NAPLEX Question of the Week: Pneumococcal Vaccines

Can you select the right patient for a pneumococcal vaccine?

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Which of the following patients would be recommended to receive Pneumovax 23 today? Select all that apply.

A. 70-year-old female who takes Humira for rheumatoid arthritis and has never received a pneumococcal vaccine as an adult

B. 45-year-old male who has diabetes and has never received a pneumococcal vaccine as an adult

C. 67-year-old male who has a left-ventricular ejection fraction of 35%, received a dose of Prevnar 13 two years ago, and received a dose of Pneumovax 23 six years ago

D. 29-year-old female who smokes a pack of cigarettes per day, received the live attenuated influenza vaccine a week ago, and has never received a pneumococcal vaccine as an adult

E. 83-year-old male who has COPD and received a dose of Pneumovax 23 ten years ago

 

Answer with rationale:

 

A, B, C, and D are the correct answers.

Pneumococcal vaccination is an important tool to prevent Streptococcus pneumoniae infections, including pneumonia and meningitis. Two pneumococcal vaccines are primarily used in practice. Prevnar 13 is the pneumococcal conjugate vaccine (PCV13). Pneumovax 23 is the pneumococcal polysaccharide vaccine (PPSV23). These vaccines are commonly administered in community pharmacies, but the recommendations on pneumococcal vaccine eligibility and timing in adults is not as straightforward as with some other vaccines.

One dose of Prevnar 13 is recommended in patients 19 years and older who are immunocompromised, have cochlear implants, have a cerebrospinal fluid leak, or have asplenia. One dose of Prevnar 13 is suggested in shared decision making in all other patients 65 years and older.

Pneumovax 23 is recommended in patients 19-64 years old who are immunocompromised, have cochlear implants, have a cerebrospinal fluid leak, have asplenia, or meet other medical criteria, including cigarette smoking or diabetes (Answers B and D are correct). Patients 19-64 years old receiving Pneumovax 23 should receive either one or two doses, depending on the eligibility criteria met. One dose of Pneumovax 23 is also recommended in all patients 65 years and older, regardless of whether or not pneumococcal vaccination was received when 19-64 years old (Answer A is correct). Once one dose of Pneumovax 23 is given at 65 years or older, another is not needed (Answer E is incorrect).

Prevnar 13 and Pneumovax 23 should not be given at the same visit. When both are indicated, Prevnar 13 should be given first. In most cases, Pneumovax 23 should be given at least 1 year (but sometimes as little as 8 weeks) after any previous dose of Prevnar 13. Pneumovax 23 should always be separated from any previous dose of Pneumovax 23 by at least 5 years (Answer C is correct).

Neither Prevnar 13 nor Pneumovax 23 is a live vaccine. Therefore, they can be given without regard to the timing of other vaccines and in patients on immunosuppressing drugs, such as Humira. With few exceptions, the only time two different vaccines are required to be spaced out is when both vaccines are live. Live vaccines must either be administered at the same time or separated by at least four weeks to ensure an adequate immune response to each.

For more details on the recommendations for pneumococcal vaccines in adults, visit the following link: https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf

Christopher M. Bland

Clinical Professor, University of Georgia College of Pharmacy

Dr. Christopher M. Bland is a Clinical Professor at the University of Georgia College of Pharmacy at the Southeast GA campus in Savannah, GA. Dr. Bland has over 20 years of academic and clinical experience in a number of clinical areas. He is a Fellow of both the Infectious Diseases Society of America as well as the American College of Clinical Pharmacy. He is co-founder of the Southeastern Research Group Endeavor, SERGE-45, with over 80 practitioners across 14 states involved. Dr. Bland serves as Associate Editor for the NAPLEX Review Guide 4th edition as well as Editor-In-Chief for the Question of the Week. He has provided live, interactive reviews for more than 10 Colleges/Schools of Pharmacy over the course of his career.