What vaccines and schedule are recommended for patients after splenectomy (removal of the spleen)?

Vaccination Schedule for Splenectomy Patients

All splenectomy patients require pneumococcal, meningococcal (both MenACWY and MenB), Haemophilus influenzae type b (Hib), and annual influenza vaccinations, ideally administered at least 2 weeks before elective surgery or at least 2 weeks after emergency splenectomy. 1, 2

Core Vaccination Requirements

Pneumococcal Vaccination

• Administer PCV13 (or newer PCV15/PCV20) first, followed by PPSV23 at least 8 weeks later for vaccine-naïve patients 2
• Give a second dose of PPSV23 five years after the first dose 2
• Reimmunize with PPSV23 every 5-10 years for lifelong protection 3, 2
• The 23-valent polysaccharide vaccine is more than 90% effective in healthy adults under age 55 3

Meningococcal Vaccination (Critical - Enhanced Protocol Required)

• Asplenic patients require a 2-dose MenACWY series given at least 8 weeks apart, NOT the single dose used for routine vaccination 1
• Administer booster doses of MenACWY every 5 years for life 1, 2
• MenB vaccination is mandatory for asplenic patients (not optional like in healthy young adults) 1
• Give MenB-FHbp as a 3-dose series at 0,1-2, and 6 months, OR MenB-4C as a 2-dose series at least 1 month apart 1
• Administer MenB booster at 1 year after primary series, then every 2-3 years if risk persists 1

Haemophilus Influenzae Type b (Hib)

• Give 1 single dose for unvaccinated adults and children >59 months 1, 2
• Administer at least 2 weeks before elective splenectomy when possible 3

Annual Influenza Vaccination

• All splenectomy patients require yearly inactivated or recombinant influenza vaccine 3, 4
• This reduces risk of secondary bacterial infections 3

Optimal Timing Strategy

For Elective Splenectomy

• Administer all vaccines at least 2 weeks before surgery (ideally 4-6 weeks) to ensure optimal antibody response 3, 4, 2
• This timing is particularly critical for pneumococcal vaccine, which produces higher antibody concentrations when given pre-operatively 2

For Emergency Splenectomy

• Wait at least 14 days post-operatively before vaccinating, as antibody response is suboptimal before this time 4, 2, 5
• Vaccinate as soon as the patient's condition stabilizes 2

Critical Clinical Pitfalls to Avoid

Common Errors

• Do NOT treat asplenic patients like routine young adults for meningococcal vaccination - they require the enhanced 2-dose MenACWY series plus mandatory MenB vaccination, not a single dose 1
• Do NOT forget lifelong MenACWY boosters every 5 years - protection wanes and infection risk persists for life 1, 2
• Patients who received rituximab in the previous 6 months may have suboptimal vaccine response and should be reassessed once B-cell recovery occurs 2

Special Populations

• Children under 2 years have inherently reduced antibody response and require reimmunization after 2 years 3, 2
• Children under 5 years have higher overall OPSI risk with increased mortality compared to adults 4

Additional Essential Preventive Measures

Antibiotic Prophylaxis

• Offer lifelong prophylactic antibiotics to all patients, with highest priority in the first 2 years post-splenectomy 3, 4, 2
• Phenoxymethylpenicillin (250-500 mg twice daily for adults) is the standard prophylactic agent 3, 2
• For penicillin-allergic patients, use erythromycin 3

Emergency Preparedness

• Provide patients with emergency standby antibiotics (amoxicillin) for home use at first sign of fever, malaise, or chills 3, 2
• Issue a Medic-Alert disc and post-splenectomy card indicating asplenic status 3, 2
• Educate patients about lifelong infection risk and need for immediate emergency department evaluation with any fever 2

Special Infection Risks

• After dog or animal bites, prescribe a 5-day course of co-amoxiclav due to susceptibility to Capnocytophaga canimorsus 3, 4, 2
• Provide malaria prophylaxis for travelers to endemic areas 4

Clinical Context and Rationale

Risk of Overwhelming Post-Splenectomy Infection (OPSI)

• OPSI carries a mortality rate of 30-70% and presents as fulminant sepsis, meningitis, or pneumonia 4, 2
• Streptococcus pneumoniae accounts for approximately 50% of OPSI cases, with Neisseria meningitidis and H. influenzae as other major pathogens 4, 2, 6
• The infection risk is highest in the first 2 years but remains clinically significant and lifelong - cases have been reported more than 20 years after splenectomy 3

Evidence Quality

While the 1996 BMJ guidelines 3 note there are no randomized controlled trials on this issue, the more recent NCCN 2024 guidelines 3 and CDC/ACP recommendations 1, 2 provide high-quality evidence for the enhanced vaccination protocols, particularly for meningococcal vaccination. Research studies demonstrate that proper vaccination could prevent at least 28% of post-splenectomy invasive bacterial infections 7, though adherence remains suboptimal in clinical practice 7, 8.