What are the pneumococcal vaccine (Pneumococcal Conjugate Vaccine (PCV) and Pneumococcal Polysaccharide Vaccine (PPSV)) guidelines for adults, including those with chronic medical conditions, such as heart disease, lung disease, or diabetes, and those with weakened immune systems, aged 65 years and older?

Pneumococcal Vaccination Guidelines for Adults

Healthy Adults ≥65 Years Without Prior Vaccination

Administer a single dose of PCV20 (preferred) at age 65 or older, which completes the series with no additional doses needed. 1, 2

• Alternatively, give PCV15 followed by PPSV23 at least 1 year later, which also completes the series. 1, 2
• No booster doses are recommended after completing this series—this is a lifetime vaccination. 2, 3
• The 2023 ACIP guidelines replaced the older 2019 recommendation for routine PCV13, now favoring the broader coverage of PCV20 or PCV15. 1, 3

Adults Aged 19-64 Years With Chronic Medical Conditions

Give a single dose of PCV20 now, which completes the series for adults with chronic medical conditions (heart disease, lung disease, liver disease, diabetes, alcoholism, or smoking history). 1, 2

• If previously received PPSV23 only, give PCV20 at least 1 year after the last PPSV23 dose. 1, 2
• If previously received PCV13 only, give PCV20 at least 1 year after PCV13, which completes the series. 1, 2
• Critical caveat: Review vaccination status again when the patient turns 65 years old to determine if any additional doses are needed based on updated guidelines and prior vaccination history. 2, 3
• Chronic medical conditions include: congestive heart failure, cardiomyopathies, chronic obstructive pulmonary disease, emphysema, asthma, chronic liver disease, diabetes mellitus, alcoholism, and cigarette smoking. 1

Immunocompromised Adults (Any Age ≥19 Years)

For immunocompromised patients, give PCV20 as a single dose (Option A, preferred), which completes the initial series. 1, 2

• Option B: Give PCV15 followed by PPSV23 at least 8 weeks later (not 1 year—this is the critical distinction from immunocompetent patients). 1, 2
• If using Option B and the first PPSV23 was given before age 65, administer a second dose of PPSV23 at least 5 years after the first PPSV23 dose. 1, 2, 3
• When the patient turns 65, if at least 5 years have passed since the last PPSV23 dose, give one final dose of PPSV23. 1, 2
• No additional PPSV23 doses are given after the dose administered at age ≥65 years. 1, 2, 3

Immunocompromising Conditions Include:

• Congenital or acquired asplenia, sickle cell disease/hemoglobinopathies 1, 4
• Chronic renal failure, nephrotic syndrome 1, 4
• Congenital or acquired immunodeficiencies (B- or T-lymphocyte deficiency, complement deficiencies) 1, 4
• HIV infection 1, 4
• Generalized malignancy, Hodgkin disease, leukemia, lymphoma, multiple myeloma 1, 4
• Iatrogenic immunosuppression (long-term systemic corticosteroids, radiation therapy) 1, 4
• Solid organ transplant 1, 4

Special High-Risk Conditions: Cochlear Implants or CSF Leaks

Follow the same accelerated schedule as immunocompromised patients: PCV first, then PPSV23 at least 8 weeks later. 1, 2, 4

• If the first PPSV23 was given before age 65, give a second PPSV23 dose at least 5 years after the first. 1, 2
• At age ≥65 years, if at least 5 years have passed since the last PPSV23, give one final dose. 1, 2

Adults Who Previously Received PPSV23 Before Age 65

Give PCV20 or PCV15 at least 1 year after the last PPSV23 dose. 1, 2, 3

• If using PCV15, follow with PPSV23 at least 1 year later (or ≥8 weeks if immunocompromised). 1, 2
• When the patient turns 65, if at least 5 years have passed since the last PPSV23 dose, give one final dose of PPSV23. 1, 2, 4
• No additional PPSV23 doses are given after the dose administered at age ≥65 years. 1, 2, 3

Adults Who Previously Received PCV13 Only

Give PCV20 at least 1 year after PCV13, which completes the series for immunocompetent patients. 1, 2

• For immunocompromised patients who received PCV13 only, add PPSV23 ≥8 weeks after PCV13, then a second PPSV23 ≥5 years later if given before age 65. 2, 3
• Review vaccination status again when the patient turns 65 years old. 1, 2

Key Timing Rules to Avoid Errors

Never coadminister pneumococcal vaccines on the same day—this reduces immune response and wastes the vaccine. 2, 3, 4

• Wait at least 1 year between PCV and PPSV23 for immunocompetent patients. 1, 2, 3
• Wait only 8 weeks between PCV and PPSV23 for immunocompromised patients, those with CSF leaks, or cochlear implants. 1, 2
• Not waiting the appropriate interval reduces immune response and wastes the vaccine. 2
• The shorter 8-week interval for immunocompromised patients reflects the greater urgency for protection in patients at higher risk for invasive pneumococcal disease. 2

Maximum Lifetime PPSV23 Doses

Immunocompetent adults: maximum of 1-2 doses total (one before age 65 if indicated, one at/after age 65). 2, 3

Immunocompromised adults: maximum of 2-3 doses total (initial dose, booster at 5 years if given before age 65, final dose at/after age 65). 2, 3

• The 5-year interval for PPSV23 boosters applies only to select high-risk immunocompromised populations who received their first dose before age 65. 2, 3
• Avoid giving multiple PPSV23 boosters beyond what is recommended—there is insufficient evidence for safety with three or more doses. 3

Important Clinical Caveats

If vaccination status is uncertain, do not delay vaccination—use the patient's verbal history and proceed with vaccination if indicated. 3

• Document vaccination clearly to avoid unnecessary future doses, but never withhold vaccination due to missing records. 3
• For patients requiring elective splenectomy or initiation of immunosuppressive therapy, vaccination should be completed at least 2 weeks before surgery or therapy initiation. 2
• PCV13 is no longer routinely recommended for all adults aged ≥65 years since 2019, as it has been replaced by newer pneumococcal conjugate vaccines (PCV15, PCV20) with broader serotype coverage. 1, 3
• PPSV23 contains 11 additional serotypes not included in PCV13, which account for 32-37% of invasive pneumococcal disease among adults aged ≥65 years. 1, 3, 4