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Update on Quality
Pneumonia Care
Tosha Wetterneck, MD
Primary Care Conference
August 18, 2004
I do not have any financial
disclosures or conflicts of
interest to disclose.
Are physicians aware of and using
pneumonia guidelines?
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Answer: We can do better
Switzer, et al. JGIM 2003
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Surveyed 621 MD’s at 7 hospitals in PA
(response rate 56%)
>70% familiar with guidelines (ATS/local)
30-60% of those reported using guideline
Guidelines / Critical pathways for pneumonia
can decrease LOS, cost and mortality*
*Marrie, JAMA 2000; Dean, Am J
Med 2001
Objectives
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Raise awareness of Community Acquired
Pneumonia (CAP) guidelines
Review quality care for Community Acquired
Pneumonia (CAP)
Understand the latest in CAP care
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Antibiotic Selection
Diagnostic testing
Prevention
Learn about CAP Quality Initiatives at UWHC
Conclusions
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CAP care is an important, publicly reported
quality indicator
JCAHO and others monitor:
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Blood Culture Use (prior to antibiotics)
Antibiotic Timing (within 4 hours of arrival)
Antibiotic Selection (new)
Smoking Cessation Counseling
Pneumococcal Screening & Vaccination
Influenza Screening & Vaccination (new)
Conclusions 2
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Use UWHC guidelines for antibiotic selection
(based on 2003 IDSA guidelines)
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Use patient setting, comorbidities, allergies and
recent antibiotic use to guide selection
Outpatient:
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Healthy: macrolide or doxycycline
Comorbidities: Resp fluoroquinolone (FQ) or Ketolide or
Macrolide + Beta-lactam
Inpatient:
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Non ICU: Cephalosporin + Macrolide or Resp FQ
ICU: must use 2 drugs, assess for pseudomonas risk
Conclusions 3
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Nursing home:
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Advanced macrolide + amox-clavulanate or
Respiratory fluoroquinolone or Ketolide
Recent antibiotic therapy (3 months)
confers risk for resistance and a different
antibiotic class should be chosen
Drug resistant pneumococcus is a
growing problem
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Save the fluoroquinolones (judicious use)
Conclusions 4
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Be aware of new antibiotics (ketolides), drug
interactions and short course therapy
An ounce of prevention…
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Patient Immunization: pneumococcal and
influenza
Health Care Worker Influenza immunization
Smoking cessation counseling
Pneumonia is a growing
health problem
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4-5 million cases of CAP yearly
1.7 million hospitalizations annually
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30-40 admissions per month at UWHC
7th leading cause of death in US
$10 billion dollars spent yearly on CAP
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Inpatient: $5700/case, Outpatient: $300
$100 million on antimicrobials
National Vital Statistics Reports,
2001 data; AHRQ Research in
Action #7
Gaps exist in quality of care
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JCAHO Performance Measures
 Agenda for Change, 1987
 Core Measures
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Developed 1999-2000; Piloted 2001, 16 hospitals
Evidence-based quality indicators
Variety of stakeholders involved
Four Core Measures Sets selected (CAP, CHF, AMI, L&D)
Data collection at UWHC since 3rd Q 2003
7 CAP Quality Indicators
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Oxygenation assessment
Blood Culture Use (prior to antibiotics)
Antibiotic Timing (within 4 hours of arrival)
Antibiotic Selection (new)
Smoking Cessation Counseling
Pneumococcal Screening & Vaccination
Influenza Screening & Vaccination (new)
Quality Indicators and Outcomes
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Early antibiotic therapy: decreased LOS and
mortality
Blood cultures in first 24 hours: decreased
