How do you assess elderly patients for the need for pneumococcal (Streptococcus pneumoniae) vaccine?

Assessment of Elderly Patients for Pneumococcal Vaccination

All adults aged ≥65 years should receive pneumococcal vaccination with a single dose of PCV20 as the preferred option, or alternatively PCV15 followed by PPSV23 at least 1 year later. 1, 2

Step 1: Determine Age and Basic Eligibility

• Universal vaccination is recommended for all adults aged ≥65 years, regardless of underlying health conditions or prior vaccination status 1, 3
• As of October 2024, ACIP expanded recommendations to include all adults aged ≥50 years, making age-based assessment even more straightforward 4
• For adults aged 19-49 years, vaccination is only indicated if specific risk factors are present (see Step 3 below) 3

Step 2: Assess Prior Vaccination History

This is the critical assessment step that determines your next action. Ask specifically about:

If Never Vaccinated (Vaccine-Naïve)

• Administer a single dose of PCV20 immediately - this is the preferred option for simplicity and broader serotype coverage 1, 2
• Alternative option: Give PCV15 now, followed by PPSV23 at least 1 year later 1
• If vaccination status is uncertain, do not delay vaccination - use the patient's verbal history and proceed with vaccination if indicated 5

If Previously Received PPSV23 Only

• If PPSV23 was given at age ≥65 years: Administer a single dose of PCV20 or PCV15 at least 1 year after the last PPSV23 dose 1
• If PPSV23 was given before age 65: The patient should have received another dose at age ≥65 (if ≥5 years elapsed), then add PCV20 or PCV15 at least 1 year after the last PPSV23 5, 1

If Previously Received PCV13 Only

• Administer PCV20 or PPSV23 at least 1 year after the PCV13 dose 1
• For immunocompromised patients, this interval shortens to ≥8 weeks 1

If Previously Received Both PCV13 and PPSV23

• No additional doses are routinely needed if completed at age ≥65 years 1
• Shared clinical decision-making may support PCV20 or PCV21 ≥5 years after the last dose 1

Step 3: Identify High-Risk Conditions That Modify the Approach

For immunocompromised patients or those with specific anatomic conditions, use shorter intervals between vaccines:

Immunocompromising Conditions (8-week interval instead of 1 year)

• Chronic renal failure or nephrotic syndrome 5, 1
• Functional or anatomic asplenia (including sickle cell disease) 5, 1
• HIV infection 5, 1
• Malignancies (leukemia, lymphoma, Hodgkin disease, multiple myeloma, generalized malignancy) 5, 1
• Immunosuppressive therapy (including long-term systemic corticosteroids, organ/bone marrow transplantation) 5, 1

Special Anatomic Conditions (8-week interval)

• Cerebrospinal fluid leak 1, 3
• Cochlear implant 1, 3

For these high-risk patients: Give PCV first, then PPSV23 at least 8 weeks later (not 1 year) 1, 2

Additional High-Risk Conditions (Standard 1-year interval)

• Chronic heart disease 3
• Chronic lung disease 3
• Diabetes mellitus 3
• Chronic liver disease 3
• Alcoholism 3
• Current cigarette smoking 3

Step 4: Consider Revaccination Needs for High-Risk Patients

Most elderly patients receive only one lifetime series and do not need repeated boosters. 1 However:

• For immunocompromised adults who received PPSV23 before age 65: A second dose of PPSV23 is recommended 5 years after the first dose 5, 1
• For adults who received PPSV23 at age ≥65 years: No additional PPSV23 doses are recommended 1
• Routine revaccination beyond a second dose is not recommended due to insufficient safety data 5

Critical Implementation Points

• Never co-administer pneumococcal vaccines on the same day - they must be given sequentially 1, 2
• Always give PCV before PPSV23 when both are needed 2
• Document vaccination clearly to avoid unnecessary future doses, but never withhold vaccination due to missing records 5
• Avoid unnecessary revaccination with PPSV23 after the dose given at age ≥65 years 1

Common Pitfalls to Avoid

• Do not delay vaccination waiting for complete medical records - use verbal history and proceed 5
• Do not give multiple PPSV23 boosters beyond what is recommended - there is insufficient evidence for safety with three or more doses 5
• Do not use the old PCV13 recommendations - since 2019, PCV13 is no longer routinely recommended, replaced by PCV15, PCV20, and PCV21 with broader coverage 1, 3
• Remember that 90.6% of unvaccinated elderly patients have had missed opportunities - assess at every healthcare encounter 6