This patient is particularly vulnerable to pneumococcal infection due to his chronic renal failure and therefore should receive both the PCV13 and the PPSV23, separated by 8 weeks to provide broader coverage against pneumococcal serotypes. (p. 219)
The pneumococcal vaccine does not decrease the rate of pneumonia but does reduce the burden of bacteremia and thereby lowers the mortality rate. Adults younger than 65 years may require pneumococcal vaccination if they have certain comorbidities, including chronic lung disease, cardiovascular disease, diabetes, chronic renal failure, nephrotic syndrome, chronic liver disease, alcoholism, cochlear implants, asplenia, cerebrospinal fluid leaks, or other immunocompromising conditions. HIV is an indication for pneumococcal vaccination. (pp. 217, 219)
This patient has gone over 10 years since his last tetanus booster. He should have a single Tdap (tetanus, diphtheria, and pertussis vaccine) to provide protection from pertussis. This vaccination with Tdap will be sufficient as a booster for tetanus, and his next Td (tetanus and diphtheria) booster should be in 10 years (Table 15–1). (pp. 218, 220)
Human papillomavirus vaccine |
All previously unvaccinated women up to age 26 |
Three doses on 0-, 2-, 6-month schedule |
Do not give during pregnancy |
Influenza vaccination |
All adults in the fall or winter |
Pneumococcal vaccine (Pneumovax) |
All patients age 65 or older get once |
Patients younger than age 65 with a chronic illness that predisposes them to pneumonia: chronic heart disease (e.g., congestive heart failure and coronary artery disease), chronic lung disease (e.g., chronic obstructive pulmonary disease, asthma), diabetes mellitus, chronic liver disease, chronic kidney disease, nephrotic syndrome, immunocompromise (due to disease or drugs) |
Active smokers and those who chronically misuse alcohol |
Patients living in high-risk settings (e.g., nursing homes, long-term care facilities) |
For patients younger than age 65 who receive the vaccine, revaccination is recommended after 5 years or age 65, whichever comes first. |
Tetanus-diphtheria (Td) or tetanus-diphtheria-pertussis (Tdap) vaccine |
For adults who have had primary series, recommended to get booster of Td every 10 years |
For adults younger than age 65 who have not had Tdap before, recommended to get once in place of Td booster |
Varicella zoster vaccine (Zostavax) |
All patients age 60 and older |
Exclude patients with cellular or acquired immunodeficiency (e.g., those who have HIV or who are undergoing chemotherapy) |
Persons with behavioral risk factors for hepatitis A include men who have sex with men, intravenous drug use, international travel, chronic liver disease, and occupational exposures. According to the history provided in the question, Mr. Spaulding does not have risk factors for hepatitis A. His diabetes is an indication for getting the hepatitis B vaccine. (pp. 223–224)
The patient has no contraindications for varicella zoster vaccination and therefore should be vaccinated because he is 60 years old (see Table 15–1). There is no need to test for immunity to varicella prior to vaccination against zoster. (pp. 218, 222–223)
Patients for whom varicella zoster vaccination is contraindicated include those with primary or acquired immunodeficiency from malignancy or HIV, those taking immunosuppressive medications (including high doses of glucocorticoids lasting 2 weeks or more), and those with evidence of impaired cellular immunity on laboratory testing. (p. 223)
HPV vaccine is indicated for men ages 22–26 years who have sex with men, because they are at increased risk of HPV infection and thus are at increased risk of acquiring conditions such as genital warts, anal cancer, and intraepithelial neoplasia. This vaccine is also recommended for all males ages 13–21 who have not been vaccinated previously. He does not have an indication for pneumococcal vaccination because he is younger than 65 years, and he received Tdap at age 18 so his next booster will be at age 28 with Td (see Table 15–1). (pp. 218, 222)
Medical risk factors for hepatitis B infection include diabetes, end-stage renal disease (including patients on hemodialysis), HIV, chronic liver disease, and any present or suspected sexually transmitted disease. Persons with behavioral risks include heterosexuals with multiple sex partners, injection drug users, men who have sex with men, and persons with household contacts or sex partners who have chronic hepatitis B infection. (p. 223)
Varicella zoster vaccine should not be administered to persons with primary or acquired immunodeficiency from malignancies, HIV/AIDS, or immunosuppressive medications (including high-dose steroids lasting 2 weeks or more), or to persons with evidence of impaired cellular immunity on laboratory testing. The remaining vaccines would be recommended for him. (pp. 219, 221, 222, 223–224)