mortality
Appropriate antibiotics: decreased LOS and
mortality
Early IV to po antibiotic switch: decreased
LOS and cost
Influenza vaccination: decreased mortality
Meehan, JAMA 1997; Battleman,
Arch Int Med 2002; Gleason, Arch
Int Med 1999; Ramirez, Arch Int
Med 1999
CAP - Oxygen Assessment
Community Acquired Pneumonia: Oxygenation Assessment
JCAHO Core Measures Performance Results
100%
100%
99%
100%
97%
98%
97%
100%
99%
98%
100%
99%
UWHC obs. rate
UHC
mean obs. rate
JCAHO mean obs. rate
Percent Compliance
80%
60%
40%
20%
0%
2Q03 Rates
3Q03 Rates
4Q03 Rates
1Q04 Rates
Source: University HealthSystem Consortium JCAHO Core Measures, CY2003Q2, CY2003Q3, CY2003Q4, CY2004Q1
Source: University HealthSystem Consortium JCAHO Core Measures, CY2003Q2, CY2003Q3, CY2003Q4, CY2004Q1
CAP – Blood Cultures
(prior to
Antibiotics)
Community Acquired Pneumonia: Blood Culture Prior to Antibiotics
JCAHO Core Measures Performance Results
100%
UWHC obs. rate
UHC
84%
82%
82%
80%
82%
80%
JCAHO mean obs. rate
84%
81%
78%
79%
78%
Percent Compliance
70%
60%
40%
20%
0%
2Q03 Rates
3Q03 Rates
4Q03 Rates
mean obs. rate
1Q04 Rates
Source: University HealthSystem Consortium JCAHO Core Measures, CY2003Q2, CY2003Q3, CY2003Q4, CY2004Q1
Source: University HealthSystem Consortium JCAHO Core Measures, CY2003Q2, CY2003Q3, CY2003Q4,
CY2004Q1
CAP - Antibiotic Timing,
mean time
UWHC mean minutes
Community Acquired Pneumonia
Mean Times to First Antibiotic Dose
430
UHC
mean minutes
JCAHO mean minutes
420
410
390
Minutes
370
350
330
316
310
290
313
302
300
294
281
274
270
250
245
241
237
Goal 240
230
2Q03 Rates
3Q03 Rates
4Q03 Rates
1Q04 Rates
Source: University HealthSystem Consortium JCAHO Core Measures, CY2003Q2, CY2003Q3, CY2003Q4, CY2004Q1
CAP - Antibiotic Timing,
median time
Community Acquired Pneumonia
Median Times to First Antibiotic Dose
UWHC median minutes
400
UHC
350
JCAHO median minutes
293
300
Minutes
250
median minutes
280
289
278
247
223
232
231
226
Goal 240
226
210
200
150
100
50
0
2Q03 Rates
3Q03 Rates
4Q03 Rates
1Q04 Rates
Source: University HealthSystem Consortium JCAHO Core Measures, CY2003Q2, CY2003Q3, CY2003Q4, CY2004Q1
CAP - Smoking Cessation
Counseling
Com m unity Acquired Pneum onia: Adult Sm oking Cessation Advice
JCAHO Core Measures Perform ance Results
UWHC obs. rate
100%
UHC
JCAHO mean obs. rate
Percent Compliance
80%
60%
55%
52%
47%
40%
mean obs. rate
39%*
49%
46%
43%
41%
33%*
26%*
20%
10%*
0%
2Q03 Rates
3Q03 Rates
4Q03 Rates
1Q04 Rates
Source: University HealthSystem Consortium JCAHO Core Measures, CY2003Q2, CY2003Q3, CY2003Q4, CY2004Q1
* <25 cases, results should be used w ith caution. 5/13 cases 2Q03, 1/10 cases 3Q03, 5/19 cases 4Q03, 8/24 cases 1Q04
CAP - Pneumococcal
Screening/Vaccine
Community Acquired Pneumonia: Pneumococcal Screen/Vaccination
JCAHO Core Measures Performance Results
UWHC obs. rate
100%
UHC
Percent Compliance
80%
mean obs. rate
JCAHO mean obs. rate
60%
43%
38%
37%
40%
29%
28%
22%
20%
14%
20%
12%
3%
2%
0%
2Q03 Rates
3Q03 Rates
4Q03 Rates
1Q04 Rates
Source: University HealthSystem Consortium JCAHO Core Measures, CY2003Q2, CY2003Q3, CY2003Q4, CY2004Q1
Everyone wants this data…
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CMS voluntary reporting (2003)
 Public data released Feb 04
 Tied to reimbursement
JCAHO public data reporting (July 2004)
WHA public reporting (March 2004)
WI Collaborative for Healthcare Quality
UWHC Quality and Safety Report
 Business report: July 2004
 Consumer report: Sept 2004
Remainder of talk…
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Understand the latest in CAP care
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Antibiotic Selection
Diagnostic testing
Prevention
Learn about CAP Quality Initiatives at
UWHC
Etiology of CAP
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Causative agent known in less than half
of patients
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Bacterial: 40-60%,
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Atypical pathogens: 10-30%
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Mycoplasma, Chlamydia, Legionella
Other agents: 5%-25%
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S pneumoniae (15-35%), H flu, Moraxella
Viruses, PCP, MTB
Unknown: 30-60%, two agents: 15%
IDSA 2003 Guidelines
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Latest guidelines for CAP treatment
