What are the pneumococcal vaccine (Pneumococcal Conjugate Vaccine (PCV) and Pneumococcal Polysaccharide Vaccine (PPSV)) guidelines for adults 65 years and older, and those with underlying medical conditions, including immunocompromised individuals?

Pneumococcal Vaccination Guidelines for Adults

Adults ≥65 Years Without Prior Pneumococcal Vaccination

Administer a single dose of PCV20 (or PCV21) as the preferred option—this 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 either regimen. 1
• PCV20 is preferred over the two-dose series for simplicity and improved adherence. 1

Adults Aged 50-64 Years Without Prior Pneumococcal Vaccination

All adults aged ≥50 years should receive a single dose of PCV20 or PCV21, regardless of risk factors. 3

• This represents the most recent ACIP recommendation (October 2024), expanding age-based vaccination from 65 to 50 years. 3
• For those with chronic medical conditions (heart disease, lung disease, liver disease, diabetes, alcoholism, or smoking history), PCV20 alone completes the series. 2
• Review vaccination status again at age 65 to determine if additional doses are needed based on prior vaccination history. 1, 2

Adults Aged 19-49 Years With Chronic Medical Conditions

Administer a single dose of PCV20, which completes the series for immunocompetent adults with chronic conditions. 2

• Chronic conditions warranting vaccination include: chronic heart disease, chronic lung disease, chronic liver disease, diabetes mellitus, alcoholism, and cigarette smoking. 4
• Review vaccination status when the patient turns 50 or 65 years old. 2

Immunocompromised Adults (Any Age ≥19 Years)

For immunocompromised patients, administer PCV20 as a single dose (Option A, preferred) or PCV15 followed by PPSV23 at least 8 weeks later (Option B). 4, 1, 2

Immunocompromising conditions include: 4, 1

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

Critical timing distinction: 1, 2

• Immunocompromised patients need only ≥8 weeks between PCV and PPSV23, while immunocompetent patients need ≥1 year. 1, 2
• If using Option B (PCV15 + PPSV23), administer a second dose of PPSV23 at least 5 years after the first PPSV23 dose if given before age 65. 4, 2

Adults With CSF Leaks or Cochlear Implants

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

• Administer a second PPSV23 dose at least 5 years after the first if given before age 65. 4, 2

Adults Previously Vaccinated With PPSV23 Only

Administer PCV20 (or PCV21) at least 1 year after the last PPSV23 dose—this completes the series. 1, 2

• This applies to both immunocompetent and immunocompromised adults. 1, 2
• If PPSV23 was given before age 65, and the patient is now ≥65 years, give PCV20 at least 1 year after the last PPSV23 dose. 1
• No additional PPSV23 doses are needed after PCV20 administration. 1

Adults Previously Vaccinated With PCV13 Only

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

• For immunocompromised adults who received only PCV13, administer PPSV23 at least 8 weeks after PCV13, then a second PPSV23 dose at least 5 years later if given before age 65. 4, 1

Adults Who Received PPSV23 Before Age 65

When the patient turns 65, if at least 5 years have passed since the last PPSV23 dose, give one final dose of PPSV23 after completing the PCV series. 4, 2, 5

• First, administer PCV20 or PCV15 at least 1 year after the last PPSV23 dose. 2
• If using PCV15, follow with PPSV23 at least 1 year later (≥8 weeks if immunocompromised). 2
• No additional PPSV23 doses are given after the dose administered at age ≥65 years. 1, 2, 5

Critical Timing Rules to Avoid Errors

Never coadminister pneumococcal vaccines on the same day—this reduces immune response and wastes the vaccine. 1, 2

• Wait at least 1 year between PCV and PPSV23 for immunocompetent patients. 1, 2
• Wait only 8 weeks between PCV and PPSV23 for immunocompromised patients, those with CSF leaks, or cochlear implants. 4, 1, 2
• If PPSV23 was given first, wait at least 1 year before giving PCV20 or PCV15. 1, 2
• Not waiting the appropriate interval reduces immune response. 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

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

• The 5-year interval for PPSV23 boosters applies only to select high-risk immunocompromised populations who received their first dose before age 65. 2, 5
• Avoid giving multiple PPSV23 boosters beyond what is recommended—there is insufficient evidence for safety with three or more doses. 1

Special Considerations for Uncertain Vaccination History

If vaccination status is uncertain, do not delay vaccination—use the patient's verbal history and proceed with vaccination if indicated. 1

• Document vaccination clearly to avoid unnecessary future doses, but never withhold vaccination due to missing records. 1
• Avoid delaying vaccination waiting for complete medical records. 1

Rationale for Current Recommendations

The 2019 ACIP decision to move from routine PCV13 for all adults ≥65 years to shared clinical decision-making was based on dramatically reduced PCV13-type disease incidence through indirect effects from pediatric PCV13 use. 4 However, the 2023-2024 guidelines have since updated recommendations to include newer conjugate vaccines (PCV15, PCV20, PCV21) with broader serotype coverage, making them the preferred option for all adults. 1 The October 2024 expansion to age 50 reflects ongoing pneumococcal disease burden in this age group and the opportunity for earlier protection. 3