What vaccinations are recommended for a patient with splenectomy (removal of the spleen)?

Vaccinations Required for Splenectomy Patients

All patients undergoing splenectomy require three core vaccines—pneumococcal, meningococcal (both MenACWY and MenB), and Haemophilus influenzae type b (Hib)—plus annual influenza vaccination, administered at least 2 weeks before elective surgery or at least 2 weeks after emergency splenectomy. 1, 2

Core Vaccine Requirements

Pneumococcal Vaccination

• For vaccine-naïve patients, administer PCV13 (or newer PCV15/PCV20) first, followed by PPSV23 at least 8 weeks later 1
• PPSV23 is more than 90% effective in healthy adults under age 55 1, 3
• Revaccinate with PPSV23 every 5 years after the initial dose 1
• For patients already vaccinated, reimmunization every 5-10 years maintains protection 1, 2

Meningococcal Vaccination

• Both quadrivalent meningococcal conjugate vaccine (MenACWY) and meningococcal serogroup B vaccine are required 1
• Revaccinate with MenACWY every 5 years 1
• Only 4.2% of patients receive the recommended two doses of MenACWY, and 8.0% receive two doses of MenB, indicating widespread non-compliance 4

Haemophilus Influenzae Type B (Hib)

• One dose of Hib vaccine is recommended for all unvaccinated asplenic adults 1, 3
• Vaccination coverage for Hib is only 18.7% in real-world practice, representing a critical gap 4

Annual Influenza Vaccination

• All asplenic patients over 6 months of age require annual influenza vaccination 2, 3
• Use only inactivated influenza vaccine, never live attenuated (nasal spray) 3
• Influenza vaccination reduces mortality by 54% and prevents secondary bacterial infections 3

Optimal Timing

Elective Splenectomy

• Administer all vaccines at least 2 weeks before surgery to ensure optimal antibody response 1, 2, 3
• The 2-week pre-surgery timing is particularly important for PPSV23, as this results in higher antibody concentrations compared to shorter intervals 1
• Ideally, vaccines can be given up to 4-6 weeks before surgery 5, 6

Emergency Splenectomy

• Vaccinate at least 2 weeks post-operatively once the patient stabilizes 1, 2, 3
• Antibody response is suboptimal before 14 days post-surgery 2
• If vaccination cannot be completed at the recommended time, administer as soon as possible after the patient's condition stabilizes 1

Critical Caveats and Special Populations

Rituximab-Treated Patients

• Patients who received rituximab in the previous 6 months may have suboptimal vaccine response 5, 1
• Vaccination should be reassessed once B-cell recovery has occurred 5, 1

Children Under 2 Years

• Children have inherently reduced antibody response and should be reimmunized after 2 years of age 1
• Children under 5 years have infection rates exceeding 10%, compared to less than 1% in adults 3
• Nearly all splenectomized children under age 10 are vaccinated with Hib and PCV as part of routine childhood immunization programs 4

Age-Related Vaccination Coverage

• Vaccination coverage decreases significantly with age across all vaccines 4
• Older patients require targeted education and follow-up to ensure compliance 4

Rationale: Risk of Overwhelming Post-Splenectomy Infection (OPSI)

Infection Risk Profile

• OPSI presents as fulminant sepsis, meningitis, or pneumonia with mortality rates of 30-70% 2, 3
• Streptococcus pneumoniae accounts for approximately 50% of OPSI cases 1, 3
• Other encapsulated bacteria include Neisseria meningitidis and Haemophilus influenzae type b 3, 7
• The risk is lifelong, with cases reported more than 20 years after splenectomy 1, 3
• Risk is highest in the first two years post-splenectomy, but up to one-third of infections occur at least five years later 2

Current Vaccination Gaps

• Meta-analysis shows suboptimal immunization coverage: pneumococcal 55.1%, Hib 48.3%, meningococcal C/ACYW135 33.7%, meningococcal B 13.3%, and influenza 53.2% 8
• Vaccination according to national recommendations could prevent at least 28% of post-splenectomy infections 4

Additional Preventive Measures Beyond Vaccination

Antibiotic Prophylaxis

• Offer lifelong prophylactic antibiotics to all patients, with highest priority in the first 2 years post-splenectomy 2, 3
• Phenoxymethylpenicillin (penicillin VK) 250-500 mg twice daily is the standard prophylactic agent 5, 3
• For penicillin-allergic patients, prescribe erythromycin 500 mg twice daily 5, 3

Emergency Standby Antibiotics

• Provide emergency standby antibiotics (amoxicillin) for home use at first sign of fever, malaise, or chills 1, 2, 3
• Instruct patients to seek immediate medical attention for fever greater than 101°F (38°C) 5, 3

Patient Education and Documentation

• Issue Medic-Alert disc and post-splenectomy card indicating asplenic status 3
• Educate patients about lifelong infection risk and the need for emergency department evaluation with fever 5, 3
• Formally notify primary care providers of the patient's asplenic status to ensure appropriate ongoing care 1, 2

Special Infection Risks

• After dog or animal bites, asplenic patients require a 5-day course of co-amoxiclav due to susceptibility to Capnocytophaga canimorsus 1, 2
• Malaria prophylaxis is strongly recommended for travelers to endemic areas 2

Functional Hyposplenism

• Patients with functional hyposplenism require identical preventive measures as those with surgical splenectomy 3
• Detected on blood film by Howell-Jolly bodies and Heinz bodies 3
• Occurs in sickle cell disease, thalassemia major, celiac disease, inflammatory bowel disease, and lymphoproliferative disorders 3
• Immunize as soon as diagnosis is made 3