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Update 2000 guidelines
UWHC guidelines based heavily on IDSA
guidelines + latest evidence
Antibiotic selection guidelines
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Setting:
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Outpatient vs. Inpatient, non-ICU vs ICU
Patient factors:
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Comorbidities: COPD, diabetes, renal
disease, CHF or malignancy
Recent antibiotic therapy: within past 3
months= choose different antibiotic class
Pseudomonal risk: severe structural lung
disease, recent Abx or stay in hospital
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Please forgive my use of unapproved
abbreviations in the remainder of the
talk
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q = every
b.i.d. = twice daily
t.i.d. = three times daily
q.i.d. = four times daily
Outpatient treatment- Previously
healthy patient, no recent
antimicrobial therapy*
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Preferred treatment:
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Macrolide or doxycycline
Specific antimicrobial choices:
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Azithromycin, one Z pak as directed OR
Clarithromycin 500mg b.i.d. x 10 days OR
Erythromycin for 10-14 days
Doxycycline 100mg b.i.d. x 10-14 days
* Patients usually young, nonsmoking
Outpatient treatment- Previously
healthy patient, +recent
antimicrobial therapy*
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Preferred treatment:
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Advanced macrolide + high dose
amoxicillin
Advanced macrolide + amox-clavulanate
Respiratory fluoroquinolone
Ketolide
* Risk factor for resistant pneumococcus
Outpatient treatment- Previously
healthy patient, +recent
antimicrobial therapy
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Specific antimicrobial choices:
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Azithromycin, one Z pak as directed OR
Clarithromycin 500mg b.i.d. x 10 days +
Amoxicillin 1g t.i.d. OR Amoxicillinclavulanate XR* 2 tablets b.i.d. x 10 days
Moxifloxacin 400mg daily x 10 days OR
Gatifloxacin 400mg daily x 10 days OR
Levofloxacin 750mg daily x 5 days
Telithromycin 800mg daily x 7-10 days
* Augmentin XR is 1000mg
amoxicillin and 125mg clavulanate
Outpatient treatmentComorbidities*, no recent
antimicrobial therapy
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Preferred treatment:
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Advanced macrolide
Respiratory fluoroquinolone
Ketolide
*COPD, diabetes, renal disease, CHF or malignancy
Outpatient treatmentComorbidities, No recent
antimicrobial therapy
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Specific antimicrobial choices:
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Azithromycin, one Z pak as directed OR
Clarithromycin 500mg b.i.d. x 10 days
Moxifloxacin 400mg daily x 10 days OR
Gatifloxacin 400mg daily x 10 days OR
Levofloxacin 750mg daily x 5 days
Telithromycin 800mg daily x 7-10 days
Outpatient treatmentComorbidities, +Recent
antimicrobial therapy
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Preferred treatment:
Advanced macrolide + beta-lactam
 Respiratory fluoroquinolone
 Ketolide
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Outpatient treatmentComorbidities, +Recent
antimicrobial therapy
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Specific antimicrobial choices:
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Azithromycin, one Z pak as directed OR
Clarithromycin 500mg b.i.d. x 10 days +
Amoxicillin 1g t.i.d. x OR Amoxicillin-clavulanate
XR* 2 tablets b.i.d. OR Cefpodoxime 200mg b.i.d.
x 10 days
Moxifloxacin 400mg daily x 10 days OR
Gatifloxacin 400mg daily x 10 days OR
Levofloxacin 750mg daily x 5 days
Telithromycin 800mg daily x 7-10 days
* Augmentin XR is 1000mg
amoxicillin and 125mg clavulanate
Outpatient treatment- Suspected
aspiration
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Preferred treatment:
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Amoxicillin-clavulanate or Clindamycin
Specific antimicrobial choices:
Amoxicillin-clavulanate 875/125mg
b.i.d. x 10 days
 Clindamycin 300mg q.i.d. x 10 days
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Outpatient treatment- Influenza
with bacterial superinfection
