Version July 2025
| Conjugate vaccine history | No prior PCV | Received PCV10 or PCV13 | Received PCV15 | Received PCV20 | Received PCV21 | |||
| PPSV23 vaccine history | No PPSV23 | Received PPSV23* | No PPSV23 | Received PPSV23* | No PPSV23 | Received PPSV23* | Not applicable | Not applicable |
| Chronic conditions¶ or ≥50 years of age | Give PCV21Δ◊ | Give PCV21◊§ ≥1 year after PPSV23 dose | Give PCV21¥ ≥1 year after PCV10/13 dose | 19 to 49 years old: The ACIP does not recommend further vaccination at this time Our authors prefer to give PCV21 or PCV20 ≥5 years after last pneumococcal vaccine dose to impart immunity against additional serotypes ≥50 years old: Give PCV21 or PCV20 ≥5 years after last pneumococcal vaccine dose‡ | Give PPSV23* ≥1 year after PCV15 dose† | No further vaccination* | No further vaccination | No further vaccination |
| Immunocompromised (except for HCT recipients)** | Give PCV21◊,¶¶ | Give PCV21◊§ ≥1 year after PPSV23 dose | Give PCV21ΔΔ ≥1 year after PCV10/13 dose | Give PCV21ΔΔ ≥5 years after last pneumococcal vaccine dose* | Give PPSV23* ≥8 weeks after PCV15 dose† | No further vaccination* | Our authors also prefer to give PPSV23 ≥8 weeks following PCV20 (if not received within past 5 years) to provide immunity against more serotypes* | No further vaccination |
| Increased risk for meningitis (eg, CSF leak, cochlear implant) | ||||||||
ACIP: United States Centers for Disease Control and Prevention Advisory Committee on Immunization Practices; CDC: Centers for Disease Control and Prevention; CSF: cerebrospinal fluid; HCT: hematopoietic cell transplant; HIV: human immunodeficiency virus; IPD: invasive pneumococcal disease; PCV: 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; PCV21: 21-valent pneumococcal conjugate vaccine; PPSV23: 23-valent pneumococcal polysaccharide vaccine.
* Our UpToDate authors continue to administer PPSV23 every 5 to 10 years to patients who received PPSV23 as part of their vaccine series (eg, PCV13 with PPSV23, PCV15 with PPSV23, or PCV20 with PPSV23 in patients at highest risk for IPD), 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 use 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, diabetes mellitus, and sickle cell disease or other hemoglobinopathies. UpToDate authors also recommend pneumococcal vaccination for those with prior history of IPD.
Δ If PCV21 is not available, PCV20 alone or PCV15 followed by PPSV23 ≥1 year later are recommended alternatives. If PPSV23 is administered, our UpToDate authors continue to revaccinate with PPSV23 every 5 to 10 years.
◊ For certain patient populations who are at increased risk of serotype 4 (eg, residents of Navajo nation, individuals residing in the Western United States who have substance use disorder or experience homelessness), PCV20 alone or PCV15 followed by PPSV23 are preferred instead of PCV21 (which lacks coverage against serotype 4).
§ If PCV21 is not available, PCV20 or PCV15 are recommended alternatives. For all patients who receive PCV15 and for patients at highest risk for IPD who receive PCV20, UpToDate authors continue to revaccinate with PPSV23 every 5 to 10 years.
¥ If PCV21 is not available, give PCV20. If PCV20 is not available, engage in shared decision making with the patient regarding whether to administer PPSV23 or wait until PCV20 or PCV21 become available. If choosing to administer PPSV23, give PPSV23 ≥1 year after last PCV10/13 dose. If PPSV23 is administered, our UpToDate authors continue to revaccinate with PPSV23 every 5 to 10 years.
‡ If the patient received PPSV23 prior to age 65 and PCV21 and PCV20 are not available, administer PPSV23 ≥1 year after the PCV13 dose and ≥5 years after the previous PPSV23 dose. If the patient received PPSV23 ≥65 years of age, the ACIP advises shared decision-making regarding the benefit of administering PCV21 or PCV20 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.
† If PPSV23 is not available, give PCV20 or PCV21.
** Immunocompromising conditions and other conditions associated with altered immunocompetence include impaired splenic function, chronic kidney disease, 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, 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 PCV21 is not available, PCV20 alone or PCV15 followed by PPSV23 ≥8 weeks later are recommended alternatives. Our authors also prefer to give PPSV23 ≥8 weeks following PCV20 to provide immunity against more serotypes. Our UpToDate authors continue to revaccinate with PPSV23 every 5 to 10 years for patients who received PPSV23 along with PCV13, PCV15, or PCV20.
ΔΔ If PCV21 is not available, give PCV20. If PCV20 is not available, give PPSV23 ≥8 weeks after last PCV10/13 dose and ≥5 years after last PPSV23 (if applicable). Our authors also prefer to give PPSV23 ≥8 weeks following PCV20 to impart immunity against additional serotypes (if not received within the past 5 years). Our UpToDate authors continue to revaccinate with PPSV23 every 5 to 10 years in patients who received PPSV23 along with PCV13, PCV15, or PCV20.