Decompensated cirrhosis.
Decompensated cirrhosis on the wards: staging, ascites and paracentesis, albumin dosing, SBP, encephalopathy, variceal prophylaxis, HCC surveillance, hyponatremia, drugs to avoid, transplant and palliative care.
Reviewed October 2026 · verify against current guidelines
Tools — score MELD and Child-Pugh in the liver scores tool. Read a tap, dose albumin for a large-volume paracentesis or SBP, and check HRS-AKI criteria in the ascites and HRS tool. Kidney failure in cirrhosis has its own guide: hepatorenal syndrome.
Scope — adults with cirrhosis. Built on AASLD 2021 (ascites, SBP, HRS), AGA 2025 (ascites and hyponatremia), AASLD 2024 (portal hypertension) with the European Baveno VIII (2026) where it adds to it, AASLD/AST 2026 (transplant referral), AASLD/EASL 2014 and ACG 2026 (encephalopathy), and AASLD 2023 (HCC). Where they differ, we say so. Numbers here frame the next decision; they are not orders.
Cirrhosis · 1 of 6
Name the stage.
Where the patient sits
| Compensated | No present or past complication of cirrhosis. Split by clinically significant portal hypertension (CSPH): patients with CSPH carry the higher risk of decompensation (Baveno VIII 3.1–3.2). |
|---|---|
| CSPH without a catheter | Transient elastography 25 kPa or more rules it in (AASLD 2024 statement 7; Baveno VIII 1.16, for viral, alcohol and non-obese MASLD). So do 20–24.9 kPa with platelets under 150,000/µL, or 15–19.9 kPa with platelets under 110,000/µL (AASLD 2024). 15 kPa or less with platelets 150,000/µL or more rules it out (Baveno VIII 1.15). Varices or collaterals on endoscopy or imaging prove it. |
| Decompensated | Clinically evident ascites or hepatic hydrothorax from portal hypertension, variceal bleeding, or overt encephalopathy (West Haven grade II or higher) (Baveno VIII 3.3). Mortality risk rises sharply at this transition (Baveno VIII 3.1). |
| Further decompensated | A more advanced stage with higher mortality. After ascites alone: 3 or more LVPs within a year, SBP, HRS-AKI, or a second event — bleeding, overt HE or jaundice (Baveno VIII 4.1). |
| Transplant trigger | Refer after any decompensating event, and consider referral for ACLF. Without decompensation the MELD threshold is unclear — waitlist survival benefit may begin above 12 — and MELD alone should not be a barrier to referral (AASLD/AST 2026). Score it in the liver scores tool. |
What tips a patient over
- Infection — can precipitate decompensation or ACLF once CSPH is present (Baveno VIII 3.10). Suspect it in any deterioration, especially new encephalopathy, AKI or jaundice: diagnostic paracentesis, blood and urine cultures, chest film (AASLD 2021).
- Superimposed liver injury — alcohol-associated hepatitis, acute viral hepatitis (A, B or E), a hepatitis B flare, autoimmune hepatitis, drug-induced injury (Baveno VIII 3.7).
- HCC (Baveno VIII 3.6) and major surgery in patients with CSPH (Baveno VIII 3.13).
- Bleeding, overdiuresis, constipation, electrolyte disorders — the classic encephalopathy precipitants (AASLD/EASL 2014, table 3).
Cirrhosis · 2 of 6
Ascites: tap it, then treat it.
Diagnostic paracentesis — who
- Every new-onset ascites that can be sampled (AASLD 2021).
- Every patient with cirrhotic ascites admitted emergently, even without signs of infection (AASLD 2021). AGA 2025: do it as soon as possible when admitted for ascites or encephalopathy.
- Anyone with ascites who develops signs, symptoms or labs suggesting infection (AASLD 2021).
- Send cell count with differential, total protein and ascitic albumin with a same-day serum albumin, plus culture inoculated into aerobic and anaerobic blood-culture bottles at the bedside before antibiotics (AASLD 2021). AGA 2025 adds Gram stain.
