Living Without a Spleen: What Changes After Splenectomy

Most people without a spleen never have the rare, fast-moving infection the operation is known for. That infection is still the best-known risk, because it can turn a mild illness into a life-threatening one within a day or two. Studies now describe a wider picture: raised rates of ordinary severe infection for years, a higher rate of blood clots in some groups, and particular findings about malaria, tick-borne parasites and dog bites. This page sets out those numbers, how they change with time, and what guideline panels state about vaccines and antibiotics. Why the operation is done for one inherited anemia, and the surgical choices involved, are on the Hereditary Spherocytosis page.

Table of Contents

  1. What the Spleen Does
  2. Why People Lose a Spleen or Have One That Does Not Work
  3. How Often Serious Infection Follows Splenectomy
  4. How the Infection Numbers Change Over Time
  5. The Signs Hospitals Treat as Urgent
  6. Blood Clot and Blood Vessel Findings
  7. What Guidelines State About Vaccines
  8. What Guidelines State About Daily and Standby Antibiotics
  9. Travel, Ticks and Animal Bites
  10. What Is Not Known
  11. Key Research Papers
  12. Connections
  13. Featured Videos

What the Spleen Does

The spleen sits under the ribs on the upper left side of the abdomen, and blood runs through it constantly. A 2005 review in Nature Reviews Immunology describes two jobs that happen in the same organ. It filters the blood, removing old red blood cells, germs and debris. It also holds a tightly organized store of immune cells, and the review calls it the most important organ for immune reactions against bacteria and fungi carried in the blood (PMID 16056254).

The combination explains why some germs are a particular problem afterwards. Some bacteria wear a slippery sugar coat, or capsule, that makes them hard for white blood cells to grab. The body deals with them by tagging them with antibodies and complement proteins, and macrophages in the spleen are critical for clearing bacteria tagged this way. Pneumococcus, meningococcus and Escherichia coli are among these germs. The same macrophages also clear the parasites that live inside red blood cells and cause malaria and babesiosis, which one major review gives as the explanation for how violently these infections can run in people without a working spleen (PMID 20930072).

The blood itself changes in measurable ways after the operation. An Australian spleen registry followed these changes in adults (PMID 21829713):

That study also looked for a practical use of the result and did not find one. In a survey of 152 registry patients, the level of these memory cells was not associated with minor infections, and no one in the registry had the overwhelming infection during the study. The authors concluded that the measurement has limited clinical use in this group (PMID 21829713).

Why People Lose a Spleen or Have One That Does Not Work

Doctors use two words here. Asplenia means the spleen is absent, which is rarely present from birth and is mostly the result of surgery. Hyposplenism means the spleen is still there but works poorly, and it is an acquired problem caused by several blood and immune diseases (PMID 21474172). A spleen that has stopped working carries many of the same concerns as one that has been removed.

Surgery for a blood disorder or another disease

A 2014 United States veterans study states that about 22,000 splenectomies are still done each year in that country (PMID 24056815). Blood disorders are a large part of the reason.

Injury

Road accidents and other blows to the abdomen can rupture the spleen. Keeping the spleen after abdominal injury has become the standard goal where it is possible (PMID 24056815). A 2019 review reports that people treated with spleen-preserving procedures such as blocking the splenic artery from inside (embolization) are regarded as having working immunity, because they keep their IgM memory B cells. The same review notes that leftover spleen tissue, common after injury, may offer some protection, but that its contribution appears variable and remains unclear (PMID 31571940).

Sickle cell disease: losing the spleen without an operation

In sickle cell anemia the spleen is the first organ injured. A 2014 review reports evidence of poor spleen function before 12 months of age in most children. Repeated blockage of its small blood vessels scars and shrinks it, a process called autosplenectomy, which is generally complete by age 5. The damage is usually silent (PMID 24862308).

Surgery is also used in sickle cell disease. The European recommendations state that splenectomy is recommended in children after two episodes of acute splenic sequestration, a sudden life-threatening pooling of blood in the spleen. All of the experts agreed, though the evidence grade is low (PMID 28550188).

The penicillin trial in these children is the foundation for much of what is said about antibiotics in spleen loss. In a randomized, double-blind trial published in 1986, children under 3 years old were given 125 mg of penicillin V twice daily or placebo. It stopped 8 months early when pneumococcal bloodstream infection was 84% lower in the penicillin group: 2 of 105 children against 13 of 110. The three deaths from this infection were all in the placebo group (PMID 3086721).

