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

Post-Splenectomy Vaccination Recommendations

Core Vaccination Requirements

All patients after splenectomy require vaccination against four key pathogens: Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b, and annual influenza to prevent overwhelming post-splenectomy infection (OPSI), which carries a 30-70% mortality rate. 1, 2

Pneumococcal Vaccination

• Administer PCV20 as the preferred initial pneumococcal vaccine 2
• Alternative approach: Give PCV15 first, followed by PPSV23 at least 8 weeks later 2, 3
• 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 1, 2
• The 23-valent polysaccharide vaccine is more than 90% effective in healthy adults under age 55 1

Meningococcal Vaccination

• Administer both MenACWY and MenB vaccines - both are required, not optional 2, 3
• Give MenACWY as 2 doses 8 weeks apart 2, 3
• Give MenB as either a 2-dose or 3-dose series depending on formulation 2, 3
• Revaccinate with MenACWY every 5 years for life 1, 2, 3
• Revaccinate with MenB every 2-3 years if risk remains 2, 3
• This is critical as meningococcal infection carries 40-70% mortality in asplenic patients 3

Haemophilus Influenzae Type B (Hib)

• Administer 1 single dose of Hib vaccine for previously unvaccinated adults 1, 2, 3
• No booster doses are typically required 2

Annual Influenza Vaccination

• All patients over 6 months of age should receive annual inactivated or recombinant influenza vaccine for life 1, 2, 3
• This reduces secondary bacterial pneumonia and sepsis risk by 54% 3

Critical Timing Guidelines

For Elective/Planned Splenectomy

• Administer all vaccines at least 2 weeks before surgery to ensure optimal antibody response 1, 2, 3
• Ideally, vaccinate 4-6 weeks before surgery if possible 2, 3
• The 2-week pre-surgery timing results in higher antibody concentrations compared to vaccination at shorter intervals 2

For Emergency/Trauma Splenectomy

• Wait at least 14 days post-operatively before vaccinating, as antibody response is suboptimal before this timeframe 1, 2, 3
• Vaccinate as soon as the patient's condition stabilizes after the 14-day minimum 2
• Antibody formation generally takes 9 days, making the 2-week minimum critical 3

Special Populations and Considerations

Children Under 5 Years

• Children under 5 years have greater overall risk of OPSI with increased mortality compared to adults 1
• Children under 2 years have inherently reduced antibody response and should be reimmunized after 2 years 1
• Nearly all splenectomized children under age 10 are vaccinated with Hib and PCV as these are included in childhood immunization programs 4

Patients on Rituximab

• Patients who received rituximab in the previous 6 months may have suboptimal vaccine response 2
• Vaccination should be reassessed once B-cell recovery has occurred 2

Splenic Embolization Patients

• Patients who lose ≥50% of splenic mass through embolization should receive the same vaccination protocol as splenectomy patients 3
• Clinical judgment should prevail if there is concern about splenic function, even with less than 50% embolization 3
• Research shows only 8% of splenic embolization patients receive appropriate immunizations, representing a critical gap in care 3, 5

Additional Preventive Measures Beyond Vaccination

Antibiotic Prophylaxis

• Offer lifelong prophylactic antibiotics to all patients, with highest priority in the first 2 years post-splenectomy 1, 2, 3
• Phenoxymethylpenicillin is the standard prophylactic agent 1, 3
• Patients should keep emergency standby antibiotics (amoxicillin) at home for immediate use at first sign of fever >101°F (38°C), malaise, or chills 1, 2, 3

Patient Education and Documentation

• Provide written information about lifelong infection risk 1
• Issue Medic-Alert disc and post-splenectomy card indicating asplenic status 2
• Primary care providers must be formally notified of the patient's asplenic status to ensure appropriate ongoing care 1, 2, 3
• Educate patients about the need for immediate emergency department evaluation with fever 2

Special Precautions

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

Common Pitfalls to Avoid

Forgetting Lifelong Revaccination

• The single most common error is failing to maintain lifelong revaccination schedules 2, 3
• Protection wanes and infection risk persists for life, with cases reported more than 20 years post-procedure 1, 3
• Up to one-third of infections occur at least five years after splenectomy 1

Inadequate Vaccination Coverage

• Real-world data shows suboptimal compliance: only 55% receive pneumococcal vaccine, 48% receive Hib, 34% receive meningococcal ACWY, and 13% receive meningococcal B 6
• In Norway, only 4.2% of patients received two doses of MenACWY and only 18.7% received both PCV and PPSV23 4
• Vaccination coverage decreases with age, requiring extra vigilance for adult patients 4

Incomplete Vaccine Series

• Current vaccines do not provide complete coverage against all serotypes, highlighting the need for ongoing vigilance 1
• None of the trauma patients in one study received any recommended booster vaccines 5

The Clinical Stakes

• OPSI presents as fulminant sepsis, meningitis, or pneumonia with 30-70% mortality, with most deaths occurring within 24 hours 1, 3
• Streptococcus pneumoniae accounts for approximately 50% of OPSI cases 1, 3
• The risk of dying from serious infection is clinically significant and almost certainly lifelong 1
• The risk is highest in the first two years but remains elevated indefinitely 1
• Vaccination according to national recommendations could prevent at least 28% of post-splenectomy invasive bacterial infections 4