Pneumococcal vaccine selection for adults ≥65 years of age

Conjugate vaccine history	No prior PCV or PCV7 only		Received PCV10 or PCV13			Received PCV15		PCV20
PPSV23 vaccine history	No PPSV23	Received PPSV23	No PPSV23	Received PPSV23 <65 years of age	Received PPSV23 at ≥65 years of age	No PPSV23	Received PPSV23
Healthy	Give PCV20^*	Give PCV20^¶ ≥1 year after PPSV23 dose	Give PCV20^Δ ≥1 year after PCV10/13 dose	Give PCV20^Δ ≥5 years after last pneumococcal vaccine dose	Give PCV20^Δ ≥5 years after last pneumococcal vaccine dose^◊	Give PPSV23 ≥1 year after PCV15 dose^§	No further vaccination^§	No further vaccination
Chronic conditions^¥
Immunocompromised patients (HCT recipients excluded)^‡	Give PCV20^† Our authors also prefer to give PPSV23 ≥8 weeks following PCV20 to provide immunity against more serotypes^§	Give PCV20^** ≥1 year after PPSV23 dose^§	Give PCV20^¶¶ ≥1 year after PCV10/13 dose Our authors also prefer to give PPSV23 ≥8 weeks following PCV20 to provide immunity against more serotypes^§	Give PCV20^¶¶ ≥5 years after last pneumococcal vaccine dose^§	Give PCV20^¶¶ ≥5 years after last pneumococcal vaccine dose^◊	Give PPSV23 ≥1 year after PCV15 dose^§	No further vaccination^§	Our authors also prefer to give PPSV23 ≥8 weeks following PCV20 to provide immunity against more serotypes^§
Increased risk for meningitis (eg, CSF leak, cochlear implant)

The ACIP updated its pneumococcal vaccine recommendations in 2022 and 2023. This table provides guidance to clinicians on vaccine selection for their adult patients ≥65 years old based on the patients' previous pneumococcal vaccination history. In some situations, the recommendations of our UpToDate authors differ slightly from that of the ACIP. Refer to the UpToDate text on pneumococcal vaccination in adults for additional information.

ACIP: United States Centers for Disease Control and Preventions Advisory Committee on Immunization Practices; CSF: cerebrospinal fluid; HCT: hematopoietic cell transplant; PCV7: 7-valent pneumococcal conjugate vaccine; PCV10: 10-valent pneumococcal conjugate vaccine; PCV13: 13-valent pneumococcal conjugate vaccine; PCV15: 15-valent pneumococcal conjugate vaccine; PCV20: 20-valent pneumococcal conjugate vaccine; PPSV23: 23-valent pneumococcal polysaccharide vaccine.

* If PCV20 is not available, PCV15 followed by PPSV23 ≥1 year later is a recommended alternative. If PPSV23 is administered, our UpToDate authors continue to revaccinate with PPSV23 every 5 to 10 years.

¶ If PCV20 is not available, PCV15 is a recommended alternative. If PCV15 is administered, our UpToDate authors continue to revaccinate with PPSV23 every 5 to 10 years.

Δ If PCV20 is not available, give PPSV23 ≥1 year after last PCV10/13 dose and ≥5 years after last PPSV23 (if applicable). If PPSV23 is administered, our UpToDate authors continue to revaccinate with PPSV23 every 5 to 10 years.

◊ The CDC ACIP advises shared decision-making regarding the benefit of administering PCV20 to patients who received their last PPSV23 dose at ≥65 years of age while our UpToDate authors believe the benefit of the additional vaccination outweighs the minimal risks associated with it. Refer to the UpToDate text on pneumococcal vaccination in adults for additional information on the ACIP and authors' recommendations.

§ Our UpToDate authors continue to administer PPSV23 every 5 to 10 years as they believe the benefit of revaccination outweighs the minimal risks. Refer to the UpToDate text on pneumococcal vaccination in adults for additional information on the ACIP and authors' recommendations.

¥ Chronic conditions include alcohol abuse disorder, chronic heart disease, including congestive heart failure and cardiomyopathies, chronic liver disease; chronic lung disease, including chronic obstructive pulmonary disease, emphysema, and asthma, cigarette smoking, and diabetes mellitus.

‡ Immunocompromised patients include those with chronic renal failure, congenital or acquired asplenia, congenital or acquired immunodeficiency (including B-[humoral] or T-lymphocyte deficiency, complement deficiencies [particularly C1, C2, C3, and C4 deficiencies], and phagocytic disorders [excluding chronic granulomatous disease]), generalized malignancy, HIV infection, Hodgkin disease, iatrogenic immunosuppression (including disease requiring treatment with immunosuppressive drugs such as long-term systemic corticosteroids and radiation therapy), leukemia, lymphoma, multiple myeloma, nephrotic syndrome, sickle cell disease or other hemoglobinopathies, and solid organ transplant. HCT recipients are excluded from this category because they have different recommendations for pneumococcal vaccination post hematopoietic cell transplant. Refer to the UpToDate text on immunizations in HCT recipients for additional information.

† If PCV20 is not available, PCV15 followed by PPSV23 ≥8 weeks later is a recommended alternative. Our UpToDate authors continue to revaccinate with PPSV23 every 5 to 10 years.

** If PCV20 is not available, PCV15 is a recommended alternative.

¶¶ If PCV20 is not available, give PPSV23 ≥8 weeks after last PCV10/13 dose and ≥5 years after last PPSV23 (if applicable). Our UpToDate authors continue to revaccinate with PPSV23 every 5 to 10 years.

Adapted from: Kobayashi M, Pilishvili T, Farrar JL, et al. Pneumococcal vaccine for adults aged ≥19 years: Recommendations of the Advisory Committee on Immunization Practices. MMWR 2023; 72:1.

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Pneumococcal vaccine selection for adults ≥65 years of age