Pneumococcal Vaccine Selection for Adults
Direct Recommendation
Base your decision on three factors in this order: (1) prior pneumococcal vaccination history, (2) age (≥65 vs 19-64 years), and (3) immune status (immunocompromised vs chronic medical conditions vs immunocompetent). 1
Decision Algorithm by Prior Vaccination Status
Never Vaccinated or PCV7 Only
- Administer PCV20 as a single dose—this completes the series. 1
- Alternative: PCV15 followed by PPSV23 ≥1 year later (requires patient to return for second dose). 1
- PCV20 is preferred because it provides broader serotype coverage in one visit and eliminates the need for follow-up. 2, 3
Previously Received PPSV23 Only
- Administer PCV20 ≥1 year after the last PPSV23 dose—this completes the series. 1, 2
- Alternative: PCV15 ≥1 year after PPSV23 (but then no additional PPSV23 is needed). 1
- The ≥1 year interval applies to all patients regardless of age or immune status. 2, 4
Previously Received PCV13 Only
- For ages 19-64 with chronic conditions or immunocompromising conditions: Administer PCV20 ≥1 year after PCV13—this completes the series. 1, 2
- For ages ≥65: Administer PCV20 ≥1 year after PCV13—this completes the series. 1, 2
- Alternative for chronic conditions only (not immunocompromised): PPSV23 ≥1 year after PCV13, then reassess at age 65. 1
Previously Received Both PCV13 and PPSV23
- For ages 19-64: No additional vaccines recommended at this time; reassess when patient turns 65. 1
- For ages ≥65 who completed series at age ≥65: No additional vaccines routinely recommended. 1, 4
- Optional exception: Shared clinical decision-making may consider PCV20 ≥5 years after last dose for immunocompromised patients or those with high-risk conditions. 2, 4
Age-Based Considerations
Adults Aged ≥65 Years
- All adults ≥65 should receive pneumococcal conjugate vaccine regardless of comorbidities. 2, 5
- PCV20 alone is the preferred single-dose option. 2, 4, 6
- If patient received PPSV23 before age 65, they still need PCV20 ≥1 year after that dose. 2, 4
Adults Aged 19-64 Years
- Vaccination is indicated only if chronic medical conditions or immunocompromising conditions are present. 1
- Chronic medical conditions include: alcoholism, chronic heart disease (CHF, cardiomyopathies), chronic liver disease, chronic lung disease (COPD, emphysema, asthma), cigarette smoking, or diabetes mellitus. 1
- Current smokers have 2.8-4.1 times the risk for invasive pneumococcal disease compared to adults without risk conditions. 2
Immune Status Considerations
Immunocompromising Conditions
These conditions require more aggressive vaccination schedules: 1
- Chronic renal failure
- Congenital or acquired asplenia
- Congenital or acquired immunodeficiency (B-cell, T-cell, complement deficiencies, phagocytic disorders)
- Generalized malignancy
- HIV infection
- Hodgkin disease
- Iatrogenic immunosuppression (long-term systemic corticosteroids, radiation therapy)
- Leukemia, lymphoma, multiple myeloma
- Nephrotic syndrome
- Sickle cell disease and other hemoglobinopathies
- Solid organ transplant
Key difference for immunocompromised patients: 1, 2
- If using PCV15 + PPSV23 strategy, the interval between PCV15 and PPSV23 can be shortened to ≥8 weeks (instead of ≥1 year for immunocompetent patients). 2, 4
- A second dose of PPSV23 may be given ≥5 years after the first PPSV23 for immunocompromised patients who received their first dose before age 65. 4
Hematopoietic Stem Cell Transplant (HSCT) Recipients
This population requires a unique 4-dose series: 1
- Administer 3 doses of PCV20, 4 weeks apart, starting 3-6 months after HSCT. 1
- Administer a fourth dose of PCV20 ≥6 months after the third dose, or ≥12 months after HSCT, whichever is later. 1
- If chronic graft-versus-host disease (GVHD) is present and using PCV15 strategy, give a fourth dose of PCV15 instead of PPSV23. 1
Why PCV20 Is Generally Preferred Over PCV15 + PPSV23
PCV20 offers several practical advantages: 2, 3, 6
- Single-dose completion: No need for patient to return for second dose. 2
- Broader serotype coverage: Covers 20 serotypes vs 15 for PCV15. 3, 7
- Superior immunologic response: Conjugate vaccines produce T-cell dependent responses and immunologic memory, unlike PPSV23. 2
- Cost-effectiveness: PCV20 alone is cost-saving compared to PCV15 + PPSV23 in most scenarios. 8
- Simplified schedule: Eliminates complexity of tracking intervals and ensuring follow-up. 2, 3
Critical Timing Rules to Avoid Errors
Never coadminister pneumococcal vaccines on the same day—this reduces immune response and wastes vaccine. 4
Minimum intervals that must be observed: 1, 2, 4
- ≥1 year between PPSV23 and subsequent PCV20 or PCV15 (all patients)
- ≥1 year between PCV13 and subsequent PCV20 (all patients)
- ≥1 year between PCV15 and PPSV23 (immunocompetent patients with chronic conditions)
- ≥8 weeks between PCV15 and PPSV23 (immunocompromised patients only)
- ≥5 years between last pneumococcal vaccine and PCV20 (only when both PCV13 and PPSV23 were previously given)
After PCV20 is administered, the pneumococcal vaccination series is complete—no additional doses are needed in most scenarios. 2, 4
Common Pitfalls to Avoid
Do not give PPSV23 after PCV20—the series is complete with PCV20 alone. 2, 4
Do not give multiple PPSV23 boosters beyond what is recommended—there is insufficient evidence for safety with three or more doses. 4
Do not delay vaccination waiting for complete medical records—use verbal history and proceed with indicated vaccination. 4
Do not give PCV20 too soon after prior pneumococcal vaccines—minimum intervals must be observed for optimal immune response. 2
For patients who received PPSV23 at age ≥65, do not give additional PPSV23 doses—only one PPSV23 dose is recommended after age 65. 4