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Preferred treatment:
Beta-lactam
 Respiratory Fluoroquinolone
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Outpatient treatment- Influenza
with bacterial superinfection
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Specific antimicrobial choices:
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Amoxicillin 1 g t.i.d. OR Amoxicillin-clavulanate
XR* 2 tablets b.i.d. OR Cefpodoxime 200mg b.i.d.
x 10 days
Moxifloxacin 400mg daily x 10 days OR
Gatifloxacin 400mg daily x 10 days OR
Levofloxacin 750mg daily x 5 days
* Augmentin XR is 1000mg amoxicillin and 125mg clavulanate
and may not be on all formularies
Inpatient treatment- Non-ICU,
No recent antimicrobial therapy
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Preferred treatment:
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Advanced macrolide + beta-lactam
 Respiratory fluoroquinolone
Specific antimicrobial choices:
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Ceftriaxone 1 g IV daily + Azithromycin
500 mg IV daily
Moxifloxacin 400mg IV daily
Inpatient treatment- Non-ICU,
+Recent antimicrobial therapy
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Preferred treatment:
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Sane as above EXCEPT choose a different
antibiotic than previous therapy
Specific antimicrobial choices:
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Ceftriaxone 1 g IV daily + Azithromycin
500 mg IV daily
Moxifloxacin 400mg IV daily
Inpatient treatment- ICU, No
pseudomonal risk*
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Preferred treatment:
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Beta-lactam + Advanced macrolide
OR Respiratory fluoroquinolone
Specific antimicrobial choices:
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Ceftriaxone 1 g IV daily + Azithromycin
500 mg IV daily OR Moxifloxacin 400mg IV
daily
*Pseudomonal risk: severe
structural lung disease, recent Abx
or stay in hospital
Inpatient treatment- ICU, No
pseudomonal risk, +Beta lactam
allergy
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Preferred treatment:
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Respiratory fluoroquinolone +/Clindamycin
Specific antimicrobial choices:
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Moxifloxacin 400mg IV daily +/Clindamycin 600-900mg IV every 6 hours
Inpatient treatment- ICU,
+Pseudomonal risk*
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Preferred treatment:
Antipseudomonal agent +
Ciprofloxacin
 Antipseudomonal agent +
Aminoglycoside + Respiratory
fluoroquinolone OR Advanced
macrolide
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*Pseudomonal risk: severe
structural lung disease, recent Abx
or stay in hospital
Inpatient treatment- ICU,
+Pseudomonal risk
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Specific antimicrobial choices:
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Piperacillin 4g IV q6h OR Piperacillin-tazobactam
4.5g IV q6h OR Cefepime 2g IV q8h OR Imipenem
500mg q6h + Ciprofloxacin 400mg IV q8h
Piperacillin 4g IV q6h OR Piperacillin-tazobactam
4.5g IV q6h OR Cefepime 2g IV q8h OR Imipenem
500mg q6h + Gentamicin OR Tobramycin OR
Amikacin + Moxifloxacin 400mg IV daily OR
Azithromycin 500 mg IV daily
Inpatient treatment- ICU,
+Pseudomonal risk +Beta-lactam
allergy
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Preferred treatment:
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Aztreonam + Antipseudomonal agent
+/- Aminoglycoside
Specific antimicrobial choices:
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Aztreonam 2g q8h + Ciprofloxacin 400mg
IV q8h OR Levofloxacin 750mg IV daily +/Gentamicin OR Tobramycin OR Amikacin
Nursing Home Treatment
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Preferred treatment:
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Advanced macrolide + amox-clavulanate
Respiratory fluoroquinolone
Ketolide
Nursing Home Treatment
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Specific antimicrobial choices:
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Azithromycin, one Z pak as directed OR
Clarithromycin 500mg b.i.d. x 10 days +
Amoxicillin-clavulanate XR 2 tablets b.i.d. x
10 days
Moxifloxacin 400mg daily x 10 days OR
Gatifloxacin 400mg daily x 10 days OR
Levofloxacin 750mg daily x 5 days
