What are the criteria for further pneumococcal vaccination in a patient with a history of splenectomy who has been previously vaccinated with pneumococcal vaccine (Prevnar 13 (PCV13) or Pneumovax 23 (PPSV23))?

Pneumococcal Revaccination Criteria for Post-Splenectomy Patients

For a splenectomy patient who has already received both PCV13 and PPSV23, you must administer a second dose of PPSV23 exactly 5 years after the first PPSV23 dose, and then reassess at age 65 for potential additional vaccination with newer conjugate vaccines. 1

Immediate Revaccination Schedule

If Previously Received PCV13 Only

• Administer PPSV23 at least 8 weeks after PCV13 (not 1 year, because asplenia is an immunocompromising condition) 1
• Schedule second PPSV23 dose for exactly 5 years after the first PPSV23 1

If Previously Received PPSV23 Only

• Administer PCV13 (or preferably PCV20 if available) at least 1 year after the last PPSV23 dose 1
• If using PCV13, follow with second PPSV23 at least 8 weeks after PCV13 and at least 5 years after the first PPSV23 1

If Previously Received Both PCV13 and PPSV23 (Your Patient's Scenario)

• No immediate vaccination needed if the series was completed correctly 2
• Mandatory second PPSV23 dose at 5 years after first PPSV23 1
• Reassess at age 65 for potential PCV20 administration 3, 2

Critical Timing Rules for Asplenic Patients

The intervals differ dramatically from immunocompetent adults because asplenia is classified as an immunocompromising condition:

• PCV13 to PPSV23: ≥8 weeks (not ≥1 year as in immunocompetent adults) 1
• PPSV23 to PCV13: ≥1 year 1
• First PPSV23 to second PPSV23: exactly 5 years 1

Age 65 Reassessment Protocol

When your splenectomy patient reaches age 65:

• If they received PPSV23 before age 65, administer another PPSV23 at age ≥65 if at least 5 years have passed since the previous dose 1
• Consider PCV20 administration ≥5 years after the last pneumococcal vaccine dose through shared clinical decision-making 3, 2
• No additional PPSV23 doses after the dose given at age ≥65 1, 3

Additional Required Vaccinations (Often Missed)

Beyond pneumococcal vaccines, asplenic patients require:

Meningococcal Vaccines (Urgent Priority)

• MenACWY: 2 doses separated by 8 weeks, then revaccination every 5 years lifelong 1, 4
• MenB: 2-dose or 3-dose series depending on formulation, booster at 1 year, then every 2-3 years 4

Haemophilus Influenzae Type B

• Single dose of Hib vaccine if unvaccinated or uncertain history 1, 4

Lifelong Antibiotic Prophylaxis

• Initiate penicillin prophylaxis immediately post-splenectomy regardless of vaccination status 4

Common Pitfalls to Avoid

Using the 1-year interval between PCV13 and PPSV23: This is the most frequent error. Asplenic patients require the shorter 8-week interval because they are immunocompromised. 1

Forgetting the mandatory 5-year PPSV23 booster: Unlike immunocompetent adults who receive only one PPSV23 before age 65, asplenic patients require a second dose at 5 years. 1

Failing to administer meningococcal vaccines: Many clinicians focus solely on pneumococcal vaccination and neglect the equally important meningococcal series, which requires lifelong boosters every 5 years. 1, 4

Delaying vaccination due to missing records: If vaccination history is uncertain, proceed with vaccination based on verbal history rather than delaying for documentation. 3

Over-revaccinating with PPSV23: Do not administer more than the recommended doses—there is insufficient evidence for safety with three or more PPSV23 doses. 3

Modern Vaccine Considerations

If using newer vaccines (available since 2021):

• PCV20 can replace the entire PCV13 + PPSV23 sequence in newly diagnosed asplenic patients 4, 3
• For patients who already completed PCV13 + PPSV23, consider PCV20 at age ≥65 if ≥5 years have passed since last pneumococcal vaccine 3, 2
• PCV20 eliminates the need for PPSV23 in asplenic patients when used as initial vaccination 4