Splenectomised and hyposplenic patients are at increased risk of life-threatening infections 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. Advice is available from Public Health on 021 4927601.

Elective splenectomy:

Recommended vaccines should be completed at least 2 weeks and preferably 4 weeks or more before surgery (see below table for the details of individual vaccines)

On admission ensure the patient has had the following:

Emergency procedures:

In the case of an emergency splenectomy or if immunisation is overlooked or incomplete pre operatively, recommended vaccines should be given at least 2 weeks post operatively, (the response to pneumococcal vaccine is poorer if given within 2 weeks of splenectomy).

Post-operatively (adult doses):

Patient should be prescribed either:
Benzylpenicillin 1.2g q12h iv
or
Oral:
either Phenoxymethylpenicillin 666mg po q12h or Amoxicillin 250-500mg q12h po.

In penicillin allergy: Clarithromycin* 250mg q12h po/iv. To be continued post-discharge from hospital – refer to chemoprophylaxis section for further information.

*Clarithromycin: several drug interactions – always check (following list not exhaustive): Statins: Increased risk of rhabdomyolysis. Simvastatin contraindicated with clarithromycin. Atorvastatin: max. 20mg /day, Pravastatin max. 40mg/day. Monitor for muscle pain and weakness. Warfarin: significant increase in INR with clarithromycin - INR must be monitored very closely and appropriate warfarin dose adjustments made as necessary. Novel oral anticoagulants (NOAC): check individual NOAC SPCs.

Vaccination Who should be immunised Vaccination required When should vaccine be given Re-immunisation
Pneumococcal Conjugate Vaccine
PCV
( Prevenar 13®)
(13 serotypes)
Aged under 2 years Immunise with PCV13 vaccine in accordance with the routine schedule (2, 6 and 12 months).
One additional dose PCV13 two months after last routine dose
If incompletely immunised contact Public Health for specialist advice.
If a second dose is indicated, it should be given two months after first dose.
Course of Pneumococcal Conjugate Vaccine should be completed before receiving Pneumococcal Polysaccharide Vaccine.

If Pneumococcal Polysaccharide Vaccine has been given wait at least 1 year before giving Pneumococcal Conjugate Vaccine
There is no data to support reimmunisation at the present time
Aged 2 years and over
  • Patients who have never received a pneumococcal vaccine: Give two doses of PCV13, two months apart.
  • Patients who have previously received PCV: Give one dose of PCV13 at least 2 months after last dose.
Pneumococcal
Polysaccharide vaccine
(PPV) (Pneumovax II®
23 serotypes)
All unimmunised patients aged 2 years and over, and those who received Pneumovax II® more than 5 years ago Give single dose.
A once only booster is recommended 5 years after first dose.
Course of Pneumococcal Conjugate Vaccine (PCV13) should be completed before receiving Pneumococcal Polysaccharide Vaccine (PPV).

Pneumococcal Polysaccharide Vaccine (PPV) can be given 8 weeks after last Pneumococcal Conjugate Vaccine (PCV13)
Antibody levels may decline more rapidly, particularly in patients with sickle cell anaemia or lymphoproliferative disorders. If age >65 years whgen received first dose, no booster recommended.
The need for and benefit of repeated booster doses is unclear and not routinely recommended.
Influenza Vaccine All patients, annually Annually for all patients. Give a second dose one month later if aged <9 years and the first year of receipt of influenza vaccine First dose at the same time as other vaccines (at a different site of injection). Second dose (if indicated) one month later Annually for hyposplenia or asplenic patients ideally at the start of flu season (September to October)
Haemophilus influenzae serotype B (HiB) Aged under 13 months Immunise with Hib vaccine in accordance with the routine schedule (2,4,6 and 13 months)
  • First dose at same time as Pneumococcal vaccine (at a different site of injection)
  • Second dose (if indicated) - two months later.
  • Those who have completed a primary series (2, 4, 6 and 13 months) should have an additional dose at least 2 months after last dose.
There are no data to support routine reimmunisation at the present time.
All patients aged 13 months or older who were previously unimmunised Give two doses of Hib vaccine, two months apart
Previously immunised patients who develop splenic dysfunction Give one additional dose of Hib vaccine a minimum of 2 months after the last Hib dose given
Meningococcal
Quadruvalent conjugate
Vaccine
ACYW135(MenACWY)   (Menveo® or
Nimenrix®)
Aged 2-11 month
Give two doses of Men ACWY