Reading the fluid
| SAAG | Serum albumin minus ascitic albumin, drawn the same day. |
|---|---|
| SAAG 1.1 g/dL or more | Portal hypertension, with about 97% accuracy (AASLD 2021): cirrhosis, massive liver metastases, cardiac ascites. |
| SAAG less than 1.1 g/dL | Not portal hypertension: peritoneal carcinomatosis, tuberculous peritonitis and other causes (AASLD 2021, table 4). |
| Protein above 2.5 g/dL | With a high SAAG, points to a cardiac source (AASLD 2021). |
| Protein below 1.5 g/dL | Low-protein ascites, one criterion for primary SBP prophylaxis (section 3). |
| PMN above 250/mm³ | SBP until proven otherwise (AASLD 2021). |
Grade and course (AASLD 2021, table 5)
| Grade 1 | Seen only on ultrasound. |
|---|---|
| Grade 2 | Moderate, symmetric distension. Sodium restriction plus diuretics. |
| Grade 3 | Marked distension. Large-volume paracentesis (LVP) first, then sodium restriction and diuretics. |
| Recurrent | Returns on at least 3 occasions in 12 months despite sodium restriction and adequate diuretics. |
| Refractory | Cannot be mobilized, or early recurrence after LVP cannot be prevented by medical therapy. |
Sodium and diuretics (AASLD 2021)
| Sodium | 2 g (90 mmol) a day. No fluid restriction unless sodium is 125 mmol/L or less. ACG 2025 found too little evidence to insist on strict restriction in patients on diuretics; do not trade ascites control for malnutrition. |
|---|---|
| Start | Spironolactone 100 mg daily, with or without furosemide 40 mg daily. A first episode often responds to spironolactone alone. |
| Titrate | Step up spironolactone no faster than every 72 hours, to a maximum of 400 mg/day. Furosemide rises toward 160 mg/day, the accepted threshold for refractoriness. |
| Monitor | Weight, creatinine and sodium. A spot urine Na/K ratio above 1 without weight loss points to dietary sodium, not diuretic failure. |
| Then | Taper to the lowest dose that keeps ascites minimal. Consider transplant referral with grade 2 or 3 ascites. |
Large taps, refractory ascites and TIPS
| Albumin with LVP | More than 5 L removed: 6–8 g of albumin per liter removed (AASLD 2021, about 40 g after 5 L and 64 g after 8 L; AGA 2025, per total liter). ICA-ADQI 2024 says 6–8 g "for every litre over 5 L", which can be read either way — check your protocol. |
|---|---|
| Smaller taps | Usually no albumin (AASLD 2021). AGA 2025: consider it with hypotension, kidney injury or electrolyte problems. |
| Big sessions | Risk of post-paracentesis circulatory dysfunction may rise above 8 L in one session (AASLD 2021). |
| Refractory, defined | Fails 2 g sodium plus spironolactone 400 mg (or amiloride 30 mg) and furosemide 160 mg for at least a week — under 0.8 kg weight loss over 4 days, or urine sodium below intake — or cannot reach those doses because of AKI, hyponatremia, potassium derangement or encephalopathy (AASLD 2021, table 7). |
| TIPS | Consider for recurrent or refractory ascites (Baveno VIII 6.3); recurrent means 3 or more LVPs within a year (Baveno VII 7.4). Covered stent under 10 mm to limit encephalopathy; ascites clears over 4–6 months, so keep the sodium restriction (AASLD 2021). |
| Beta-blockers | Not automatically contraindicated in refractory ascites; use cautiously, especially with systolic BP under 90 mmHg, sodium under 130 or creatinine above 1.5 mg/dL (AASLD 2021). European: reduce or stop for systolic BP under 90 mmHg, MAP under 65 mmHg or HRS-AKI (Baveno VIII 4.6). |
| Transplant | Refractory ascites or hydrothorax: evaluate regardless of MELD (AGA 2025). |
Cirrhosis · 3 of 6
SBP: count, cover, give albumin.
