What vaccinations are recommended for a patient undergoing splenectomy?

Vaccination for Splenectomy Patients

All patients undergoing splenectomy require four essential vaccines: pneumococcal (PCV followed by PPSV23), meningococcal (both MenACWY and MenB), Haemophilus influenzae type b (Hib), and annual influenza vaccination, administered at least 2 weeks before elective surgery or at least 2 weeks after emergency splenectomy. 1, 2

Core Vaccination Protocol

Pneumococcal Vaccination

• Administer PCV13 (or newer PCV15/PCV20) first, followed by PPSV23 at least 8 weeks later for vaccine-naïve patients aged ≥2 years 1, 2
• For patients previously vaccinated with PCV13 only, give PCV20 at least 1 year later 2, 3
• A second dose of PPSV23 should be administered 5 years after the first dose, then revaccinate every 5-10 years for lifelong protection 1, 2
• This prime-boost strategy with PCV followed by PPSV23 produces higher antibody levels than PPSV23 alone 1

Meningococcal Vaccination

• Administer both MenACWY and MenB vaccines due to 40-70% mortality rates from meningococcal infections in asplenic patients 1, 2, 4
• Give MenACWY as a 2-dose primary series, 8 weeks apart, for patients aged ≥10 years 2, 3
• Revaccinate with MenACWY every 5 years for life 1, 2
• Administer MenB as either a 2-dose or 3-dose series depending on formulation 2, 3
• Revaccinate with MenB every 2-3 years if risk remains 2, 3

Haemophilus Influenzae Type b (Hib)

• One dose of Hib vaccine is required for all unvaccinated asplenic persons aged ≥5 years 1, 2, 4
• No revaccination is needed if the patient completed the childhood Hib series 3

Influenza Vaccination

• Annual inactivated or recombinant influenza vaccine for life for all asplenic patients aged ≥6 months 2, 3, 4
• Never use live attenuated influenza vaccine (nasal spray) in asplenic patients 4

Critical Timing Considerations

Elective Splenectomy

• Administer all vaccines at least 2 weeks before elective surgery (ideally 4-6 weeks if scheduling permits) to ensure optimal antibody response 1, 2
• The 2-week pre-surgery timing is essential because antibody formation generally takes 9 days, and this timing results in higher antibody concentrations compared to vaccination at shorter intervals 1, 3

Emergency Splenectomy

• Wait at least 14 days post-operatively before vaccinating once the patient is stable after emergency/trauma splenectomy 1, 2
• Antibody response is suboptimal if vaccines are given before this 14-day window 1, 3

Additional Preventive Measures

Antibiotic Prophylaxis

• Offer lifelong prophylactic antibiotics (typically phenoxymethylpenicillin) to all patients, with highest priority in the first 2 years post-splenectomy 1, 2, 3
• Use erythromycin for penicillin-allergic patients 1
• Provide emergency standby antibiotics (amoxicillin) for home use at the first sign of fever, malaise, or chills 1, 2, 3

Patient Education and Documentation

• Issue medical alert identification indicating asplenic status 2, 3
• Formally notify primary care providers of the patient's asplenic status to ensure appropriate ongoing care 2, 3
• Educate patients about their lifelong increased infection risk and the need for immediate medical attention with fever >101°F (38°C) 2, 3, 4
• Provide written information about overwhelming post-splenectomy infection (OPSI) risk 3

Understanding the Clinical Stakes

• 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 3, 4, 5
• Streptococcus pneumoniae accounts for approximately 50% of OPSI cases 2, 3
• The risk of OPSI 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 1, 3
• Cases of fulminant infection have been reported more than 20 years after splenectomy 1, 2

Common Pitfalls to Avoid

Forgetting Lifelong Revaccination

• Do not forget lifelong revaccination schedules: MenACWY boosters every 5 years, MenB boosters every 2-3 years, and PPSV23 every 5-10 years 1, 2, 3
• Protection wanes over time, and infection risk persists for life 2

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, 3
• Children under 2 years have inherently reduced antibody response and should be reimmunized after age 2 1, 3
• Patients with functional hyposplenism (sickle cell disease, celiac disease, inflammatory bowel disease) require identical preventive measures as those with surgical splenectomy 1, 3

Inadequate Follow-Up

• Studies show that while initial vaccination rates are reasonable, booster adherence is extremely poor, with patients receiving boosters at suboptimal rates and beyond the advised timeframe 6
• Improved coordination with primary care practitioners is essential to ensure ideal defense against infectious complications 6

Special Situations

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