What are the vaccine recommendations for a patient with a splenic issue?

Vaccination Recommendations for Asplenic Patients

All asplenic patients (whether from surgical splenectomy or functional hyposplenism) must receive pneumococcal, meningococcal (both MenACWY and MenB), Haemophilus influenzae type b (Hib), and annual influenza vaccines, with specific timing and lifelong booster schedules to prevent overwhelming post-splenectomy infection (OPSI), which carries a 30-70% mortality rate. 1, 2, 3

Core Vaccination Requirements

Pneumococcal Vaccination

• Administer PCV20 (preferred) or PCV15 as the initial pneumococcal vaccine for all asplenic patients 2
• If PCV15 is used, follow with PPSV23 at least 8 weeks later 2
• For patients previously vaccinated with PCV13 only, give PCV20 at least 1 year later 2
• Revaccinate with PPSV23 every 5 years for life if that vaccine was part of the series 4, 2
• The pneumococcal vaccine series is critical as Streptococcus pneumoniae accounts for approximately 50% of OPSI cases 2

Meningococcal Vaccination

• Administer 2 doses of MenACWY vaccine at least 8 weeks apart (not a single dose as in routine young adults) 1
• Administer MenB vaccine: either MenB-FHbp as a 3-dose series at 0,1-2, and 6 months, OR MenB-4C as a 2-dose series given at least 1 month apart 1
• Revaccinate with MenACWY every 5 years for life 1, 2
• Revaccinate with MenB every 2-3 years if risk remains 1, 2
• Both MenACWY and MenB are mandatory for asplenic patients, unlike the general population where MenB is permissive 1

Haemophilus influenzae Type b (Hib) Vaccination

• Administer 1 single dose of Hib vaccine for all unvaccinated asplenic adults and children >59 months 1, 2
• This should be given regardless of childhood vaccination history 4

Influenza Vaccination

• All asplenic patients must receive annual inactivated or recombinant influenza vaccine 2, 3
• This reduces the risk of secondary bacterial infections that can trigger OPSI 3

Optimal Timing of Vaccination

Elective Splenectomy

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

Emergency/Trauma Splenectomy

• Wait at least 14 days post-operatively before vaccinating once the patient stabilizes 2, 3
• If vaccination cannot be completed at the optimal time, administer as soon as possible after the patient's condition stabilizes 2

Critical Clinical Pitfalls to Avoid

Lifelong Revaccination

• Do not forget lifelong booster schedules: MenACWY every 5 years and MenB every 2-3 years, as protection wanes and infection risk persists for life 1, 2
• PPSV23 boosters every 5 years are essential for maintained protection 4, 2
• The risk of OPSI is lifelong, with cases reported more than 20 years after splenectomy 2

Enhanced Dosing Protocol

• Do not treat asplenic patients like routine young adults: they require the enhanced 2-dose MenACWY series (not a single dose) and mandatory MenB vaccination 1
• Asplenic patients have impaired immune response requiring both enhanced initial dosing and regular boosters 1

Special Populations

• Patients who received rituximab in the previous 6 months may have suboptimal vaccine response; vaccination should be reassessed once B-cell recovery has occurred 2
• Patients with functional hyposplenism (e.g., sickle cell disease) require identical preventive measures as those with surgical splenectomy 2

Splenic Embolization

• If 50% or more of splenic mass is lost through embolization, treat the patient as asplenic and follow all vaccination recommendations 5
• This is a commonly missed indication for post-splenectomy vaccination protocols 5

Additional Preventive Measures

Antibiotic Prophylaxis

• Offer lifelong prophylactic antibiotics to all patients, with highest priority in the first 2 years post-splenectomy 2, 3
• Standard prophylactic agent is phenoxymethylpenicillin (penicillin VK) 250-500 mg twice daily, or erythromycin for penicillin-allergic patients 4, 3

Emergency Standby Antibiotics

• Provide emergency standby antibiotics (amoxicillin 3g starting dose, then 1g every 8 hours) for home use at first sign of fever, malaise, or chills 2, 3
• Patients should be educated to seek immediate medical attention for any fever over 101°F (38°C) 2

Patient Education and Documentation

• Issue Medic-Alert identification and provide written information about lifelong infection risk 4, 2, 3
• Formally notify primary care providers of the patient's asplenic status to ensure appropriate ongoing care 2
• After dog or animal bites, asplenic patients require a 5-day course of co-amoxiclav due to susceptibility to Capnocytophaga canimorsus 4, 2