Spontaneous bacterial peritonitis
| Diagnose | Ascitic PMN above 250/mm³. In hydrothorax, pleural PMN above 250/mm³ is spontaneous bacterial empyema: treat the same way, and do not place a chest tube (AASLD 2021). |
|---|---|
| Not SBP | High PMN with a focal source (perforation, abscess, cholecystitis, diverticulitis) is secondary peritonitis: image and call surgery. PMN 250/mm³ or less with a positive culture and no signs of infection is bacterascites: no antibiotics, repeat the tap (AASLD 2021). |
| Antibiotics | Community-acquired: IV third-generation cephalosporin, such as cefotaxime 2 g every 12 hours. Healthcare-associated or nosocomial infection, recent broad-spectrum exposure, sepsis or shock: broad-spectrum cover per local resistance. Usual course 5–7 days (AASLD 2021). |
| Albumin | 1.5 g/kg at diagnosis and 1 g/kg on day 3. In the trial, kidney impairment fell from 33% to 10% and in-hospital death from 29% to 10% (Sort, NEJM 1999). Benefit was clearest with BUN above 30 mg/dL, creatinine above 1.0 mg/dL or bilirubin above 5 mg/dL (AASLD 2021). ICA-ADQI 2024: let volume status guide the dose. |
| 48 hours | Repeat the tap. A PMN fall of less than 25% means failure: broaden cover and look for secondary peritonitis (AASLD 2021). |
| Beta-blockers | Hold if MAP drops under 65 mmHg or AKI develops (AASLD 2021). |
Prophylaxis (AASLD 2021 unless stated)
- After any SBP episode — long-term daily norfloxacin; oral ciprofloxacin where norfloxacin is unavailable.
- Upper GI bleeding — IV ceftriaxone 1 g every 24 hours, for no more than 7 days. AASLD 2024 shortens this to up to 5 days, stopping once bleeding is controlled and no infection is present.
- Primary, selected patients — ascitic protein below 1.5 g/dL plus kidney dysfunction (creatinine above 1.2 mg/dL, BUN above 25 mg/dL or sodium below 130 mmol/L) or liver failure (Child-Pugh above 9 with bilirubin above 3 mg/dL). The evidence is weak; individualize.
- European view (Baveno VIII) — no long-term primary antibiotic prophylaxis to prevent further decompensation after a first decompensating event (4.12); stop SBP prophylaxis if the patient recompensates (6.22).
Cirrhosis · 4 of 6
Encephalopathy: grade it, find the trigger.
West Haven grades, in brief (AASLD/EASL 2014)
| Covert | Minimal HE (abnormal psychometric tests only) and grade I: trivial lack of awareness, euphoria or anxiety, short attention, trouble with simple arithmetic, altered sleep. |
|---|---|
| Grade II | Lethargy or apathy, disorientation to time, obvious personality change, inappropriate behavior, asterixis. |
| Grade III | Somnolent to semistuporous but responsive; confused, grossly disoriented, including to place. |
| Grade IV | Coma: no response even to pain. |
| Overt | Grade II or higher. It defines decompensation (Baveno VIII 3.3). |
Precipitants and mimics
- Correcting the precipitant alone treats nearly 90% of patients with overt HE (AASLD/EASL 2014).
- Common triggers: infection, GI bleeding, diuretic overdose, electrolyte disorders, constipation (AASLD/EASL 2014, table 3).
- Rule out mimics: hypoglycemia and other diabetic emergencies; alcohol intoxication, withdrawal or Wernicke; benzodiazepines, opioids and neuroleptics; hyponatremia or hypercalcemia; nonconvulsive seizures; intracranial bleeding or stroke (AASLD/EASL 2014, table 4). See delirium and alcohol withdrawal.
- No routine brain imaging for confusion without new focal deficits (ACG 2026).
Treat and prevent
| Lactulose | 25 mL every 1–2 hours until at least 2 soft or loose stools, then titrate to 2–3 a day (AASLD/EASL 2014). More is not better: overuse causes aspiration, dehydration and hypernatremia and can itself precipitate HE. ACG 2026 suggests adding the Bristol stool scale to stool counts when titrating. |
|---|---|
| PEG | High-volume polyethylene glycol is an alternative to lactulose for overt HE (ACG 2026). |
| Rifaximin | 550 mg twice daily (FDA label). ACG 2026 suggests adding it to lactulose in the acute setting and after overt HE to prevent recurrence. Before elective TIPS, start 14 days ahead and continue for at least 6 months in decompensated cirrhosis (ACG 2026). |
| Protein | 1.2–1.5 g/kg a day; do not restrict protein (ACG 2026). |
| Refractory | Zinc if levels are low; consider shunt embolization when HE persists on optimized therapy. Repeated HE with MELD under 15: consider living-donor transplant evaluation (ACG 2026). |
Do not chase ammonia — ACG 2026 suggests against routine ammonia testing to guide HE treatment. A high level alone adds no diagnostic, staging or prognostic value (AASLD/EASL 2014). Its use is the other way round: a normal level in a confused patient should make you question the diagnosis.
