What is the recommended dosing regimen for Pneumococcal Conjugate Vaccine (PCV13) (Prevnar 13) in adults 65 years and older?

How to Prescribe PCV13 for the Elderly

PCV13 is no longer routinely recommended for all adults ≥65 years; instead, use shared clinical decision-making for immunocompetent patients, while PPSV23 remains universally recommended, and newer vaccines (PCV20, PCV15) are now preferred over PCV13. 1, 2

Current Recommendation Framework (2019 Update)

The landscape for pneumococcal vaccination in older adults changed dramatically in 2019. ACIP shifted away from universal PCV13 recommendation to a shared clinical decision-making approach for immunocompetent adults ≥65 years. 1 This change occurred because:

• PCV13-type disease burden dropped to historically low levels due to indirect protection from pediatric vaccination programs 2, 3
• The remaining PCV13-type disease accounts for only 4% of all-cause pneumonia in this age group 3
• Population-level impact from universal PCV13 use was minimal 1

Algorithm for Prescribing Pneumococcal Vaccines to Adults ≥65 Years

Step 1: Determine Risk Category

High-Risk Patients (Mandatory PCV13 or newer PCV):

• Immunocompromising conditions (chronic renal failure, nephrotic syndrome, HIV, malignancies, immunosuppressive therapy, transplant recipients) 1
• Anatomic/functional asplenia or sickle cell disease 1, 4
• CSF leaks or cochlear implants 1

For these high-risk patients: Give PCV13 (or PCV15/PCV20) first, followed by PPSV23 at least 8 weeks later (not 1 year). 1, 2, 4

Step 2: For Immunocompetent Adults ≥65 Years

Preferred Modern Approach (2024 Guidelines):

• Single dose of PCV20 alone (simplest option) 2, 3
• Alternative: PCV15 followed by PPSV23 ≥1 year later 2, 3

If Using PCV13 (Older Protocol via Shared Decision-Making):

• Discuss individual risk factors: exposure risk to PCV13 serotypes, underlying chronic conditions, living situation 1
• If decision is made to give PCV13: administer it before PPSV23 1
• Wait ≥1 year between PCV13 and PPSV23 for immunocompetent patients 1

Step 3: PPSV23 Administration (Universal for All ≥65 Years)

All adults ≥65 years must receive PPSV23 regardless of PCV status, as it covers 11 additional serotypes accounting for 32-37% of invasive disease. 1, 4

Timing rules:

• If received PPSV23 before age 65: Give one additional dose at age ≥65, at least 5 years after previous PPSV23 1, 4
• If received PPSV23 at age ≥65: No additional PPSV23 doses needed 2, 4

Critical Prescribing Rules

Never co-administer PCV13 and PPSV23 on the same day. 1, 3

Interval requirements:

• Immunocompetent: ≥1 year between any pneumococcal vaccines 1
• Immunocompromised: ≥8 weeks between PCV and PPSV23 1, 2, 4

Dosing: PCV13 is given as a single 0.5 mL intramuscular injection. 5

Common Pitfalls to Avoid

Pitfall 1: Assuming PCV13 is still universally recommended. It's not—only through shared decision-making for immunocompetent patients or mandatory for high-risk conditions. 1

Pitfall 2: Giving PPSV23 before PCV13. If both are indicated, always give PCV13 first, as prior PPSV23 diminishes subsequent PCV13 response. 1, 6

Pitfall 3: Using 1-year interval for immunocompromised patients. These patients need the shorter 8-week interval between vaccines. 1, 2

Pitfall 4: Giving multiple PPSV23 boosters after age 65. Only one dose of PPSV23 is recommended at age ≥65 years; avoid unnecessary revaccination. 2, 3

Pitfall 5: Delaying vaccination for missing records. Use verbal history and proceed with indicated vaccination rather than waiting for documentation. 2

Practical Considerations for Shared Clinical Decision-Making

When discussing PCV13 with immunocompetent patients ≥65 years, consider: 1

• Increased exposure risk: Living in long-term care facilities, frequent contact with children, healthcare workers
• Chronic conditions: Even without immunocompromise, conditions like diabetes, heart disease, and lung disease increase pneumococcal risk
• Individual preference: Some patients desire maximum protection despite low population-level benefit

The evidence shows PCV13 is safe and effective, but the remaining disease burden is low due to herd immunity from pediatric vaccination. 1, 5

Transition to Newer Vaccines

The 2024 ACIP guidelines now recommend PCV20 or PCV15 (followed by PPSV23) as preferred options over PCV13 for broader serotype coverage. 2, 3, 7 If your patient has never received pneumococcal vaccination, consider starting with these newer vaccines rather than PCV13.