Telithromycin 800mg daily x 7-10 days
Caveats to Antibiotic Therapy
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Drug resistant pneumococci
Monotherapy vs. dual therapy
Fluoroquinolone therapy
Ketolides
QT prolongation side effects
Short course therapy
S. Pneumoniae : Growing
Antimicrobial resistance
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PCN resistance growing
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in US
39% of 2000-01 US isolates have high or
intermediate level resistance
3-4% increase yearly from 1995
¾ PCN resistant also macrolide resistant
Erythromycin resistance: 31%
Cefuroxime resistance: 30%
Fluoroquinolone resistance: 1%
Doern, J Inf 2004
Drug Resistant Pneumococci
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Risk Factors:
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Age > 65
Beta-lactam therapy last 3 months*
Alcoholism
Immunosuppression (including steroids)*
Exposure to child in day care
Multiple comorbidities*
*Shown in multiple studies
Ewig, J Respir Crit Care Med 1999
Clinical Impact of Pneumococcal
Resistance in CAP patients
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Aspa, et al. CID 2004
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Prospective, multi-center obs study of 638 patients
with CAP due to S pneumo in Spain
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Isolates: 10% PCN-R, 26% PCN-I
Morbidity: DIC, empyema & bacteremia more common
with PCN-S isolates
Mortality: 18% (PCN-R) vs. 18% (PCN-I) vs. 12% (PCNS), p=.054 (underpowered)
Song, et al. CID 2004. Asia, 233 patients.
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No difference in mortality but underpowered
Clinical Impact of Pneumococcal
Resistance in Bacteremic patients
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Yu, et al. CID 2003
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Prospective, international, multi-center study of
844 bacteremic patients
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PCN resistance: 9.6%; 14 d mortality rate 16.9%
Overall, persons with PCN resistant S. pneumo who
received monotherapy with ‘the wrong’ antibiotic died at
same rate as those who received ‘the right’ antibiotic
 Exception: Cefuroxime (standard dosing does not
achieve levels above MIC)
65% deaths occurred w/i 3 days of BCx
Macrolide Resistant Pneumococci
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Mechanisms of resistance:
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Efflux pump
Ribosomal alteration- prevents macrolide binding
to ribosome
Macrolide failures in CAP caused by S.
pneumo resistance
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Associated with breakthrough bacteremia
Not recommended as monotherapy in bacteremic
patients
Lonks, CID 2002
Fluoroquinolone resistant
pneumococcus
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In US: resistance to FQ low but reported
In Canada and Spain: resistance with FQ use
Likelihood of FQ resistance increases with prior FQ
exposure in past year
Reports of patients on FQ who have FQ resistant
pneumococcus show increased morbidity and
mortality
Resistance may develop during treatment
Some guidelines recommend FQ as first line agent
due to low resistance rates
Chen, NEJM 1999
Fluoroquinolone Recommendations
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Fluoroquinolones have established efficacy in
CAP treatment
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Serious CAP, S. pneumo bacteremia, Macrolide &
PCN resistant S. pneumo
Most experts and IDSA guidelines recommend
restricted use over concern of increased
resistance
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Patients who fail or are allergic to beta lactam +
macrolide therapy
Documented highly drug resistant pneumococcus
File, CID 2004
Take home points – Drug Resistant
Pneumococci
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Rates of drug resistant pneumococcus are
increasing
Clear reports of macrolide and
fluoroquinolone resistant strains causing
morbidity and mortality in patients receiving
those antibiotics
PCN resistance so far does not seem to cause
worse outcomes…more evidence is needed
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Can be overcome with higher doses of drug
Fluoroquinolones are a last resort
Monotherapy vs. Dual therapy
