Splenectomised and hyposplenic patients are at increased risk of life-threatening infection due to encapsulated micro-organisms such as Streptococcus pneumoniae (90%), Neisseria meningitidis, and Haemophilus influenzae as well as certain parasitic infections such as Malaria and Babesiosis. The risk of sepsis is probably lifelong but can be reduced with simple measures, such as immunisation, the prophylactic administration of antibiotics, and patient education.
Hyposplenic patients should be immunised as soon as the diagnosis is made. Where a patient has had a splenectomy in the past, and has not received the required vaccines at the time, they should be immunised at the earliest possible opportunity.
Elective splenectomy vaccines:
On admission ensure the patient has had the following at least 2 weeks (ideally 4-6 weeks) prior to surgery:
- Pneumococcal vaccine
- Meningococcal vaccine
- Haemophilus influenza B vaccine
- Influenza vaccine
If these vaccines haven’t been given, please follow guidelines below for emergency procedures.
Emergency procedures vaccines:
All the above vaccinations should be given at least 2 weeks POST surgery (the response to Pneumococcal vaccine is poorer if given within 2 weeks of splenectomy).
Post-operative antibiotics (adult doses):
Patient should be prescribed either:
- ORAL: either (penicillin V 666mg po q12h) OR (amoxicillin 250-500mg q12h po)
OR IV Benzylpenicillin 1.2g q12h if oral route not available
- In penicillin allergy: clarithromycin 250mg q12h po or IV if oral route unavailable
Antibiotics usually continued for life
Ongoing Management of Patients Post Splenectomy and Patients with Functional Hyposplenism
Susceptibility to infection is greatest in the first two years post splenectomy but persists for life.
|All adults||Prophylactic antibiotics should ideally be continued for life.|
|Patients with functional hyposplenism||Lifelong prophylactic antibiotics should be considered for these patients.|
|Vaccination||Who should be immunised||When should vaccine be given||Re-immunisation|
|Pneumococcal Conjugate Vaccine
PCV ( Prevenar 13)
|All aged less than 18 years old||
||There is no data to support re-immunisation at the present time|
|Pneumococcal Polysaccharide vaccine (Pneumovax II®) (23 serotypes)||All unimmunised patients aged 2 years and over, and those who received Pneumovax II® more than 5 years ago||
|Haemophilus influenzae serotype B (Hib)||
splenectomy may benefit from an additional dose of Hib preferably at least 2 weeks prior to the operation.
There are no data to support routine re-immunisation at the present time.
|Meningococcal Quadruvalent conjugate vaccine ACYW135 (Menveo®)||
||First dose at same time as Pneumococcal vaccine (at a different site of injection)
Second dose – at least one month later
|The need for additional doses in high risk groups has not been clearly established - not recommended for the present. Print version
|Influenza Vaccine||All patients, annually.||Initial dose - at same time as other vaccines (separate site of
|Annually for hyposplenic or asplenic patients ideally at start of flu season (September to October).|
|Lifelong prophylactic antibiotics||Prophylaxis Dose (adult)*||Treatment Doses
|Phenoxymethylpenicillin||333-666mg q12h po (Calvepen®)
(666mg q24h po can be given if compliance is a problem)
|Oral absorption of phenoxymethylpenicillin can be unpredictable so it should not be used for serious infections. For emergency self initiated therapy of a suspected systemic infection, treatment doses of amoxicillin are preferable (see below).|
|Amoxicillin||250-500mg q12h po (500mg po q24h if compliance is a problem).||500mg -1g 8 hourly po|
|If penicillin allergy:
|250mg q12h po||500mg q12h po|
*NB: Please seek specialist advice on dosing in children
- For patients not allergic to penicillin where infection is suspected, a dose of 1g of amoxicillin should be taken immediately and medical attention sought.
- Patients taking clarithromycin as prophylaxis who suspect infection should take a dose of 1g clarithromycin or change to an alternative broader spectrum preparation (e.g. moxifloxacin or levofloxacin) and seek medical attention immediately.
- Patient records should be clearly labelled to indicate the underlying risk of infection. Vaccination and re-vaccination status should be clearly and adequately documented. Patients should be provided with emergency supplies of antibiotics to take at first signs of infection.
Empiric treatment of hospitalised hypo/asplenic patients with acute infection:
- Ceftriaxone 2g q24h IV. Take blood samples before commencing antibiotics. May need to increase dose if meningitis suspected.
- Department of Health UK (2006). Immunisation against infectious disease (the Green Book). 3rd ed. London: The Stationery Office. Immunisation of individuals with underlying medical conditions. Chapter 7(July 2010). Immunisation against infectious disease- 'the Green Book' 30th October 2007.
- Working Party of the British Committee for Standards in Haematology Task Force. Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. BMJ 1996 312:430-434;.
- Immunisation advisory committee: Royal College of Physicians of Ireland. Immunisation Guidelines for Ireland 2008
- Newland A, Provan D, Myint S. Preventing severe infection after splenectomy. BMJ 2005 ;331 ;417-418.
- Health Protection Agency North West, UK. Guidance on minimising infection in patients with an absent or dysfuntional spleen (2007) Available at www.hpa.org.uk.
- British Committee for Standards in Hematology, prepared by a Working Party of the Haemato-Oncology Task Force. Update of Guidelines for the Prevention and Treatment of Infection in Patients with an Absent or Dysfunctional Spleen. Published in Clinical Medicine (Journal of the Royal College of Physicians of London), Vol 2, Nos 5 ; 440-443 (2002)
- National Immunisations Advisory Committee Guidelines (2008 as updated Dec 2010), Chapters 2 & 12.