What vaccinations are needed after a splenectomy (removal of the spleen)?

Post-Splenectomy Vaccination Requirements

All patients undergoing splenectomy require vaccination against three encapsulated bacteria—Streptococcus pneumoniae, Haemophilus influenzae type B, and Neisseria meningitidis—plus annual influenza vaccination to prevent life-threatening overwhelming post-splenectomy infection (OPSI). 1, 2

Core Required Vaccinations

Pneumococcal Vaccines

• Administer PCV20 (preferred) or PCV15 as the initial pneumococcal vaccine, followed by PPSV23 at least 8 weeks later if using PCV15 3, 4
• For patients previously vaccinated with PCV13 only, give PCV20 at least 1 year later 3
• Revaccinate with PPSV23 every 5 years for life to maintain protection, as antibody levels wane over time 2, 3

Meningococcal Vaccines

• Administer both MenACWY and MenB vaccines 3, 4
• Give MenACWY as a 2-dose primary series, 8 weeks apart 3, 4
• Administer MenB as either a 2-dose or 3-dose series depending on formulation 3, 4
• Revaccinate with MenACWY every 5 years for life 3, 4
• Revaccinate with MenB every 2-3 years if risk remains 3

Haemophilus Influenzae Type B (Hib)

• Administer one single dose of Hib vaccine for previously unvaccinated adults 3, 4

Influenza Vaccine

• Give annual inactivated or recombinant influenza vaccine for life to all patients over 6 months of age 1, 2, 3
• This reduces the risk of secondary bacterial infections that can be catastrophic in asplenic patients 2

Critical Timing Considerations

For Elective Splenectomy

• Administer all vaccines at least 2 weeks before surgery (ideally 4-6 weeks if scheduling permits) to ensure optimal antibody response 3, 4
• This timing allows adequate antibody formation, which typically requires 9 days 4
• Vaccinating before surgery provides protection before the patient becomes functionally asplenic 3

For Emergency/Trauma Splenectomy

• Wait at least 14 days post-operatively before vaccinating once the patient is stable 1, 3, 4
• Antibody response is suboptimal before this time 2
• If patients are discharged before 15 days and the risk of missing vaccination is high, vaccinate before discharge 1

Additional Preventive Measures Beyond Vaccination

Antibiotic Prophylaxis

• Offer lifelong prophylactic antibiotics (typically phenoxymethylpenicillin), with highest priority in the first 2 years post-splenectomy 2, 3, 4
• Provide emergency standby antibiotics (amoxicillin) for home use at the first sign of fever >101°F (38°C), malaise, or chills 2, 3, 4

Patient Education and Documentation

• Issue medical alert identification indicating asplenic status 4
• Formally notify primary care providers of the patient's asplenic status to ensure appropriate ongoing care 1, 2, 4
• Educate patients about their lifelong increased infection risk and the need for immediate medical attention with fever 3, 4

Special Situations

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

Understanding the Clinical Stakes

Risk of OPSI

• OPSI presents as fulminant sepsis, meningitis, or pneumonia with a mortality rate of 30-70%, with most deaths occurring within 24-48 hours of symptom onset 1, 2, 4
• Streptococcus pneumoniae accounts for approximately 50% of OPSI cases 1, 4
• The risk is highest in the first year after splenectomy but remains elevated for life, with one-third of infections occurring at least 5 years after surgery 2, 4

High-Risk Populations

• Children under 5 years have a greater overall risk of OPSI with increased mortality compared to adults 1, 2
• The risk is more than 30% in neonates 1
• Children under 2 years have inherently reduced antibody response and should be reimmunized after 2 years 3

Common Pitfalls to Avoid

• Do not forget lifelong revaccination schedules, as protection wanes and infection risk persists for life 3
• Do not use MCV4-D (meningococcal vaccine) before completing all PCV13 doses in children under 2 years with asplenia, as simultaneous administration reduces antibody response to certain pneumococcal serotypes; use MCV4-CRM instead 4
• Patients who received rituximab in the previous 6 months may have suboptimal vaccine response; vaccination should be reassessed once B-cell recovery has occurred 3, 4
• Patients with functional hyposplenism (from conditions like sickle cell disease) require identical preventive measures as those with surgical splenectomy 3