Cirrhosis · 5 of 6
Varices and HCC: prevent, then surveil.
Varices — preventing the first bleed
| Compensated with CSPH | A nonselective beta-blocker (NSBB) prevents decompensation; carvedilol is preferred (AASLD 2024 statements 1 and 12; Baveno VIII 3.15). No NSBB without CSPH (AASLD 2024 statement 9; Baveno VIII 3.16). |
|---|---|
| Carvedilol | 6.25 mg daily; after 2–3 days raise to 12.5 mg a day as one dose or 6.25 mg twice daily. Maintenance 6.25–12.5 mg a day; back to 6.25 mg if not tolerated or systolic BP falls under 90 mmHg. No heart-rate target. Lower starting doses may suit Child-Pugh B or C (AASLD 2024). |
| Propranolol or nadolol | Propranolol 20–40 mg twice daily, raised every 2–3 days; maximum 320 mg a day without ascites, 160 mg with ascites. Nadolol 20–40 mg at bedtime; maximum 160 mg a day without ascites, 80 mg with. Target heart rate 55–60 if tolerated; keep systolic BP at 90 mmHg or above (AASLD 2024, table 3). |
| Already on an NSBB | No screening endoscopy needed — it will not change management (Baveno VIII 3.18; AASLD 2024 statement 14). |
| Cannot take an NSBB | Screening endoscopy can be skipped when liver stiffness is under 20 kPa with platelets above 150,000/µL (Baveno VI criteria), rechecked yearly; spleen stiffness is not yet validated for this (AASLD 2024). Band ligation (EVL) for high-risk varices (AASLD 2024 statement 19). European: spleen stiffness under 40 kPa can also spare endoscopy (Baveno VIII 1.19). |
| Decompensated | Never bled and not on an NSBB: annual endoscopy. High-risk varices: NSBB or EVL, with an NSBB (including carvedilol) preferred for its benefits beyond bleeding (AASLD 2024 statements 22–23). European: with ascites and any varices, carvedilol or a conventional NSBB, carvedilol preferred (Baveno VIII 4.4); EVL alone only if neither can be taken (Baveno VIII 4.5). |
| Hold or reduce | Persistently low systolic BP (under 90 mmHg) or severe adverse effects; stopping should prompt endoscopy for high-risk varices (AASLD 2024 statement 24). European: also for MAP under 65 mmHg or HRS-AKI (Baveno VIII 4.6); restart or re-titrate once resolved (Baveno VIII 4.6–4.7). |
| After a bleed | NSBB plus EVL; carvedilol preferred in Baveno VIII 4.8. TIPS if bleeding recurs despite both (Baveno VIII 4.13). |
Acute variceal bleeding — the short version
| First hour | Vasoactive drug (octreotide, somatostatin, or terlipressin where available) and IV antibiotics as soon as possible; ceftriaxone 1 g every 24 hours is the usual choice (AASLD 2024 statements 25 and 27). |
|---|---|
| Blood | Transfuse to a hemoglobin near 7 g/dL; do not give plasma or platelets to reach INR or platelet targets (AASLD 2024 statements 28–29). European: restrictive target of 7–8 g/dL, individualized (Baveno VIII 5.4). |
| Scope | Within 12 hours. Band ligation for esophageal varices. Continue the vasoactive drug for 2–5 days (AASLD 2024 statements 26, 30–31). |
| Pre-emptive TIPS | Child-Pugh C 10–13, or B above 7 with active bleeding at endoscopy: within 72 hours, ideally within 24 (AASLD 2024 statement 32; Baveno VIII 5.31). |
| Full workflow | See the GI bleeding guide and the GI bleed tool. |
HCC surveillance (AASLD 2023)
| Who | Cirrhosis of any cause, Child-Pugh A or B; Child-Pugh C only if on the transplant list; subsets of chronic hepatitis B without cirrhosis. Not when comorbidity limits life expectancy to under 1–2 years. |
|---|---|
| How | Ultrasound plus AFP every 6 months. Ultrasound alone has 53% sensitivity for early HCC; adding AFP raises it to 63% (meta-analysis cited in AASLD 2023). |
| After SVR | HCV cirrhosis stays at risk: continue surveillance indefinitely. |
| Recall | A new or growing lesion 1 cm or larger, or an elevated AFP (20 ng/mL is the usual cutoff): multiphase CT or contrast MRI. A lesion under 1 cm: repeat ultrasound and AFP in 3–6 months. |
| LI-RADS | LR-1 (benign) to LR-5 (HCC). LR-5 lesions are HCC 95–99% of the time; LR-4 about 75%, which calls for biopsy or 3-month imaging after multidisciplinary review. |
Cirrhosis · 6 of 6
The rest of the list.
