What is the recommended pneumococcal vaccine (Pneumococcal Conjugate Vaccine (PCV) or Pneumococcal Polysaccharide Vaccine (PPSV)) schedule for adults aged 65 and older or those with chronic medical conditions, such as chronic heart disease, lung disease, or impaired immune system?

Pneumococcal Vaccination for Adults ≥65 Years and Those with Chronic Conditions

For adults aged ≥65 years who have never received pneumococcal vaccination, administer a single dose of PCV20 (or PCV21), which completes the series with no additional doses needed. 1

Vaccination Strategy by Age and Risk Status

Adults ≥65 Years (No Prior Vaccination)

Preferred approach: Administer a single dose of PCV20, which provides complete protection without requiring additional doses. 1, 2

Alternative approach: Administer PCV15 followed by PPSV23 at least 1 year later, which also completes the series. 1, 2

• Both strategies provide lifetime protection with no booster doses required after completion. 2, 3
• PCV20 is preferred for simplicity and patient compliance, as it eliminates the need for a second visit. 2, 3

Adults Aged 19-64 Years with Chronic Medical Conditions

For patients with chronic heart disease, lung disease (COPD, emphysema, asthma), liver disease, diabetes, alcoholism, or smoking history, administer a single dose of PCV20 now. 1, 2

• This single dose completes the series for immunocompetent adults with chronic conditions. 1, 2
• Review vaccination status again when the patient turns 65 years old to determine if additional doses are needed based on prior vaccination history. 1, 2

Immunocompromised Adults (Any Age ≥19 Years)

For patients with immunocompromising conditions (chronic renal failure, asplenia, HIV infection, malignancies, immunosuppressive therapy, sickle cell disease, transplant recipients, complement deficiencies), use an accelerated schedule with shorter intervals. 2, 4

Option A (preferred): Single dose of PCV20, which completes the series. 2

Option B: PCV15 followed by PPSV23 at least 8 weeks later (not 1 year), with a second dose of PPSV23 at least 5 years after the first PPSV23 dose if given before age 65. 2, 4

• The critical distinction is the 8-week interval for immunocompromised patients versus the 1-year interval for immunocompetent patients. 2, 4
• This shorter interval reflects the greater urgency for protection in high-risk patients. 4

Managing Patients with Prior Vaccination History

Previously Received PPSV23 Only

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

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

Previously Received PCV13 Only

For immunocompetent adults aged 19-64 years: Administer PPSV23 at least 1 year after PCV13, then review recommendations again at age 65. 1

For immunocompromised adults: Administer PPSV23 at least 8 weeks after PCV13, with a second PPSV23 dose at least 5 years later if given before age 65. 2

For adults ≥65 years: Administer PCV20 at least 1 year after PCV13, which completes the series. 1

Previously Received Both PCV13 and PPSV23

For adults aged 19-64 years: No vaccines are recommended at this time; review recommendations again when the patient turns 65. 1

For adults ≥65 years: Shared clinical decision-making may be considered to administer PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine. 3

Critical Timing Rules to Avoid Errors

Never coadminister pneumococcal vaccines on the same day, as this reduces immune response. 2, 3, 4

Minimum intervals between doses:

• Immunocompetent adults: Wait at least 1 year between PCV and PPSV23. 2, 4
• Immunocompromised adults: Wait only 8 weeks between PCV and PPSV23. 2, 4
• Not waiting the appropriate interval reduces immune response and wastes the vaccine. 2

For patients requiring elective splenectomy or initiation of immunosuppressive therapy, complete vaccination at least 2 weeks before surgery or therapy initiation. 4

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, as there is insufficient evidence for safety with three or more doses. 3

Special High-Risk Conditions

For patients with cochlear implants or cerebrospinal fluid leaks, follow the same accelerated schedule as immunocompromised patients: PCV first, then PPSV23 at least 8 weeks later, with a second PPSV23 dose at least 5 years after the first if given before age 65. 2, 4

Documentation and Uncertain Vaccination Status

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
• Avoid delaying vaccination waiting for complete medical records—use verbal history and proceed. 3