What is the recommended pneumococcal vaccine for an elderly patient with diabetes mellitus (Diabetes)?

Pneumococcal Vaccination for Elderly Diabetic Patients

For an elderly diabetic patient aged ≥65 years, administer a single dose of PCV20 (20-valent pneumococcal conjugate vaccine) as the preferred option, or alternatively PCV15 followed by PPSV23 at least 1 year later. 1, 2

Primary Recommendation for Vaccine-Naïve Patients

• PCV20 as a single dose is the preferred approach for simplicity and comprehensive coverage, eliminating the need for any additional pneumococcal vaccines 2, 3
• If PCV20 is unavailable, administer PCV15 followed by PPSV23 after a minimum interval of ≥1 year 1
• Both options provide protection against the pneumococcal serotypes most commonly causing invasive disease in adults with diabetes 1

Rationale for Vaccination in Diabetic Patients

• Diabetes is classified as a chronic medical condition that significantly increases risk for pneumococcal infection, with mortality rates as high as 50% for bacteremic pneumococcal disease [1, @22@]
• People with diabetes have higher rates of hospitalization and death from pneumococcal pneumonia compared to the general population 1
• The Advisory Committee on Immunization Practices (ACIP) specifically designates diabetes as an indication for pneumococcal vaccination 1, 3

Vaccination Schedule Based on Prior History

If Previously Received PPSV23 Only (Before Age 65)

• Administer PCV20 or PCV15 at least 1 year after the last PPSV23 dose 1, 2
• If PCV15 is used, follow with PPSV23 at least 1 year later 1
• No additional doses needed after completing this series 2

If Previously Received PCV13 Only

• Administer PCV20 at least 1 year after the PCV13 dose 1
• Alternatively, administer PPSV23 at least 1 year after PCV13 if PCV20 is unavailable 1
• This completes the vaccination series 2

If Previously Received Both PCV13 and PPSV23 at Age ≥65

• The vaccination series is complete; no additional doses are routinely recommended 2
• Shared clinical decision-making may be considered for administering PCV20 ≥5 years after the last pneumococcal vaccine dose 2

If Vaccination Status Unknown

• Do not delay vaccination waiting for records 2
• Use verbal history and proceed with PCV20 or PCV15 as if vaccine-naïve 2
• Document vaccination clearly to prevent unnecessary future doses 2

Special Considerations for Immunocompromised Diabetic Patients

Conditions Requiring Modified Schedule

• Chronic renal failure, nephrotic syndrome, or dialysis 1, 2
• Functional or anatomic asplenia 1
• HIV infection or other immunodeficiencies 1
• Active malignancy or immunosuppressive therapy (including long-term corticosteroids) 1
• Solid organ transplant recipients 1

Modified Vaccination Schedule for Immunocompromised

• If using PCV15, the interval before PPSV23 can be shortened to ≥8 weeks (instead of ≥1 year) 1
• A second dose of PPSV23 is recommended ≥5 years after the first PPSV23 dose 1, 2
• If previously received only PCV13, administer PPSV23 ≥8 weeks after PCV13, then a second PPSV23 ≥5 years later 1

Important Clinical Caveats

• PCV20 and PPSV23 should never be co-administered on the same day 2
• Avoid unnecessary revaccination with PPSV23 after the dose given at age ≥65 years, as no additional doses provide proven benefit 2
• The ACIP does not recommend multiple PPSV23 revaccinations due to uncertainty regarding clinical benefit and potential safety concerns 2
• Elderly patients may not tolerate vaccines as well as younger individuals; some have experienced severe adverse reactions requiring hospitalization, particularly those with underlying medical conditions 4
• For patients requiring elective splenectomy or initiation of immunosuppressive therapy, complete vaccination at least 2 weeks before the procedure 2

Evolution of Recommendations

• Prior to 2019, both PCV13 and PPSV23 were recommended for all adults ≥65 years 2
• In 2019, routine PCV13 was no longer recommended for all adults ≥65 years due to declining rates of PCV13-serotype disease 1
• The 2023-2024 ACIP guidelines introduced newer conjugate vaccines (PCV15, PCV20, PCV21) with broader serotype coverage, making them the preferred initial vaccination 1, 2
• The 2024 ACIP recommendations represent the strongest current evidence, establishing PCV20 as the preferred single-dose option for simplicity and comprehensive protection 2, 3