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Update on Quality Pneumonia Care

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  1. Update on Quality Pneumonia Care Tosha Wetterneck, MD Primary Care Conference August 18, 2004

  2. I do not have any financial disclosures or conflicts of interest to disclose.

  3. Are physicians aware of and using pneumonia guidelines? • Answer: We can do better • Switzer, et al. JGIM 2003 • 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

  4. Objectives • Raise awareness of Community Acquired Pneumonia (CAP) guidelines • Review quality care for Community Acquired Pneumonia (CAP) • Understand the latest in CAP care • Antibiotic Selection • Diagnostic testing • Prevention • Learn about CAP Quality Initiatives at UWHC

  5. Conclusions • CAP care is an important, publicly reported quality indicator • JCAHO and others monitor: • 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)

  6. 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

  7. 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)

  8. 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

  9. Pneumonia is a growing health problem • 4-5 million cases of CAP yearly • 1.7 million hospitalizations annually • 30-40 admissions per month at UWHC • 7th leading cause of death in US • $10 billion dollars spent yearly on CAP • Inpatient: $5700/case, Outpatient: $300 • $100 million on antimicrobials National Vital Statistics Reports, 2001 data; AHRQ Research in Action #7

  10. Gaps exist in quality of care • JCAHO Performance Measures • Agenda for Change, 1987 • Core Measures • 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

  11. 7 CAP Quality Indicators • 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)

  12. Quality Indicators and Outcomes • 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

  13. CAP - Oxygen Assessment Source: University HealthSystem Consortium JCAHO Core Measures, CY2003Q2, CY2003Q3, CY2003Q4, CY2004Q1

  14. CAP – Blood Cultures (prior to Antibiotics) Source: University HealthSystem Consortium JCAHO Core Measures, CY2003Q2, CY2003Q3, CY2003Q4, CY2004Q1

  15. CAP - Antibiotic Timing, mean time

  16. CAP - Antibiotic Timing, median time

  17. CAP - Smoking Cessation Counseling

  18. CAP - Pneumococcal Screening/Vaccine

  19. Everyone wants this data… • 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

  20. Remainder of talk… • Understand the latest in CAP care • Antibiotic Selection • Diagnostic testing • Prevention • Learn about CAP Quality Initiatives at UWHC

  21. Etiology of CAP • Causative agent known in less than half of patients • Bacterial: 40-60%, • S pneumoniae (15-35%), H flu, Moraxella • Atypical pathogens: 10-30% • Mycoplasma, Chlamydia, Legionella • Other agents: 5%-25% • Viruses, PCP, MTB • Unknown: 30-60%, two agents: 15%

  22. IDSA 2003 Guidelines • Latest guidelines for CAP treatment • Update 2000 guidelines • UWHC guidelines based heavily on IDSA guidelines + latest evidence

  23. Antibiotic selection guidelines • Setting: • Outpatient vs. Inpatient, non-ICU vs ICU • Patient factors: • 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

  24. Please forgive my use of unapproved abbreviations in the remainder of the talk • q = every • b.i.d. = twice daily • t.i.d. = three times daily • q.i.d. = four times daily

  25. Outpatient treatment- Previously healthy patient, no recent antimicrobial therapy* • Preferred treatment: • Macrolide or doxycycline • Specific antimicrobial choices: • 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, non-smoking

  26. Outpatient treatment- Previously healthy patient, +recent antimicrobial therapy* • Preferred treatment: • Advanced macrolide + high dose amoxicillin • Advanced macrolide + amox-clavulanate • Respiratory fluoroquinolone • Ketolide * Risk factor for resistant pneumococcus

  27. Outpatient treatment- Previously healthy patient, +recent antimicrobial therapy • Specific antimicrobial choices: • Azithromycin, one Z pak as directed OR Clarithromycin 500mg b.i.d. x 10 days + Amoxicillin 1g t.i.d. OR 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 * Augmentin XR is 1000mg amoxicillin and 125mg clavulanate

  28. Outpatient treatment- Comorbidities*, no recent antimicrobial therapy • Preferred treatment: • Advanced macrolide • Respiratory fluoroquinolone • Ketolide *COPD, diabetes, renal disease, CHF or malignancy

  29. Outpatient treatment- Comorbidities, No recent antimicrobial therapy • Specific antimicrobial choices: • 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

