What vaccinations and regimens are recommended for post-splenectomy patients?

Post-Splenectomy Vaccination Protocol

All post-splenectomy patients require vaccination against pneumococcus, meningococcus (both ACWY and B), Haemophilus influenzae type b, and annual influenza to prevent overwhelming post-splenectomy infection (OPSI), which carries 30-70% mortality. 1, 2

Core Vaccination Requirements

Pneumococcal Vaccination

• Start with PCV20 (preferred) or PCV15 as the initial pneumococcal vaccine 3, 2
• If PCV15 is used, follow with PPSV23 at least 8 weeks later 3, 2
• If PCV20 is used alone, no PPSV23 is needed unless the patient was previously vaccinated with PCV13 only 2
• For patients previously vaccinated with PCV13 only, give PCV20 at least 1 year later 3
• Revaccinate with PPSV23 every 5 years for life if that vaccine was part of the series 3, 2

Meningococcal Vaccination

• Administer both MenACWY and MenB vaccines - this is non-negotiable as asplenic patients face 40-70% mortality from meningococcal infections 2
• MenACWY: Give as 2 doses 8 weeks apart, then revaccinate every 5 years for life 3, 2
• MenB: Give as either a 2-dose or 3-dose series depending on formulation, then revaccinate every 2-3 years if risk remains 3, 2

Haemophilus influenzae Type B (Hib)

• One single dose of Hib vaccine for previously unvaccinated adults 3, 2

Influenza Vaccination

• Annual inactivated or recombinant influenza vaccine for all post-splenectomy patients over 6 months of age 1, 2
• This reduces secondary bacterial pneumonia and sepsis risk 2

Critical Timing Guidelines

For Elective Splenectomy

• Administer all vaccines at least 2 weeks before surgery to ensure optimal antibody response 1, 3, 2
• Ideally 4-6 weeks before surgery if possible 3
• This timing is particularly important for pneumococcal vaccines, as it results in higher antibody concentrations compared to vaccination at shorter intervals 3

For Emergency/Trauma Splenectomy

• Wait at least 14 days post-operatively before vaccinating once the patient's condition is stable 1, 3, 2
• Antibody response is suboptimal before 14 days 1
• Delaying vaccination beyond 14 days provides no additional benefit 2
• The 14-day timing allows for adequate immune recovery while antibody formation generally takes 9 days 2

Lifelong Revaccination Schedule (Critical - Often Missed)

Do not forget lifelong revaccination - protection wanes and infection risk persists for life, with cases reported more than 20 years post-splenectomy 3, 2

• PPSV23: Every 5 years 3, 2
• MenACWY: Every 5 years for life 3, 2
• MenB: Every 2-3 years if risk remains 3, 2
• Influenza: Annually 1, 2

Children under 2 years should be reimmunized after 2 years due to inherently reduced antibody response 3

Additional Protective Measures Beyond Vaccination

Antibiotic Prophylaxis

• Offer lifelong prophylactic antibiotics to all patients, with highest priority in the first 2 years post-splenectomy when risk is highest 1, 3, 2
• Phenoxymethylpenicillin is the standard prophylactic agent 3, 2

Emergency Standby Antibiotics

• Provide emergency standby antibiotics (amoxicillin) for home use with clear instructions to take immediately if fever >101°F (38°C), malaise, or chills develop 1, 3, 2
• Most OPSI deaths occur within 24 hours of symptom onset 2

Patient Education and Documentation

• Issue medical alert identification (Medic-Alert disc and post-splenectomy card) indicating asplenic status 3, 2
• Formally notify primary care providers of the patient's asplenic status to ensure appropriate ongoing care 1, 2
• Provide written information about lifelong infection risk 3
• Educate about the need for immediate emergency department evaluation with fever 3

Special Precautions

• After dog or animal bites, prescribe a 5-day course of co-amoxiclav due to susceptibility to Capnocytophaga canimorsus 1, 3, 2
• Malaria prophylaxis is strongly recommended for travelers to endemic areas 1

Common Pitfalls to Avoid

Suboptimal Vaccine Response

• Patients who received rituximab in the previous 6 months may have suboptimal vaccine response 3
• Vaccination should be reassessed once B-cell recovery has occurred 3

Incomplete Coverage

• Current vaccines do not provide complete coverage against all serotypes 1
• Streptococcus pneumoniae accounts for approximately 50% of OPSI cases 3, 2
• Proper vaccination timing and adherence to revaccination schedules significantly reduce but do not eliminate infection risk 2

High-Risk Populations

• Children under 5 years have greater overall risk of OPSI with increased mortality compared to adults 1
• The risk of serious infection is highest in the first two years after splenectomy, but up to one-third of infections occur at least five years later 1
• The risk of dying from serious infection is clinically significant and almost certainly lifelong 1

Functional Hyposplenism

• Patients with functional hyposplenism (e.g., sickle cell disease, celiac disease) require identical preventive measures as those with surgical splenectomy 3