The surgical picture in sickle cell disease is less clear-cut than the infection numbers suggest. An Italian study of 534 patients followed over about three decades, 170 of whom had the operation, found no significant difference in survival or age at death between those with and without splenectomy. Survival was significantly lower in children who had the operation before age 5. The study was observational and from a high-income setting, and it reports what happened in centers with continuous specialist care (PMID 35924578).

How Often Serious Infection Follows Splenectomy

Different studies give very different numbers, mainly because they count different things. The figures below are not contradictions. They measure anything from the rare overwhelming infection up to any severe infection needing hospital care.

The rare overwhelming infection

Overwhelming post-splenectomy infection is a sudden, fulminant sepsis in a person without a working spleen. A 2019 review gives an incidence of 0.13 per 100 person-years, with mortality of up to 50–70% (PMID 31571940). In plain terms, that incidence is roughly 1 case per year among every 770 people without a spleen. A British national survey of 42 cases published in 1997 recorded 45% mortality (PMID 9459404). Case-series death rates of this kind come from people who were already severely ill and do not describe the outlook of everyone without a spleen.

Infection and death across all patients

A literature review covering 1966 to 1996 pooled reports on 19,680 patients with a median follow-up of 6.9 years. It reported infection after splenectomy in 3.2% and death from it in 1.4%. Rates were highest in thalassemia major and sickle cell anemia (PMID 11798256).

Group in the 2001 reviewInfectionDeath
All patients3.2%1.4%
Children3.3%1.7%
Adults3.2%1.3%
Thalassemia major8.2%5.1%
Sickle cell anemia7.3%4.8%

The age and disease breakdowns come from the 6,942 reports detailed enough to analyze, and these older studies pre-date many current vaccines (PMID 11798256).

National registers: the reason for surgery matters

A Swedish national study followed 20,132 people who had the operation between 1970 and 2009. Their rate of hospital care for sepsis was 5.7 times that of the general population. The reason for surgery made a large difference: 3.4 times for injury, up to 18 times for blood cancers. Sepsis death rates ranged from 3.1 times for injury to 8.7 times for blood disease (PMID 24374533).

A Scottish study of 1,648 patients counted any first severe infection, a much wider net, and reported 7.0 per 100 person-years overall and 9.2 in people who had the operation for a blood cancer. After a first severe infection the rates of a second and third were far higher, at 44.9 and 109.3 per 100 person-years (PMID 16490477).

How much is the missing spleen and how much the illness

People who lose a spleen are often sick already, which makes this hard to separate. A Danish study of all 3,812 people who had the operation from 1996 to 2005 addressed it by using three comparison groups. Against the general population, the risk of a hospital contact for infection more than a year after surgery was 2.5 times higher. Against people with the same underlying diseases who kept their spleen, it was 1.2 times higher (PMID 19841456). The excess is real, but much smaller once the underlying illness is taken into account. The authors note that closer medical watching of these patients may have affected the findings.

A similar pattern appears in immune thrombocytopenia. In a United States cohort of 9,976 patients, sepsis occurred in 11.1% of those who had the operation and 10.1% of those who did not, while the adjusted risk was higher after surgery both early (hazard ratio 3.3) and late (1.6 or 3.1, depending on other illnesses) (PMID 23637127).

Which germs

Older population studies raised doubt about whether pneumococcus was still the main cause. A prospective study across 173 German intensive care units compared 52 people with severe sepsis who had no working spleen with 52 who had one. Pneumococcus was found in 42% of those without a spleen against 12% of the others, and purpura fulminans, a dangerous spreading bleeding into the skin, developed in 19% against 5%. The authors concluded that pneumococcus remains the most important cause (PMID 26703862). The range of germs involved has also been described as wider than the classic three of pneumococcus, meningococcus and Haemophilus influenzae (PMID 19388926).

How the Infection Numbers Change Over Time

Risk is highest soon after surgery, falls, and does not return to normal in the studies that follow people longest.

Time after splenectomy (Danish cohort)Finding, compared with the general population
First 90 days10.2% had a hospital contact for infection, against 0.6% (adjusted odds ratio 18.1)
91 to 365 daysHazard 4.6 times higher
More than 365 daysHazard 2.5 times higher

Part of the first-90-day number reflects the operation itself. Compared with people who had their appendix out, the same 10.2% stood against 4.2% (PMID 19841456).