  30. Outpatient treatment- Comorbidities, +Recent antimicrobial therapy • Preferred treatment: • Advanced macrolide + beta-lactam • Respiratory fluoroquinolone • Ketolide

  31. Outpatient treatment- Comorbidities, +Recent antimicrobial therapy • Specific antimicrobial choices: • Azithromycin, one Z pak as directed ORClarithromycin 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

  32. Outpatient treatment- Suspected aspiration • Preferred treatment: • 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

  33. Outpatient treatment- Influenza with bacterial superinfection • Preferred treatment: • Beta-lactam • Respiratory Fluoroquinolone

  34. Outpatient treatment- Influenza with bacterial superinfection • Specific antimicrobial choices: • 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

  35. Inpatient treatment- Non-ICU, No recent antimicrobial therapy • Preferred treatment: • Advanced macrolide + beta-lactam • Respiratory fluoroquinolone • Specific antimicrobial choices: • Ceftriaxone 1 g IV daily + Azithromycin 500 mg IV daily • Moxifloxacin 400mg IV daily

  36. Inpatient treatment- Non-ICU, +Recent antimicrobial therapy • Preferred treatment: • Sane as above EXCEPT choose a different antibiotic than previous therapy • Specific antimicrobial choices: • Ceftriaxone 1 g IV daily + Azithromycin 500 mg IV daily • Moxifloxacin 400mg IV daily

  37. Inpatient treatment- ICU, No pseudomonal risk* • Preferred treatment: • Beta-lactam + Advanced macrolide OR Respiratory fluoroquinolone • Specific antimicrobial choices: • 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

  38. Inpatient treatment- ICU, No pseudomonal risk, +Beta lactam allergy • Preferred treatment: • Respiratory fluoroquinolone +/- Clindamycin • Specific antimicrobial choices: • Moxifloxacin 400mg IV daily +/- Clindamycin 600-900mg IV every 6 hours

  39. Inpatient treatment- ICU, +Pseudomonal risk* • Preferred treatment: • Antipseudomonal agent + Ciprofloxacin • Antipseudomonal agent + Aminoglycoside + Respiratory fluoroquinolone OR Advanced macrolide *Pseudomonal risk: severe structural lung disease, recent Abx or stay in hospital

  40. Inpatient treatment- ICU, +Pseudomonal risk • Specific antimicrobial choices: • 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

  41. Inpatient treatment- ICU, +Pseudomonal risk +Beta-lactam allergy • Preferred treatment: • Aztreonam + Antipseudomonal agent +/- Aminoglycoside • Specific antimicrobial choices: • Aztreonam 2g q8h + Ciprofloxacin 400mg IV q8h OR Levofloxacin 750mg IV daily +/- Gentamicin OR Tobramycin OR Amikacin

  42. Nursing Home Treatment • Preferred treatment: • Advanced macrolide + amox-clavulanate • Respiratory fluoroquinolone • Ketolide

  43. Nursing Home Treatment • Specific antimicrobial choices: • 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

  44. Caveats to Antibiotic Therapy • Drug resistant pneumococci • Monotherapy vs. dual therapy • Fluoroquinolone therapy • Ketolides • QT prolongation side effects • Short course therapy

  45. S. Pneumoniae : Growing Antimicrobial resistance in US • PCN resistance growing • 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

  46. Drug Resistant Pneumococci • Risk Factors: • 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

  47. Clinical Impact of Pneumococcal Resistance in CAP patients • Aspa, et al. CID 2004 • Prospective, multi-center obs study of 638 patients with CAP due to S pneumo in Spain • 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% (PCN-S), p=.054 (underpowered) • Song, et al. CID 2004. Asia, 233 patients. • No difference in mortality but underpowered

  48. Clinical Impact of Pneumococcal Resistance in Bacteremic patients • Yu, et al. CID 2003 • Prospective, international, multi-center study of 844 bacteremic patients • 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

  49. Macrolide Resistant Pneumococci • Mechanisms of resistance: • Efflux pump • Ribosomal alteration- prevents macrolide binding to ribosome • Macrolide failures in CAP caused by S. pneumo resistance • Associated with breakthrough bacteremia • Not recommended as monotherapy in bacteremic patients Lonks, CID 2002

  50. Fluoroquinolone resistant pneumococcus • 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