About the Authors
Yosef Nissim, PharmD, MBA, BCIDP, is an infectious diseases clinical pharmacy specialist and a PGY-1 pharmacy residency program director at Hackensack Meridian Health Ocean University Medical Center in Brick, New Jersey.
Kirsten M. Adkins, PharmD, is an assistant professor of pharmacy practice at the Department of Pharmacy Practice and Administration at Palm Beach Atlantic University’s Lloyd L. Gregory School of Pharmacy in West Palm Beach, Florida.
Elias B. Chahine, PharmD, FCCP, BCPS, FASCP, FFSHP, BCIDP, is a professor and chair of the Department of Pharmacy Practice and Administration at Palm Beach Atlantic University’s Lloyd L. Gregory School of Pharmacy in West Palm Beach, Florida.
Invasive pneumococcal disease (IPD) affects about 30,000 adults annually in the United States, with incidence rates of 13.2 per 100,000 in adults aged 50 to 64 years and 17.2 per 100,000 in those 65 years or older.1 Noninvasive pneumococcal disease, particularly otitis media, accounts for over 15 million physician visits annually, with Streptococcus pneumoniae causing approximately 25% of acute otitis media cases.2 Additionally, pneumococcal pneumonia accounts for about 225,000 adult hospitalizations annually, which is approximately 12% to 13% of all hospitalized pneumonia cases.1 Pneumococcal infections range from asymptomatic nasopharyngeal carriage to severe invasive disease. Noninvasive manifestations include otitis media, sinusitis, and pneumonia without bacteremia. In contrast, IPD occurs when bacteria invade normally sterile sites, leading to bacteremic pneumonia, meningitis, bacteremia without a focus, osteomyelitis, or septic arthritis.3
S pneumoniae has over 100 documented serotypes based on capsular polysaccharide composition.3 There are currently 4 vaccines licensed by the FDA and recommended by the CDC to prevent pneumococcal infections.4-7 Each vaccine includes different combinations of these serotypes to balance broad coverage with a strong immune response.8 The pneumococcal conjugate vaccines (PCVs) target the most clinically significant serotypes and elicit a T-cell–dependent immune response, leading to memory B-cell formation and longer-lasting, more robust immunity. This is especially beneficial in populations with a weaker immune system, such as older adults and those with altered immunocompetence. Conversely, the pneumococcal polysaccharide vaccine (PPSV23) covers a broader range of serotypes but induces a T-cell–independent response without immune memory; as a result, protection may wane over time, and repeat dosing may be necessary. Table 1 lists the available pneumococcal vaccines in the United States.4-7
Since the introduction of PCV13 in February 2010, serotype 3 has become the most prevalent cause of IPD, accounting for approximately 14% to 18% of cases in adults.9 This was followed by an increase in non-PCV13 serotypes, including 8, 22F, 15B/C, 33F, 10A, 12F, and 9N, due to serotype replacement. In response, newer, higher-valency pneumococcal vaccines have been developed to expand coverage against these emerging serotypes, leading to the removal of PCV13 from the market in April 2024.
The newly approved pneumococcal vaccines offer advantages through expanded serotype coverage and improved immunogenicity. For example, PCV15 demonstrated superior immune responses against serotypes 3, 22F, and 33F, and comparable immune responses for the remaining shared serotypes compared with PCV13.10 PCV21 demonstrated comparable immunogenicity to PCV15, PCV20, and PPSV23 for shared serotypes while eliciting robust immune responses against its unique serotypes.1 Although direct comparisons of clinical outcomes among PCV15, PCV20, and PCV21 are limited, available immunogenicity data are robust.11
Adult Recommendations
The Advisory Committee on Immunization Practices provides recommendations for pneumococcal vaccinations as outlined in Table 2.
Adults 50 years or older who have never received a pneumococcal vaccine or whose vaccination history is unknown should receive a single dose of either PCV20 or PCV21. If PCV15 is used, it should be followed by a dose of PPSV23 at least 1 year later. Adults who have previously received PPSV23 alone should receive a single dose of PCV15, PCV20, or PCV21 at least 1 year after PPSV23. Lastly, adults who previously received PCV13 alone should receive a single dose of PCV20 or PCV21 at least 1 year later.
Disclosures and SIDP Reviewers
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. No financial support was provided for the research, authorship, and/or publication of this article.
This article was reviewed by Society of Infectious Diseases Pharmacists committee members Nicole Bradley, PharmD, BCPS, BCIDP; and Amer El-Ghali, PharmD.