Hydrothorax and hyponatremia
| Hepatic hydrothorax | Transudate, usually right-sided; a serum-to-pleural albumin gradient above 1.1 g/dL suggests it (AASLD 2021). Sodium restriction and diuretics, thoracentesis for dyspnea or hypoxemia, TIPS second line. Avoid chest tubes; an indwelling tunneled catheter is an option only for non-TIPS candidates. Refer for transplant (AASLD 2021; AGA 2025). |
|---|---|
| Mild, 126–135 | Monitor and restrict water (AASLD 2021). |
| Moderate, 120–125 | Water 1 L a day and stop diuretics (AASLD 2021). AGA 2025 also reviews laxatives and diuretics and looks for bleeding, infection, thyroid and adrenal causes. |
| Severe, under 120 | Stricter water restriction plus albumin (AASLD 2021). Hypertonic saline only for symptoms, severe cases or imminent transplant; vaptans only short term (30 days or less). |
| Correction rate | 4–6 mmol/L per 24 hours, never more than 8 (AASLD 2021). See hyponatremia and the hyponatremia tool. |
Drugs to avoid or limit
- NSAIDs, ACE inhibitors and ARBs with ascites; also alpha-1 blockers and dipyridamole (AASLD 2021).
- Aminoglycosides whenever possible (AASLD 2021).
- Acetaminophen is the preferred analgesic: 500 mg every 6 hours, up to 2 g a day. Avoid opioids for chronic pain when possible (AASLD 2022 palliative guidance). See pain.
- Avoid chronic benzodiazepines (AASLD 2022); like opioids and neuroleptics, they can mimic HE (AASLD/EASL 2014).
- Statins are not off-limits. Simvastatin: no more than 20 mg a day in decompensated cirrhosis, only 10–20 mg a day in Child-Pugh B or C, and with caution if bilirubin is above 3 mg/dL (AASLD 2024).
Nutrition, vaccines, goals
| Protein | 1.2–1.5 g/kg a day, no restriction even with HE (ACG 2026). See malnutrition. |
|---|---|
| Timing | Late-evening snack to shorten the overnight fast (ACG 2025). |
| Scale | Malnutrition affects about 20% of patients with compensated and up to 60% with decompensated cirrhosis (ACG 2025). |
| Vaccines | ACG 2026 preventive-care guidance strongly recommends hepatitis A testing and vaccination, plus influenza, SARS-CoV-2 and RSV immunization. The CDC adult schedule also lists chronic liver disease for hepatitis B and pneumococcal vaccination. Check immunity and the current schedule. |
| Palliative care | Offer it at any stage, alongside transplant evaluation; start advance care planning at diagnosis, before decompensation erodes capacity (AASLD 2022). For hospice discussions, AASLD 2022 links MELD above 21 or Child-Pugh 12 or more to a life expectancy of about 6 months (its formal guidance statement pairs MELD above 21 with Child-Pugh above 12). |
CSPH clinically significant portal hypertensionSAAG serum-ascites albumin gradientLVP large-volume paracentesis (more than 5 L)TIPS transjugular intrahepatic portosystemic shuntNSBB / EVL nonselective beta-blocker / endoscopic variceal ligationSBP spontaneous bacterial peritonitisHE hepatic encephalopathyPMN polymorphonuclear leukocytesPEG polyethylene glycolLI-RADS Liver Imaging Reporting and Data SystemSVR sustained virologic responseMASH metabolic dysfunction-associated steatohepatitis
Educational reference only — not medical advice. Doses and thresholds summarize the cited guidance in our own words; confirm against the current guideline, the product label and your local protocol before acting.