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Guidelines for antibiotics in hospitalized patients:
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Non-ICU: Macrolide addition to beta-lactam/cephalosporin or
fluoroquinolone alone; some macrolide alone
ICU: 2 drugs: FQ or macrolide + beta-lactam/inh or ceph
Multiple retrospective and prospective observational
studies have shown decreased LOS a/o mortality with
dual therapy with macrolide addition vs.
cephalosporin or augmentin alone
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Fluoroquinolone monotherapy also with lower mortality
Macrolide monotherapy studies mixed
Martinez, CID 2004
Monotherapy vs. Dual therapy
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Quasi RCTs examining monotherapy vs. dual therapy
show no difference
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Limited due to small ‘n’, non-blinded medication assignment
Data for fluoroquinolone monotherapy more convincing
 Fogarty, et al. CID 2004
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Randomized, non-blinded study of 269 patients with serious
CAP to show Abx equivalence
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Initial Rx: Levofloxacin vs. Ceftriaxone + erythromycin
No difference in clinical response, mortality
Similar findings seen in 5 other studies of FQs
2 studies support dual therapy in
S pneumo bacteremia
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Waterer, Arch Int Med 2001
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Retrospective study of 255 patients with S.
pneumo bacteremia, outcome=14 day mortality
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Monotherapy associated with death (even FQ)
Dual therapy with ceph + macrolide or FQ best outcomes
Martinez, CID 2003
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Observational study of 409 patients with S.
pneumo bacteremia who received initial betalactam therapy, outcome=in hospital mortality
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1/3 also received macrolide therapy
Lack of initial macrolide therapy associated with death
FQ not studied
Why might dual therapy work
better?
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Macrolide or FQ addition thought to cover
atypical bacteria co-infection
Macrolides have immunomodulatory effects
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Benefit seen in bronchiolitis and cystic fibrosis
Not a proven mechanism in CAP
Doesn’t explain similar results with FQ addition in
Waterer study
Studies based on initial empiric antibiotics,
not focused S pneumo therapy
Martinez, CID 2004
How do you know who could be
bacteremic?
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Initial antibiotic choice made before blood
culture results known
High risk patients for bacteremia:
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High risk for complications from bacteremia:
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≥65 years old
Asplenic or immunocompromised
Above + Comorbid disease: CV, lung, liver,
diabetes
Bacteremia is a risk factor for death
Monotherapy vs. Dual therapy
Conclusions
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In hospitalized patients, cephalosporins and
beta-lactamase inh should not be used as
single therapy
Macrolide monotherapy should be reserved
for young, non-ill / immunocompromised /
bacteremic patients
Use 2 drugs in ICU patients: beta lactam +
macrolide or FQ
Ketolides
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Semi-synthetic derivative of
erythromycin designed to overcome
macrolide resistant S. pneumo
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Binds to 2 subunits on ribosome, weak
inducer of efflux pump
Used in Europe since 2001, FDA
approved April 2004
Expect to see marketing soon
Ackermann, J Antimicr Chemo
2003
Ketolides 2
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3 RCTs document equivalence with
amoxicillin, clarithromycin and
quinolones
Role in macrolide-resistant S pneumo:
No resistance seen yet
No firm data in patients with S. pneumo
bacteremia
Ketolides 3
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Dosing: 800 mg per day (p.o. only)
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No change in renal / hepatic dysfxn
7-10 day course for pneumonia
ADRs: diarrhea (13%), nausea, h/a
Significant drug interactions:

