What is the recommended prescribing guideline for Pneumococcal Conjugate Vaccine (PCV) 20?

PCV20 Prescribing Guidelines

For adults ≥50 years who have never received a pneumococcal vaccine, administer a single dose of PCV20 intramuscularly—this completes the pneumococcal vaccination series and no additional doses are needed. 1, 2, 3

Age-Based Recommendations

Adults ≥65 Years (No Prior Vaccination)

• Administer a single 0.5 mL dose of PCV20 intramuscularly 1, 3
• No additional pneumococcal vaccines are required after PCV20—the series is complete 2
• This is the preferred option over the PCV15 + PPSV23 sequence due to simplicity and equivalent protection 1, 4

Adults 50-64 Years (No Prior Vaccination)

• Administer a single dose of PCV20 for all adults ≥50 years as of October 2024 ACIP recommendations 5
• This expanded age recommendation reflects increased pneumococcal disease burden in this age group 5

Adults 19-49 Years with Risk Conditions

• Administer PCV20 for immunocompromising conditions (HIV, malignancy, immunosuppressive therapy, transplant recipients, chronic renal failure, asplenia) 1, 4
• Administer PCV20 for chronic medical conditions (diabetes, chronic heart/lung/liver disease, alcoholism, smoking) 1, 4
• Administer PCV20 for CSF leak or cochlear implant 1

Prior Vaccination History: Critical Timing Intervals

Previously Received PPSV23 Only

• Administer PCV20 ≥1 year after the last PPSV23 dose 1
• This completes the pneumococcal series—no additional PPSV23 is needed 2, 4
• Common pitfall: Do not reflexively add PPSV23 after PCV20, as PCV20 stands alone 2

Previously Received PCV13 Only

• Administer PCV20 ≥1 year after the PCV13 dose for immunocompetent adults 1
• For immunocompromised adults, the same ≥1 year interval applies 4
• This completes the series—no PPSV23 is required 2, 4

Previously Received Both PCV13 and PPSV23

• If PPSV23 was given before age 65: Administer PCV20 ≥5 years after the last PCV13 or PPSV23 dose (whichever is later) 1
• If PPSV23 was given at age ≥65: Use shared clinical decision-making to consider PCV20 ≥5 years after the last dose 1
• This is optional, not routinely recommended for all patients who completed the PCV13/PPSV23 series 4

Previously Received PCV7 Only

• Treat as vaccine-naïve and follow standard recommendations for age and risk status 1

Special Population: Hematopoietic Stem Cell Transplant (HSCT)

HSCT recipients require a 4-dose PCV20 series, not a single dose 1

• Start 3-6 months after HSCT 1
• Give 3 doses 4 weeks apart 1
• Give fourth dose ≥6 months after the third dose OR ≥12 months after HSCT, whichever is later 1
• If PCV20 unavailable, use 3 doses of PCV15 (4 weeks apart) followed by PPSV23 ≥1 year after HSCT 1

Administration Technique

Preparation 3

• Hold pre-filled syringe horizontally and shake vigorously until homogeneous white suspension
• Visually inspect for particulate matter or discoloration—do not use if present
• Remove syringe cap by turning counterclockwise while holding Luer lock adapter
• Attach sterile needle appropriate for intramuscular injection

Injection 3

• Administer 0.5 mL intramuscularly using attached sterile needle
• Do not mix with other vaccines in the same syringe 3
• Can be given concomitantly with other vaccines at different injection sites 1

Key Clinical Principles

PCV20 is a Standalone Vaccine

• Once PCV20 is administered, the pneumococcal vaccination series is complete 2
• Do not follow PCV20 with PPSV23 or any other pneumococcal vaccine (except in HSCT recipients) 2
• Critical distinction: PCV15 requires PPSV23 follow-up, but PCV20 does not 2

Immunocompromised Patients

• Use the same intervals as immunocompetent adults for PCV20 (≥1 year after prior vaccines) 4
• The shorter 8-week interval applies only when using PCV15 followed by PPSV23, not for PCV20 1, 4
• Consider individual risk-benefit assessment for severely immunocompromised patients 3

Common Pitfalls to Avoid

• Do not give PCV20 <1 year after PCV13 or PPSV23—this violates ACIP recommendations and may result in suboptimal immune response 4
• Do not add PPSV23 after PCV20—the series is complete with PCV20 alone 2, 4
• Do not confuse PCV20 with PCV15—only PCV15 requires PPSV23 follow-up 2
• Do not delay vaccination waiting for complete medical records—use verbal history and proceed 6
• For patients with both PCV13 and PPSV23 at age ≥65, PCV20 is optional via shared decision-making, not routinely recommended 1, 4

Contraindications 3

• Severe allergic reaction (anaphylaxis) to any component of PCV20
• Severe allergic reaction to diphtheria toxoid
• Have epinephrine and appropriate medical treatment immediately available for acute anaphylactic reactions 3

Safety Considerations

• Most common reactions in adults ≥18 years: injection site pain (>50%), muscle pain (>30%), fatigue (>30%), headache (>20%) 3
• Apnea may occur in premature infants—consider individual risk-benefit 3
• Immunocompromised individuals may have reduced immune responses 3