Pneumonia Shots- Part 2: Immunocompromised Adults

Welcome back to Part 2 of the great Prevnar vs Pneumovax Update here at I Hate Rashes.

Last time, I talked about the differences between the two vaccines and the current recommendations for adults >65.  To recap, Pneumovax is a polysaccharide vaccine that covers 23 serotypes of S. Pneumoniae (PPSV23).  This is great because it is so broad.  Prevnar is a Conjugate polysaccharide vaccine that covers 13 serotypes (PCV13).  This is great because conjugating the pneumococcal polysaccharide to a diphtheria toxin boosts immunity and helps lead to herd immunity.  ACIP currently recommends that we give both PCV13 and PPSV 23 to our patients over 65. It is probably best to give PCV 13 first if the patient hasn’t had any pneumococcal vaccines. 
But what about all of those adults who get the pneumococcal vaccine BEFORE age 65? What should we do with them?  It is probably helpful to divide our recommendations between the immunocompetent vs immunocompromised conditions.

Those who are immunocompromised actually have long been recommended to get both PCV13 and PPSV23. This includes patients with asplenia, CSF leaks,  cochlear implants, HIV and other immunodeficiencies, nephrotic syndrome, leukemia/lymphoma, myeloma, transplants, and iatrogenic immunosuppression.  Iatrogenic immunosuppression includes chronic steroids, radiation therapy, and probably immunomodulators used in rheumatologic diseases. Most of these will need revaccination with PPSV23 5 years after their first vaccine: there is no need to revaccinate with the PCV13.

The immunocompetent patients continue to get just the PPSV23 prior to age 65.  This is for our patients with diabetes, COPD/Asthma/smoking, chronic heart disease, and chronic liver disease/alcoholism.  Once they turn 65, give them PCV13 and then repeat the PPSV23 about a year later.

Here’s a handy chart if you are more of a visual learner.

Risk group

Underlying medical condition

PCV13

PPSV23

Recommended

Recommended

Revaccination 5 yrs after first dose

Immunocompetent persons

Chronic heart disease

Chronic lung disease§

Diabetes mellitus

Cerebrospinal fluid leak

Cochlear implant

Alcoholism

Chronic liver disease, cirrhosis

Cigarette smoking

Persons with functional or anatomic asplenia

Sickle cell disease/other hemoglobinopathy

Congenital or acquired asplenia

Immunocompromised persons

Congenital or acquired immunodeficiency

Human immunodeficiency virus infection

Chronic renal failure

Nephrotic syndrome

Leukemia

Lymphoma

Hodgkin disease

Generalized malignancy

Iatrogenic immunosuppression**

Solid organ transplant

Multiple myeloma

Let’s practice some more:  For each patient, do you give PCV13 vs PPSV2, or both

  1. 55 newly diagnosed diabetic
  2. 60 year old with COPD, never had pneumococcal vaccine before
  3. 62 year old with COPD, had PPSV23 3 years ago, takes prednisone 5mg daily.
  4. 25 year old with coclear implants, never had pneumococcal vaccine before
  5. 35 year old with well controlled HIV, never had PCV13, had PPSV23 10 years ago, at diagnosis.

Let me know your answers or questions in the comments!

Here’s a link to the CDCs Adult Vaccine Schedule- note the new guideline for adults age 65 and over is not included here, yet.  There’s also an app for that.

 

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