The other long-term data agree on the shape:

Young age is a separate factor. The European recommendations describe sepsis risk as highest when the operation is done before age 5, highest in the first year, and probably raised for life, and add that the current risk above age 5 is hard to estimate because most studies are retrospective and mix diseases and people who were not fully immunized (PMID 28550188).

The Signs Hospitals Treat as Urgent

Overwhelming infection may start like a mild viral illness and worsen into fulminant sepsis within 24–48 hours, which is why it can be hard to recognize early. The 2019 review lists these features: high fever above 38°C, shakes, chills, diarrhea, vomiting, headache and altered consciousness (PMID 31571940).

The same review describes hospital care in this setting as blood cultures before antibiotics, an urgent blood film, aggressive fluids and intensive monitoring, and reports that early recognition and prompt treatment give the best chance of survival. Because staff cannot always tell that a spleen is missing, the review notes that a history from family or a surgical scar can reveal it (PMID 31571940). In the British survey, only one of the 42 people with overwhelming infection carried a medical alert card (PMID 9459404).

Blood Clot and Blood Vessel Findings

Infection used to be the only long-term risk discussed. A 2009 review in Blood describes thrombosis as a more recently appreciated complication, involving many different diseases, kinds of clot and possible mechanisms (PMID 19636061). The findings split into early clots near the spleen and later clots elsewhere.

Early clots in the veins of the spleen and liver

A 2008 review put the overall risk of clots in the splenic and portal veins after the operation at 3.3%. Large spleens and inherited hemolytic anemias carried more risk, while immune thrombocytopenia and injury carried low risk. Rates were about the same for keyhole and open surgery. The median time to a symptomatic clot was 8 to 12 days. Treated with heparin and warfarin, 67% resolved completely and 13% partly, and 20% left persistent blockage, portal hypertension or a cavernoma. Whether to give anti-clotting drugs after surgery, and for how long, ranged from nothing to heparin for seven days or longer, and the authors state that well-designed randomized trials are urgently needed (PMID 18556406).

Later clots in the legs and lungs

Heart attack, stroke and lung pressure

A Danish study of 5,306 people answers part of the question of cause. Compared with the general population, it found raised adjusted risk of heart attack (hazard ratio 1.24), pulmonary hypertension (3.25) and stroke (2.04). Compared with people with the same underlying diseases who kept their spleen, only stroke remained raised, at a 5-year risk of 3.0% against 2.3%. The authors concluded that underlying disease explains the heart attack and pulmonary hypertension excess (PMID 28572164). The absolute risk of heart attack over 5 years was actually lower after surgery, at 1.3% against 1.8%, before statistical adjustment.

The hereditary spherocytosis family study

Part of this family study is covered on the Hereditary Spherocytosis page. What adds to the picture is the third group. At age 70, artery events had occurred in 22% of women and 32% of men with the condition who had the operation, in 3% and 2% of those with the condition who kept the spleen, and in 10% and 17% of family members without the condition. The people with the condition who kept the spleen therefore did better than their unaffected relatives (PMID 18485083). The study's author has suggested a protective effect of long-term mild anemia as the probable reason (PMID 19388926). The study relied on systematically questioning family members, and the European recommendations note a separate study of 39 adults with the condition that found no clots over a median of 25 years (PMID 28550188).

Cancer

The veterans study also found raised rate ratios for several solid tumors (1.3 to 1.9) and blood cancers (1.8 to 6.0) (PMID 24056815). The French matched cohort found similar cancer incidence with and without surgery (PMID 27902585). Whether the missing spleen plays a causal part has not been settled by these studies.

What Guidelines State About Vaccines

Several bodies publish guidance for people without a working spleen, including the British Committee for Standards in Haematology, whose guidance dates from 1996 and has been reviewed in 2002 and 2011 (PMID 21988145), and Spleen Australia, whose guideline covers Australia and New Zealand (PMID 27925427). Recommendations are periodically revised as new vaccines arrive. The statements below are reported as the documents state them on their publication dates.

Pneumococcus

The United States Advisory Committee on Immunization Practices lists congenital or acquired asplenia, sickle cell disease and other hemoglobinopathies among the risk conditions for pneumococcal disease. Its 2024 report states that a pneumococcal conjugate vaccine is recommended for adults aged 19–64 years with a risk condition who have not had one or whose history is unknown, and adds the 21-valent vaccine as an option (PMID 39264843). More detail is on Pneumococcal Vaccines.