Sources
Verify against current guidelines and local protocol before acting.
- Biggins SW, Angeli P, Garcia-Tsao G, et al. Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: 2021 practice guidance by the AASLD. Hepatology 2021;74(2):1014-1048. doi:10.1002/hep.31884 (erratum Hepatology 2025;82(6):E160).
- Orman ES, Fortune BE, John BV, Asrani SK, et al. AGA Clinical Practice Update on the management of ascites, volume overload, and hyponatremia in cirrhosis: expert review. Gastroenterology 2025;169(7):1547-1557. doi:10.1053/j.gastro.2025.08.029 (Best Practice Advice 1-13).
- Kaplan DE, Ripoll C, Thiele M, et al. AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology 2024;79(5):1180-1211. doi:10.1097/HEP.0000000000000647.
- de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C; Baveno VII Faculty. Baveno VII - Renewing consensus in portal hypertension. J Hepatol 2022;76(4):959-974. doi:10.1016/j.jhep.2021.12.022 (statement 7.4, recurrent ascites).
- Baveno VIII Faculty (Berzigotti A, Mandorfer M, Pons M, et al.). Baveno VIII - Advancing consensus in portal hypertension. J Hepatol 2026;85(5):993-1018. doi:10.1016/j.jhep.2026.07.030 (accepted pre-proof, 31 July 2026; statements 1.15-1.19, 3.1-3.18, 4.1-4.13, 5.4, 5.31, 6.3, 6.22). Baveno VIII is a European consensus; where it differs from AASLD we label it.
- Vilstrup H, Amodio P, Bajaj J, et al. Hepatic encephalopathy in chronic liver disease: 2014 practice guideline by the AASLD and EASL. Hepatology 2014;60(2):715-735. doi:10.1002/hep.27210.
- Bajaj JS, Jakab SS, Jesudian AB, Rahimi RS, et al. ACG Clinical Guideline: Hepatic encephalopathy. Am J Gastroenterol 2026;121(3):588-618. doi:10.14309/ajg.0000000000003899 (recommendations as summarized in the ACG Guideline Highlights and Guideline Central summary).
- XIFAXAN (rifaximin) prescribing information, section 2.2. Salix Pharmaceuticals; revised 08/2025.
- Singal AG, Llovet JM, Yarchoan M, et al. AASLD Practice Guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma. Hepatology 2023;78(6):1922-1965. doi:10.1097/HEP.0000000000000466.
- Dove L, Chadha RM, Lai JC, et al. AASLD-AST Practice Guideline on adult liver transplantation: candidate evaluation. Hepatology 2026;83(6):1609-1645. doi:10.1097/HEP.0000000000001644 (referral guideline statements).
- Tapper EB, Kardashian A, Debes JD, et al. ACG Clinical Guideline: Preventive care for patients with cirrhosis. Am J Gastroenterol 2026 (published online October 5, 2026). doi:10.14309/ajg.0000000000004186 (strong recommendations as listed in the abstract).
- Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 1999;341(6):403-409. doi:10.1056/NEJM199908053410603.
- Nadim MK, Kellum JA, Forni L, et al. Acute kidney injury in patients with cirrhosis: ADQI and ICA joint multidisciplinary consensus meeting. J Hepatol 2024;81(1):163-183. doi:10.1016/j.jhep.2024.03.031.
- Singal AK, Wong RJ, Dasarathy S, et al. ACG Clinical Guideline: Malnutrition and nutritional recommendations in liver disease. Am J Gastroenterol 2025;120(5):950-972. doi:10.14309/ajg.0000000000003379.
- Rogal SS, Hansen L, Patel A, et al. AASLD Practice Guidance: Palliative care and symptom-based management in decompensated cirrhosis. Hepatology 2022;76(3):819-853. doi:10.1002/hep.32378.
- Centers for Disease Control and Prevention. Adult Immunization Schedule Notes, ages 19 years or older, United States, 2025 (hepatitis A, hepatitis B, pneumococcal and RSV notes). cdc.gov/vaccines/hcp/imz-schedules/adult-notes.html.
- Tables and figures from these sources are not reproduced; facts are restated in our own words.