MenACWY can replace the MenC if the child requires MenACWY at the same time as the routine MenC
  • First dose at same time as Pneumococcal vaccine (at different site of injection)
  • Second dose - two months later
Additional booster at age ≥12 months at least 2 months after last dose then every 5 years.
Aged 1 year and over Give two doses of MenACWY at least two months apart
  • First dose at same time as Pneumococcal vaccine (at a different site of injection)
  • Second dose – at least two months later
Booster every 5 years
Meningococcal B vaccine* (Bexsero®) Aged 2-<12 months Immunise with MenB in accordance with the routine schedule (2, 4 and 12 months)
  • In accordance with the routine schedule (2, 4 and 12 months)
Increased risk of fever in children under 12 months –paracetamol prophylaxis recommended
The need for additional doses in high risk groups has not been clearly established - not recommended for the present.
12 months and older if previously unimmunised 2 doses 2 months apart
  • First dose at same time as Pneumococcal vaccine (at a different site of injection)
  • Second dose – at least two months later

Chemoprophylaxis

The risk for invasive pneumococcal infection is elevated throughout life but highest for those <16 and > 50 years of age. At minimum and regardless of immunisation status, antibiotic prophylaxis is recommended for children with asplenia (congenital absence or surgical removal) or sickle cell disease until 5 years of age and for otherwise healthy patients post splenectomy for a minimum of 1 to 2 years post splenectomy. Although the risk of infection decreases over time, continuing antibiotic prophylaxis throughout childhood and, for those considered at higher risk of infection, for life is recommended.

High risk patients include poor clinic attendees, patient with sickle cell disease with surgical splenectomy, splenectomised patient with malignancy, and those with poor antibody response to pneumococcal vaccination. Physicians may elect to use antibiotic prophylaxis in other hyposplenic states.

Antibiotic prophylaxis should only be discontinued if the patient is fully immunized and education and counselling is given regarding the risks of pneumococcal, meningococcal and haemophilus B infection and the need for prompt early management of febrile illness (refer to general information below)

Antibiotics prophylaxis Prophylaxis Dose Treatment Doses
(adult)*
Notes
Phenoxymethylpenicillin
Penicillin V
1 month to < 6 years: 125mg po q12h
6 years to < 12 years: 250mg po q12h
≥12 years: 666mg po q12h (Calvepen®) (666mg po q24h can be given if compliance is a problem)
Oral absorption of phenoxymethylpenicillin can be unpredictable and plasma concentrations variable 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 20mg/kg po q24h (max 500mg po q24h) 500-1000mg po q8h If need H. influenzae cover
Clarithromycin* 250mg po q12h
(500mg LA po q24h if compliance a problem)
For dosing in children seek specialist advice
500mg po q12h If penicillin allergic

*Clarithromycin: several drug interactions – always check (following list not exhaustive): Statins: Increased risk of rhabdomyolysis. Simvastatin contraindicated with clarithromycin. Atorvastatin: max. 20mg /day, Pravastatin max. 40mg/day. Monitor for muscle pain and weakness. Warfarin: significant increase in INR with clarithromycin - INR must be monitored very closely and appropriate warfarin dose adjustments made as necessary. Novel oral anticoagulants (NOAC): check individual NOAC SPCs.


general information for all patients

Other information


*Clarithromycin: several drug interactions – always check (following list not exhaustive): Statins: Increased risk of rhabdomyolysis. Simvastatin contraindicated with clarithromycin. Atorvastatin: max. 20mg /day, Pravastatin max. 40mg/day. Monitor for muscle pain and weakness. Warfarin: significant increase in INR with clarithromycin - INR must be monitored very closely and appropriate warfarin dose adjustments made as necessary. Novel oral anticoagulants (NOAC): check individual NOAC SPCs.

References: