What is the recommended pneumonia vaccine regimen for adults 65 years and older or those with underlying medical conditions, such as chronic heart or lung disease, or immunocompromised individuals?

Pneumococcal Vaccination Recommendations for Adults

Direct Answer

For adults ≥65 years who have never received pneumococcal vaccine, administer a single dose of PCV20 (preferred option) to complete the series—no additional doses are needed. 1, 2, 3 Alternatively, give PCV15 followed by PPSV23 at least 1 year later. 1, 2

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Vaccination Strategy by Patient Population

Healthy Adults ≥65 Years (No Prior Vaccination)

Option A (Preferred): Single dose of PCV20 completes the series 1, 2, 3

• No booster doses required 3
• Simplest approach with broadest serotype coverage 2

Option B: PCV15 followed by PPSV23 ≥1 year later 1, 2

• Also completes the series with no additional doses 3

Adults 19-64 Years with Chronic Medical Conditions

Chronic conditions include: chronic heart disease (including congestive heart failure, cardiomyopathies), chronic lung disease (COPD, emphysema, asthma), chronic liver disease, diabetes mellitus, alcoholism, or cigarette smoking 1

If never vaccinated:

• Give single dose of PCV20 (completes series) 1, 3
• OR PCV15 followed by PPSV23 ≥1 year later 1
• Review vaccination status again at age 65 to determine if additional doses needed 1, 3

If previously received PPSV23 only:

• Give PCV20 ≥1 year after last PPSV23 dose 1, 2

If previously received PCV13 only:

• Give PPSV23 ≥1 year after PCV13 1
• Review again at age 65 1

Immunocompromised Adults (Any Age ≥19 Years)

Immunocompromising conditions include: congenital or acquired asplenia, sickle cell disease, chronic renal failure, nephrotic syndrome, congenital or acquired immunodeficiencies, HIV infection, generalized malignancy, Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplant, iatrogenic immunosuppression (including long-term systemic corticosteroids), CSF leak, or cochlear implant 1, 2, 3

Critical timing difference: Immunocompromised patients need only ≥8 weeks between PCV and PPSV23, while immunocompetent patients need ≥1 year 1, 2, 3

Option A: Single dose of PCV20 completes the series 1, 3

Option B: PCV15 followed by PPSV23 ≥8 weeks later 1, 3

• Second dose of PPSV23 ≥5 years after first PPSV23 if given before age 65 2, 3
• Final PPSV23 dose at/after age 65 if ≥5 years since last dose 3

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Special Scenarios Based on Prior Vaccination History

Previously Received PPSV23 Before Age 65

• Give PCV20 or PCV15 ≥1 year after last PPSV23 dose 1, 2, 3
• If PCV15 chosen, follow with PPSV23 ≥1 year later (≥8 weeks if immunocompromised) 2, 3
• At age 65: if ≥5 years since last PPSV23, give one final PPSV23 dose 3, 4
• No additional PPSV23 doses after the dose given at age ≥65 years 2, 3, 4

Previously Received PCV13 Only

• Give PCV20 ≥1 year after PCV13 (completes series) 1, 2
• OR give PPSV23 ≥1 year after PCV13 1
• Review at age 65 for additional doses 1

Previously Received Both PCV13 and PPSV23 Before Age 65

• No additional vaccines recommended until age 65 1
• At age 65: shared clinical decision-making may consider PCV20 ≥5 years after last pneumococcal vaccine 2

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Critical Timing Rules to Avoid Errors

Never coadminister pneumococcal vaccines on the same day 2, 3, 4

• Reduces immune response and wastes vaccine 3

Interval between PCV and PPSV23:

• Immunocompetent adults: ≥1 year 1, 2, 3
• Immunocompromised adults: ≥8 weeks 1, 2, 3
• Not waiting appropriate interval reduces immune response 3

For patients requiring elective splenectomy or immunosuppressive therapy:

• Complete vaccination ≥2 weeks before surgery or therapy initiation 2

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Maximum Lifetime PPSV23 Doses

Immunocompetent adults: Maximum 1-2 doses total 3

• One before age 65 if indicated, one at/after age 65 3

Immunocompromised adults: Maximum 2-3 doses total 3

• Initial dose, booster at 5 years if given before age 65, final dose at/after age 65 3
• The 5-year interval for PPSV23 boosters applies only to select high-risk immunocompromised populations who received first dose before age 65 2, 3

Adults who received PPSV23 at age ≥65 years receive only a single dose without additional boosters 2, 4

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Common Pitfalls and How to Avoid Them

Uncertain vaccination history:

• Do not delay vaccination waiting for records 2
• Use patient's verbal history and proceed with indicated vaccination 2
• Document clearly to avoid unnecessary future doses 2

Avoid multiple unnecessary PPSV23 boosters:

• Insufficient evidence for safety with three or more doses 2
• Follow maximum dose guidelines strictly 3

Concomitant vaccine administration:

• Reduced immune response to zoster vaccine when given with PPSV23 on same day 5
• Consider separating by ≥4 weeks 5

Special populations requiring accelerated schedules:

• Cochlear implants and CSF leaks follow same schedule as immunocompromised patients 1, 3
• Use ≥8 week interval, not ≥1 year 3