Meningococcus

The committee's 2020 report recommends routine quadrivalent meningococcal conjugate vaccination for people aged 2 months and older with anatomic or functional asplenia, routine serogroup B vaccination for those aged 10 and older with asplenia, and booster doses for people who remain at increased risk (PMID 33417592). See Meningococcal Vaccines.

Timing and the other shots

A 2019 review of the guidelines reports the following (PMID 31571940):

What the evidence behind vaccination looks like

The clearest finding is how often the measures are missing. In the German intensive care study pneumococcal vaccine coverage among those with overwhelming infection was 42% (PMID 26703862). In the British survey only 12 of 42 had received pneumococcal vaccine, and four cases were possible vaccine failures (PMID 9459404). The infection can therefore still occur after vaccination.

Evidence on whether vaccination lowers disease is mixed and mostly indirect:

What Guidelines State About Daily and Standby Antibiotics

Guidelines describe two separate antibiotic approaches: a daily low dose taken while well, and a personal supply kept for sudden illness.

Daily antibiotics

According to the 2019 review, most guidelines recommend a period of daily antibiotics after splenectomy, with lifelong use depending on infection risk. The Australian guidance recommends 3 years. Others differ: some recommend no such initial period and some recommend lifelong use for everyone (PMID 31571940).

The review is frank about the basis for this. The recommendations rest on studies in children with sickle cell disease, such as the penicillin trial above. It states that no studies have evaluated daily antibiotics for other reasons for splenectomy or in adults, and that long-term use raises questions of resistance and of people keeping up with it (PMID 31571940). The Scottish authors suggested that antibiotics could offer the most benefit in the first 3 years or in the first 6 months after a first severe infection, which is an inference from when infections happened, not a trial result (PMID 16490477).

Among children with sickle cell anemia, a 2014 review states that infection with encapsulated bacteria is notably reduced by penicillin and immunization (PMID 24862308).

Standby antibiotics

The review reports that guidelines recommend people without a spleen hold their own supply of high-dose antibiotics. Those recommendations describe taking a high dose at the onset of illness or symptoms of overwhelming infection, and getting urgent medical attention as well (PMID 31571940).

Real-world uptake has been low. Only 22% in the British survey had taken any antibiotic prevention since surgery (PMID 9459404). In the German education study, stand-by antibiotics showed the largest absolute gain of any measure once people were contacted, which implies they were commonly missing beforehand (PMID 37653288).

The education lists in the 2019 review also include a medical alert card or similar item, telling health workers that the spleen has been removed, medical attention after animal bites and scratches, and medical advice before travel (PMID 31571940).

Travel, Ticks and Animal Bites

The European recommendations name asplenia as an important risk factor for serious infection with Plasmodium (malaria), Capnocytophaga canimorsus and Capnocytophaga cynodegmi after an animal bite, Babesia after a tick bite, and Bordetella holmesii (PMID 28550188).

Malaria

Two studies from malaria-endemic regions put numbers on this.

Both studies were done among people living in these regions, so they do not directly measure the risk to a short-term traveler. The 2019 review lists pre-travel medical advice among its education points, particularly for malaria areas (PMID 31571940). More on the parasite is on Malaria.

Ticks and babesiosis

Human babesiosis was first recognized in a person without a spleen in Europe, though most reported cases now come from the northeastern and upper midwestern United States in people with a spleen and no known immune problem (PMID 25999229). In 128 patients with Babesia microti infection followed over 16 years, those with asplenia or immune-weakening conditions were more likely to have severe infection, need hospital care and receive prolonged antimicrobial treatment (PMID 28722598). See Severe Babesiosis.

Dog and cat bites

Capnocytophaga canimorsus is a bacterium found in the saliva of healthy dogs and cats. A 2015 review collected about 484 laboratory-confirmed cases, with these findings (PMID 25828064):

Those 59 patients are a minority of the cases, so most reported infections had no recorded splenectomy. This is a collection of published cases, which tends to record severe illness, so the fatality figure may not reflect milder infections that were never reported. It also gives no rate of infection per bite.

What Is Not Known

Key Research Papers

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PubMed Topic Searches

  1. PubMed: overwhelming post-splenectomy infection
  2. PubMed: splenectomy and venous thromboembolism
  3. PubMed: asplenia and vaccination guidelines
  4. PubMed: hyposplenism in sickle cell disease
  5. PubMed: Capnocytophaga canimorsus and splenectomy

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