Metabolized by CYP3A4 system : Do not
use with Statins (hold statin), protease
inhibitors (HIV), CSA, tacrolimus
Ackermann, J Antimicr Chemo
2003
CAP drugs with QT
prolongation potential
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Telithromycin
Moxifloxacin – moreso than levo, gati,
cipro
Recommend use with caution if:
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Known QT prolongation
Taking drugs that prolong the QT interval
Uncorrected hypokalemia
Short course antibiotic therapy

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Proposed to decrease antimicrobial
resistance, side effects & non-adherence
Hospitalized patients with CAP:
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
Levofloxacin 750mg daily x 5 days just as good as
500mg daily x 10 days
Outpatients with CAP:


Telithromycin 800mg daily for 5 days as good as 7
days
Azithromycin 500mg daily x 3 days as good as
Clarithromycin 500mg twice daily x 10 days
File, CID 2004
Diagnostic testing on
Hospitalized patients




2 v Chest X ray (confirm dx, effusion)
Blood cultures on arrival (before abx)
Sputum GS and culture (before abx)
Urine Legionella antigen- only patients with
risk factors




Seriously ill
Immunocompromised
Non-responsive to beta-lactams
Suggestive clinical features
New diagnostic test:
Pneumococcal Urinary Antigen



Detects pneumococcal cell wall
polysaccharide in urine
Rapid turnaround: 15 min –1 hour
Sensitivity: 50-80%, specificity: 90%


70-80% in bacteremic patients
Should not replace cultures

Needed for susceptibility testing
New diagnostic test:
Pneumococcal Urinary Antigen 2

Considered a “possibly useful addition”
by IDSA panel



Helpful for patients already on antibiotics
at the time of evaluation
High risk patients with non-diagnostic
sputum
Should be available at UWHC later this
year or early 2005

Back to the Quality piece……
CAP Quality efforts at UWHC

CAP guidelines on CRIT (updated 8/2004)


Includes PSI, antibiotic selection
Focused Efforts: PICC team for CAP





Time to First dose antibiotics
Inpatient Immunization Protocol – Pneumococcal
and Influenza vaccines
Smoking Cessation counseling
Documentation standardization
Blood culture protocol update
Time to First dose antibiotics


Goal < 4 hours, door to drug time
How Physicians can help:

Treat 1st dose of antibiotics as “STAT”




Write for antibiotics on admission ASAP
Verbally communicate with Pharmacy and
nursing
Be prepared to help ensure IV access
Attendings: encourage your residents!
Inpatient Immunization Protocol –
Pneumococcal and Influenza vaccines



Hospitalized patients at UW will be screened
by pharmacists and case managers for prior
pneumococcal and influenza immunization
based on ACIP guidelines
Eligible patients will receive vaccine at
discharge by protocol (no physician order
needed)
Immunization will be documented in WISCR
and patient given vaccine card
Prevention of Pneumonia

Patient Immunization:

Influenza vaccine shown to:



Reduce hospitalization for cardiac disease and
stroke in elderly
Reduce mortality in elderly
Pneumococcal vaccine:


Prevent invasive disease (bacteremia)
Reduce hospitalizations and death in elderly
with chronic lung disease
Prevention of Pneumonia 2

Health Care Worker Influenza
Immunization



Reduced absenteeism from work
Reduced patient and colleague morbidity
and mortality from work transmission
Please vaccinate your patients and
yourself!
Prevention of Pneumonia 3

Smoking Cessation Counseling

Need to document this for all inpatients
with Pneumonia who:



Currently smoke
Smoked in the past year
Multidisciplinary team convening to
implement this on the inpatient setting
Conclusions


CAP care is an important, publicly reported
quality indicator
JCAHO and others monitor:







Oxygenation assessment
Blood Culture Use (prior to antibiotics)
Antibiotic Timing (within 4 hours of arrival)
Antibiotic Selection (new)
Smoking Cessation Counseling
Pneumococcal Screening & Vaccination
Influenza Screening & Vaccination (new)
Conclusions 2

Use UWHC guidelines for antibiotic selection
(based on 2003 IDSA guidelines)


Use patient setting, comorbidities, allergies and
recent antibiotic use to guide selection
Outpatient:



Healthy: macrolide or doxycycline
Comorbidities: Resp fluoroquinolone (FQ) or Ketolide or
Macrolide + Beta-lactam
Inpatient:


Non ICU: Cephalosporin + Macrolide or Resp FQ
ICU: must use 2 drugs, assess for pseudomonas risk
Conclusions 3

Nursing home:



Advanced macrolide + amox-clavulanate or
Respiratory fluoroquinolone or Ketolide
Recent antibiotic therapy (3 months)
confers risk for resistance and a different
antibiotic class should be chosen
Drug resistant pneumococcus is a
growing problem

Save the fluoroquinolones (judicious use)
Conclusions 4


Be aware of new antibiotics (ketolides), drug
interactions and short course therapy
An ounce of prevention…



Patient Immunization: pneumococcal and
influenza
Health Care Worker Influenza immunization
Smoking cessation counseling
Resources


UWHC Pneumonia guidelines (CRIT)
IDSA guidelines online


www.idsociety.org
Pneumonia Bibliography