What is the recommended schedule for pneumonia vaccination in adults, including vaccine types such as pneumococcal conjugate vaccine (PCV13 or Prevnar 13) and pneumococcal polysaccharide vaccine (PPSV23 or Pneumovax 23), for individuals with varying ages and underlying medical conditions?

Adult Pneumococcal Vaccination Schedule and Vaccine Types

For adults aged ≥65 years without prior pneumococcal vaccination, administer a single dose of PCV20 (20-valent pneumococcal conjugate vaccine) as the preferred option, which completes the series with no additional doses needed. 1, 2

Available Pneumococcal Vaccines

Three pneumococcal vaccines are currently used in adults: 1

• PCV20 (20-valent pneumococcal conjugate vaccine) - covers 20 serotypes
• PCV15 (15-valent pneumococcal conjugate vaccine) - covers 15 serotypes
• PPSV23 (23-valent pneumococcal polysaccharide vaccine) - covers 23 serotypes

Note that PCV13 (13-valent) is no longer routinely recommended since 2019 due to reduced disease burden from pediatric vaccination programs. 1, 3

Vaccination Schedule for Adults ≥65 Years

For Adults With No Prior Pneumococcal Vaccination

Option A (Preferred): 1, 2

• Single dose of PCV20 - this completes the series, no additional doses needed

Option B: 1, 2

• PCV15 followed by PPSV23 at least 1 year later - this completes the series

For Adults Who Previously Received PPSV23 Only

• Administer PCV20 or PCV15 at least 1 year after the last PPSV23 dose 1
• If PCV15 is given, follow with PPSV23 at least 1 year later 1

For Adults Who Previously Received PCV13 Only

• Administer PCV20 at least 1 year after the PCV13 dose 1
• Alternatively, administer PPSV23 at least 1 year after PCV13 1

For Adults Who Previously Received Both PCV13 and PPSV23

• If PPSV23 was given at age ≥65 years, the series is complete 1
• Shared clinical decision-making may be used to consider PCV20 at least 5 years after the last dose 1, 2

Vaccination Schedule for Adults Aged 19-64 Years

Adults With Chronic Medical Conditions

Chronic conditions include: chronic heart disease, chronic lung disease, diabetes mellitus, chronic liver disease, alcoholism, or cigarette smoking. 1

Recommended schedule: 1, 4

• PCV20 as a single dose (completes the series), OR
• PCV15 followed by PPSV23 at least 1 year later

Review vaccination status again when the patient turns 65 years old. 1, 4

Adults With Immunocompromising Conditions

Immunocompromising conditions include: chronic renal failure, asplenia (functional or anatomic), sickle cell disease, HIV infection, malignancies, immunosuppressive therapy, solid organ transplant, congenital immunodeficiencies, leukemia, lymphoma, multiple myeloma, or nephrotic syndrome. 1

Recommended schedule (shorter intervals): 1

• PCV20 as a single dose, OR
• PCV15 followed by PPSV23 at least 8 weeks later (not 1 year)
• If PPSV23 is given before age 65, administer a second dose of PPSV23 at least 5 years after the first dose 1, 4
• When patient turns 65, if at least 5 years have passed since last PPSV23, give one final PPSV23 dose 4

Adults With CSF Leak or Cochlear Implant

Follow the same accelerated schedule as immunocompromised patients: 1

• PCV15 or PCV20 first
• If using PCV15, follow with PPSV23 at least 8 weeks later
• Second PPSV23 dose at least 5 years after the first if given before age 65 4

Critical Timing Rules to Avoid Errors

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

Interval between PCV and PPSV23: 1, 2, 4

• ≥1 year for immunocompetent adults
• ≥8 weeks for immunocompromised adults, those with CSF leak, or cochlear implant

Interval if PPSV23 was given first: 1

• Wait at least 1 year before giving PCV20 or PCV15

PPSV23 booster intervals: 1, 4

• For immunocompromised adults who received PPSV23 before age 65: give second dose at least 5 years after first dose
• Final PPSV23 dose at age ≥65 years if at least 5 years have passed since previous PPSV23

Maximum Lifetime PPSV23 Doses

Immunocompetent adults: Maximum of 1-2 doses total (one before age 65 if indicated, one at/after age 65) 4

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) 4

No additional PPSV23 doses are given after the dose administered at age ≥65 years. 1, 2, 4

Common Pitfalls to Avoid

Do not delay vaccination waiting for complete medical records - use verbal history and proceed with vaccination if indicated. 2

Do not give multiple PPSV23 boosters beyond recommendations - there is insufficient evidence for safety with three or more doses. 2

Do not revaccinate unnecessarily - once the series is complete at age ≥65 years, no routine boosters are recommended for immunocompetent adults. 2, 4

Prior PPSV23 diminishes response to subsequent PCV13 - this is why PCV (conjugate vaccine) should ideally be given first when possible. 5