What vaccinations are recommended for patients undergoing splenectomy (removal of the spleen)?

Splenectomy Vaccination Recommendations

Core Vaccination Requirements

All patients undergoing splenectomy require three essential vaccines: pneumococcal (PCV13/PCV15/PCV20 followed by PPSV23), meningococcal (both MenACWY and MenB), and Haemophilus influenzae type b (Hib), administered at least 2 weeks before elective surgery or at least 2 weeks after emergency splenectomy. 1

Optimal Timing Strategy

• For elective splenectomy: Administer all vaccines ≥2 weeks prior to surgery to ensure optimal antibody response before the patient becomes functionally asplenic 1, 2, 3
• For emergency splenectomy: Vaccinate ≥2 weeks post-operatively once the patient's condition stabilizes 1, 3
• The 2-week pre-surgery window is critical because antibody formation takes approximately 9 days, and this timing results in significantly higher antibody concentrations compared to shorter intervals 2, 3

Pneumococcal Vaccination Protocol

Administer PCV13 (or newer PCV15/PCV20) first, followed by PPSV23 at least 8 weeks later for vaccine-naïve patients aged ≥2 years. 1, 3

• For patients aged <2 years, follow routine CDC childhood immunization schedule with PCV13 1
• PPSV23 should be given ≥8 weeks after PCV13 for optimal protection 1
• Second dose of PPSV23: Administer 5 years after the first dose 1
• Reimmunization schedule: PPSV23 every 5-10 years for lifelong protection 1, 3

The sequential approach (PCV13 followed by PPSV23) produces higher antibody levels than PPSV23 alone, particularly important given that Streptococcus pneumoniae accounts for approximately 50% of overwhelming post-splenectomy infections 1, 4

Meningococcal Vaccination Protocol

Asplenic patients require both MenACWY and MenB vaccines due to 40-70% mortality rates from meningococcal infections. 2, 4

MenACWY (Quadrivalent Conjugate Vaccine)

• For patients aged ≥10 years: Administer 2 doses given ≥8 weeks apart 2
• For patients aged 2 months to <10 years: Follow age-appropriate dosing per CDC guidelines 1
• Avoid MCV4-D in children <2 years when given simultaneously with PCV due to reduced pneumococcal antibody response 1
• Revaccination: Every 5 years for lifelong protection 1, 2

MenB (Serogroup B Vaccine)

• Administer primary series according to product-specific schedule 2
• Booster schedule: First booster at 1 year after primary series completion, then every 2-3 years thereafter 2

Haemophilus Influenzae Type b (Hib) Vaccination

One dose of Hib vaccine is required for all unvaccinated asplenic persons aged ≥5 years. 1, 3

• Children <5 years should complete routine childhood Hib vaccination series 1
• Hib vaccination demonstrates similar safety and immunogenicity profiles in asplenic patients as in controls 1

Influenza Vaccination

Annual inactivated influenza vaccine (IIV) is mandatory for all asplenic patients aged ≥6 months. 4

• Reduces mortality by 54% and prevents secondary bacterial infections 4
• Never use live attenuated influenza vaccine (LAIV/nasal spray) in asplenic patients 1, 4
• Administer yearly before flu season 1

Simultaneous Vaccine Administration

All recommended vaccines can be administered simultaneously at different injection sites without compromising efficacy. 2

This approach is particularly valuable when vaccination timing is suboptimal (e.g., emergency splenectomy or previously unvaccinated patients) 2

Age-Specific Considerations

Children Under 5 Years (Especially Infants)

• Infection rates exceed 10%, compared to <1% in adults 1, 4
• Antibody levels decline more rapidly, requiring reimmunization as early as 3 years after initial vaccination 1
• Children under 2 years have inherently reduced antibody response; consider relying on prophylactic antibiotics initially and immunizing after the second birthday 1, 3
• Avoid elective splenectomy in children <3-4 years when possible, as most serious infections occur in this age group 4

Adults

• Standard vaccination protocol applies 1
• Vaccination coverage decreases with age in real-world practice, requiring enhanced education efforts 5

Additional Preventive Measures

Antibiotic Prophylaxis

Lifelong prophylactic antibiotics should be offered to all asplenic patients, with highest priority in the first 2 years post-splenectomy. 1, 3, 4

• First-line: Phenoxymethylpenicillin (penicillin VK) daily 1, 3, 4
• Penicillin allergy: Erythromycin 1, 3
• Emergency standby antibiotics: Provide amoxicillin for home use at first sign of fever, malaise, or chills 3, 4

Patient Education Requirements

Educate all patients about lifelong infection risk, as overwhelming post-splenectomy infection can occur >20 years after surgery. 1, 3, 4

• Seek immediate medical attention for fever >101°F (38°C) 2, 4
• Issue Medic-Alert identification and post-splenectomy card 4
• Formally notify primary care providers of asplenic status 3
• After animal bites, require 5-day course of co-amoxiclav due to Capnocytophaga canimorsus susceptibility 3

Common Pitfalls to Avoid

Timing Errors

• If preoperative vaccination was not possible: Still vaccinate as soon as possible post-operatively; protection is better late than never 2, 3
• Do not withhold vaccination due to concerns about suboptimal timing—some protection is vastly superior to none 3

Incomplete Vaccination Series

• Overlooking MenB vaccine: Many protocols focus only on MenACWY, missing critical serogroup B coverage 2, 5
• Forgetting Hib in adults: This vaccine is often omitted in adult protocols despite clear recommendations 1, 5
• Real-world data shows only 18.7% of splenectomized patients receive Hib vaccination 5

Revaccination Failures

• Pneumococcal revaccination: Required every 5-10 years but frequently forgotten 1, 3
• MenACWY revaccination: Required every 5 years for lifelong risk 1, 2
• MenB boosters: Required every 2-3 years after initial booster at 1 year 2
• Studies show vaccination could have prevented 28% of post-splenectomy invasive bacterial infections 5

Special Populations

• Rituximab-treated patients: May have suboptimal vaccine response if vaccinated within 6 months of treatment; reassess timing after B-cell recovery 3
• Functional hyposplenism: Patients with sickle cell disease, thalassemia major, celiac disease, inflammatory bowel disease require identical vaccination protocols 4

Documentation Failures

• Failure to provide written vaccination records to patients and primary care providers leads to missed revaccinations 3, 4
• Inadequate documentation of asplenic status in medical records results in preventable infections 4

Risk Magnitude

The lifelong risk of overwhelming post-splenectomy infection is clinically significant with mortality rates of 30-70%, making proper vaccination critical 1, 3, 4. Cases of fulminant infection have been reported more than 20 years after splenectomy, emphasizing the need for lifelong vigilance and revaccination compliance 1, 3.