What are the vaccination recommendations for influenza and pneumococcal disease in a patient being treated for pneumonia and taking steroids (corticosteroids)?

Vaccination Recommendations for Patients Being Treated for Pneumonia and on Steroids

For patients currently being treated for pneumonia and on corticosteroids, influenza vaccination should be administered regardless of steroid dose, while pneumococcal vaccination should be deferred until the steroid dose is tapered to less than 20 mg daily of prednisone equivalent. 1, 2

Influenza Vaccination Recommendations

• Influenza vaccination is conditionally recommended for patients taking prednisone ≥20 mg daily (or equivalent) regardless of the current pneumonia treatment 2, 1
• Administering influenza vaccination on schedule is recommended rather than deferring vaccination, even in patients on high-dose steroids 2, 1
• The antibody response to influenza vaccination may be suboptimal in patients on high-dose steroids, but vaccination still provides some protection and should not be delayed 1, 3
• High-dose or adjuvanted influenza vaccination is conditionally recommended over regular-dose influenza for patients on immunosuppressive medications 3

Pneumococcal Vaccination Recommendations

• For patients on prednisone ≥20 mg daily (or equivalent), it is conditionally recommended to defer pneumococcal vaccination until glucocorticoids are tapered to less than 20 mg daily 2
• This recommendation is based on low-quality evidence showing that high-dose steroids may significantly impair the immune response to pneumococcal vaccines 2
• For patients on moderate doses of prednisone (>10 mg but <20 mg daily), pneumococcal vaccination can be administered without deferral 2, 1
• Pneumococcal vaccination is strongly recommended for patients with chronic conditions who are taking immunosuppressive medications 3

Impact of Corticosteroids on Vaccine Response

• High-dose steroid therapy (prednisone ≥20 mg/day or equivalent for ≥14 days) is considered significantly immunosuppressive 1
• Corticosteroids can reduce vaccine immunogenicity by suppressing B-cell and T-cell responses, but generally do not completely abolish protective responses 1, 4
• A study in steroid-dependent asthma patients showed that chronic prednisone treatment (10-35 mg daily or alternate day) did not significantly affect pneumococcal antibody responses 4
• The timing of vaccination relative to steroid therapy is important - higher steroid doses are associated with greater suppression of immune responses 1, 5

Special Considerations for Patients with Active Pneumonia

• For patients currently being treated for pneumonia with corticosteroids, the primary concern is optimizing treatment of the acute infection 6, 7
• Low-to-moderate-dose corticosteroids (≤400 mg hydrocortisone equivalent daily) may be beneficial in severe pneumonia with respiratory failure (PaO₂/FiO₂ <300 mmHg) 8, 7
• However, high-dose corticosteroids (>150 mg/day) have not shown benefit and may increase mortality in some patients with viral pneumonia 6, 9
• The current pneumonia treatment should not be interrupted for vaccination purposes 1, 7

Practical Approach to Vaccination in These Patients

1. For influenza vaccination:

   • Administer as soon as clinically appropriate, regardless of steroid dose 2, 1
   • Do not delay influenza vaccination even if the patient is on high-dose steroids 2, 3

2. For pneumococcal vaccination:

   • If on prednisone <20 mg daily: Administer pneumococcal vaccine without delay 2, 1
   • If on prednisone ≥20 mg daily: Defer until steroid dose is tapered below 20 mg daily 2
   • If pneumococcal vaccination is urgently needed despite high-dose steroids, consider measuring antibody response after vaccination 1

3. For patients on other immunosuppressants in addition to steroids:

   • Continue most immunosuppressive medications around the time of vaccination 2, 5
   • For patients on rituximab, administer influenza vaccination on schedule but consider deferring pneumococcal vaccination until just before the next rituximab dose 2

Common Pitfalls and Caveats

• Avoid live-attenuated vaccines (e.g., intranasal influenza vaccine) in patients on high-dose steroids (≥20 mg/day of prednisone for ≥14 days) 1
• Do not assume that vaccination during steroid therapy will be completely ineffective - most patients still achieve some level of protection 1, 4
• Remember that the risk of severe influenza or pneumococcal disease in unvaccinated patients often outweighs the risk of suboptimal vaccine response 3
• Consider revaccination 3 months after discontinuation of high-dose steroid therapy if vaccination was administered during immunosuppression 1