoxymethylpenicillin or erythromycin if penicillin-allergic), especially for the first 2 years post-splenectomy 2, 1, 3
• Provide emergency standby antibiotics (amoxicillin) for patients to keep at home and use immediately at first sign of fever, malaise, or chills 2, 1, 3
• Educate patients to seek immediate medical attention for fevers over 101°F (38°C) 1
• After animal bites, prescribe a 5-day course of co-amoxiclav due to susceptibility to Capnocytophaga canimorsus infection 2, 1, 3