For adults aged 19 to 49 years with certain underlying medical conditions or other risk factors, the recommendations are similar. At-risk individuals—including those with chronic heart, lung, or liver disease; diabetes; alcoholism; or cigarette smoking—should receive either a single dose of PCV20 or PCV21, or PCV15 followed by PPSV23. In patients with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak, the interval between PCV15 and PPSV23 may be shortened to 8 weeks.11
Although newer conjugate vaccines are preferred for initial pneumococcal vaccination, PPSV23 continues to play a role when PCV15 is used; however, if PCV20 or PCV21 is used, a subsequent dose of PPSV23 is not necessary. Vaccine selection should be based on the patient’s age, risk factors, and prior vaccination history to optimize protection against pneumococcal disease.
Safety Considerations
All available pneumococcal vaccines demonstrate a favorable safety profile.4-7 Table 3 summarizes their contraindications, precautions, and common adverse reactions. All 4 vaccines are contraindicated in individuals with a severe allergic reaction to any component of the vaccine. Specifically, all 3 PCVs are contraindicated in those with an allergy to diphtheria toxoid and carry a precaution for use in people with altered immunocompetence. Although altered immunocompetence is a listed precaution, pneumococcal vaccines can be safely administered in this population. Additionally, PPSV23 carries a precaution against its use in individuals with moderate to severe acute illness, compromised cardiopulmonary status, or chronic cerebrospinal fluid leak, or those receiving antibiotic prophylaxis.
Across all formulations, the most common adverse events (AEs) are mild to moderate and include injection-site pain, fatigue, myalgia, and headache, with higher rates of local reactions observed in younger adults than in older populations. Generally, AEs are self-limited, supporting the continued use of these agents to prevent pneumococcal infection in at-risk populations.1,3-7
REFERENCES
Kobayashi M, Leidner AJ, Gierke R, et al. Expanded recommendations for use of pneumococcal conjugate vaccines among adults aged ≥50 years: recommendations of the Advisory Committee on Immunization Practices - United States, 2024. MMWR Morb Mortal Wkly Rep. 2025;74(1):1-8. doi:10.15585/mmwr.mm7401a1
Shaikh N. Otitis media in young children. N Engl J Med. 2025;392(14):1418-1426. doi:10.1056/NEJMcp2400531
Kobayashi M, Pilishvili T, Farrar JL, et al. Pneumococcal vaccine for adults aged ≥19 years: recommendations of the Advisory Committee on Immunization Practices, United States, 2023. MMWR Recomm Rep. 2023;72(3):1-39. doi:10.15585/mmwr.rr7203a1
Vaxneuvance (pneumococcal 15-valent conjugate vaccine). Prescribing information. Merck & Co; 2021. Accessed April 20, 2026. https://www.merck.com/product/usa/pi_circulars/v/vaxneuvance/vaxneuvance_pi.pdf
Prevnar 20 (pneumococcal 20-valent conjugate vaccine). Prescribing information. Pfizer; 2021. Accessed April 20, 2026. https://labeling.pfizer.com/ShowLabeling.aspx?id=15428
Capvaxive (pneumococcal 21-valent conjugate vaccine). Prescribing information. Merck & Co; 2024. Accessed April 20, 2026. https://www.merck.com/product/usa/pi_circulars/c/capvaxive/capvaxive_pi.pdf
Pneumovax 23 (pneumococcal vaccine polyvalent). Prescribing information. Merck & Co; 2024. Accessed April 20, 2026. https://www.merck.com/product/usa/pi_circulars/p/pneumovax_23/pneumovax_pi.pdf
Gentile A, Bazán V. Prevention of pneumococcal disease through vaccination. Vaccine. 2011;29(suppl 3):C15-C25. doi:10.1016/j.vaccine.2011.07.121
Garcia Quesada M, Peterson ME, Bennett JC, et al; PSERENADE Team. Serotype distribution of remaining invasive pneumococcal disease after extensive use of ten-valent and 13-valent pneumococcal conjugate vaccines (the PSERENADE project): a global surveillance analysis. Lancet Infect Dis. 2025;25(4):445-456. doi:10.1016/S1473-3099(24)00588-7
Wagner G, Gartlehner G, Thaler K, et al. Immunogenicity and safety of the 15-valent pneumococcal conjugate vaccine, a systematic review and meta-analysis. NPJ Vaccines. 2024;9(1):257. doi:10.1038/s41541-024-01048-y
EtR framework for adults aged 50-64 years who have not received a pneumococcal conjugate vaccine. Advisory Committee on Immunization Practices. January 6, 2025. Accessed July 7, 2026. https://www.cdc.gov/acip/evidence-to-recommendations/adults-50-64-without-pneumococcal-vaccine-etr.html
