What vaccinations are recommended for an elderly patient after undergoing a splenectomy (removal of the spleen)?

Vaccination Recommendations for Elderly Post-Splenectomy Patients

All elderly patients after splenectomy require three mandatory vaccines—pneumococcal, meningococcal (both MenACWY and MenB), and Haemophilus influenzae type b (Hib)—plus 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. 1, 2 This sequential "prime-boost" strategy produces superior antibody responses compared to PPSV23 alone. 2
• Give a second dose of PPSV23 five years after the first dose. 1, 2
• Reimmunize with PPSV23 every 5-10 years for lifelong protection. 1, 2 The 23-valent polysaccharide vaccine is more than 90% effective in healthy adults under age 55, though efficacy may be reduced in elderly patients. 3

Meningococcal Vaccination

• Administer both MenACWY and MenB vaccines—this is mandatory, not optional. 1, 2 Asplenic patients face 40-70% mortality rates from meningococcal infections. 1, 2
• For MenACWY: Give 2 doses at least 8 weeks apart (not a single dose) for patients aged ≥10 years. 1, 2
• Revaccinate with MenACWY every 5 years for life. 1, 2, 4
• For MenB: Administer either MenB-FHbp (3 doses at 0,1-2, and 6 months) OR MenB-4C (2 doses at least 1 month apart). 2
• MenB booster: Single dose at 1 year after primary series, then every 2-3 years. 2, 4

Haemophilus Influenzae Type b (Hib)

• Administer one dose of Hib vaccine to all unvaccinated asplenic persons. 3, 1, 2 No revaccination is needed if the patient completed a childhood Hib series. 2

Annual Influenza Vaccination

• Give annual inactivated influenza vaccine (IIV) to all asplenic patients. 1, 2, 4 This reduces the risk of secondary bacterial infection. 3
• Never use live attenuated influenza vaccine (LAIV/nasal spray) in asplenic patients. 1, 2

Optimal Timing Considerations

Pre-Operative Vaccination (Elective Splenectomy)

• Administer all vaccines at least 2 weeks (ideally 2-6 weeks) before elective splenectomy to ensure optimal antibody response before the patient becomes functionally asplenic. 1, 2, 4
• The 2-week pre-surgery timing results in significantly higher antibody concentrations compared to vaccination at shorter intervals. 2, 4

Post-Operative Vaccination (Emergency Splenectomy)

• If preoperative vaccination is not possible, administer vaccines at least 2 weeks after surgery once the patient's condition is stable. 1, 2, 4

Critical Pitfalls to Avoid

Common errors that compromise patient safety:

• Do NOT treat elderly asplenic patients like routine adults—they require the enhanced 2-dose MenACWY series, not a single dose. 2, 4
• Do NOT skip MenB vaccination—it is mandatory for all asplenic patients regardless of age. 1, 2
• Do NOT forget lifelong revaccination—protection wanes and infection risk persists for life, with cases of overwhelming post-splenectomy infection reported more than 20 years after surgery. 1, 2, 4
• Do NOT assume vaccination alone is sufficient—lifelong prophylactic antibiotics are also required. 3, 1

Essential Non-Vaccine Preventive Measures

Antibiotic Prophylaxis

• Prescribe lifelong prophylactic antibiotics (phenoxymethylpenicillin 250-500 mg twice daily), with highest priority in the first 2 years post-splenectomy. 3, 1, 2
• For penicillin-allergic patients, offer erythromycin. 3
• Provide emergency standby antibiotics (amoxicillin) for home use at the first sign of fever, malaise, or chills. 3, 2, 4

Patient Education

• Educate patients about lifelong infection risk and the need for immediate medical attention for fever >101°F (38°C). 1, 2, 4
• Issue a Medic-Alert disc and carry card indicating asplenic status. 3, 4
• After dog or animal bites, ensure a 5-day course of co-amoxiclav due to susceptibility to Capnocytophaga canimorsus. 3, 4

Risk Magnitude Justifying These Measures

• The lifelong risk of overwhelming post-splenectomy infection (OPSI) carries mortality rates of 30-70%. 1, 2, 4
• Streptococcus pneumoniae accounts for approximately 50% of OPSI cases. 2, 4
• Though most infections occur within the first two years after splenectomy, up to a third may manifest at least five years later. 3
• Cases of fulminating infection have been reported more than 20 years after splenectomy, confirming lifelong risk. 3, 2

Real-World Implementation Challenges

Vaccination coverage remains suboptimal in clinical practice. Meta-analysis data shows pneumococcal vaccination coverage at only 55.1%, anti-Hib at 48.3%, and meningococcal C/ACYW135 at 33.7%. 5 In Norway, only 4.2% of splenectomized patients received two doses of meningococcal ACWY vaccine. 6 These gaps result in preventable infections—at least 28% of post-splenectomy invasive bacterial infections could have been prevented with proper vaccination. 6

Implementing a pharmacist-driven electronic vaccination tracking system and bundled order sets can increase complete initial vaccination rates from 68.3% to 77.3%. 7 Primary care physicians must be formally notified of the patient's asplenic status to ensure appropriate ongoing care and revaccination. 3, 4