MKSAP quiz: Pneumonia vaccination of type 2 diabetes patient
This month's quiz asks readers to evaluate a 58-year-old man with type 2 diabetes mellitus, hypertension, and hyperlipidemia as a new patient.
A 58-year-old man is evaluated as a new patient. A review of his previous records shows he received a pneumococcal vaccination 6 years ago when he was admitted to the hospital with community-acquired pneumonia. He feels well with no acute symptoms.
He has type 2 diabetes mellitus, hypertension, and hyperlipidemia. Medications are insulin glargine, metformin, lisinopril, and simvastatin. Results of the physical examination are unremarkable.
When should this patient receive an additional pneumococcal vaccination?
A. Today
B. Today and repeat every 5 years
C. Today and at age 65 years
D. At age 65 years
E. No further pneumococcal vaccinations are required
MKSAP Answer and Critique
The correct answer is D. At age 65 years. This item is available to MKSAP 16 subscribers as item 74 in the General Internal Medicine section. Information about MKSAP 16 is available online.
This man should receive a single pneumococcal polysaccharide vaccination at age 65 years. Adults 65 years and older should be immunized against pneumococcal pneumonia. The vaccine contains 23 antigen types of Streptococcus pneumoniae and protects against 60% of bacteremic disease. The vaccine is also recommended in some populations of younger patients, including Alaskan natives and certain American Indian populations; residents of long-term care facilities; patients who are undergoing radiation therapy or are on immunosuppressive medication; patients who smoke; and patients with chronic pulmonary disorders (including asthma), diabetes mellitus, cardiovascular disease, chronic liver or kidney disease, cochlear implants, asplenia, immune disorders, or malignancies. There is no information on vaccine safety during pregnancy. The vaccine is reasonably effective, with high levels of antibody typically found for at least 5 years. Currently, immunocompetent persons vaccinated after age 65 years are not recommended to receive a booster. Immunocompetent persons vaccinated before age 65 years, such as this patient, should receive a single booster vaccination at age 65 years, or 5 years after their first vaccination if they were vaccinated between the ages of 60 and 64 years.
Immunocompromised patients (including those with HIV infection and kidney disease) as well as patients with asplenia should receive a single pneumococcal vaccine booster 5 years after their first vaccine. This strategy would be inappropriate for this patient.
Current recommendations do not support more than a single booster after initial pneumococcal vaccination for any persons. Hence, a strategy of vaccination every 5 years would be inappropriate.
All patients vaccinated before age 65 years need a booster at some point. Hence, withholding further pneumococcal vaccination is inappropriate.
Key Point
- Immunocompetent persons who received the pneumococcal polysaccharide vaccine before age 65 years should receive a single booster vaccination at age 65 years, or 5 years after their first vaccination if they were vaccinated between the ages of 60 and 64 years.