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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? 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 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 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) 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 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 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 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) 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 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… 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… Understand the latest in CAP care Antibiotic Selection Diagnostic testing Prevention Learn about CAP Quality Initiatives at UWHC Etiology of CAP Causative agent known in less than half of patients Bacterial: 40-60%, Atypical pathogens: 10-30% Mycoplasma, Chlamydia, Legionella Other agents: 5%-25% S pneumoniae (15-35%), H flu, Moraxella Viruses, PCP, MTB Unknown: 30-60%, two agents: 15% IDSA 2003 Guidelines Latest guidelines for CAP treatment Update 2000 guidelines UWHC guidelines based heavily on IDSA guidelines + latest evidence 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 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 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, nonsmoking 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 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 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 Preferred treatment: Advanced macrolide Respiratory fluoroquinolone Ketolide *COPD, diabetes, renal disease, CHF or malignancy Outpatient treatmentComorbidities, 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 Outpatient treatmentComorbidities, +Recent antimicrobial therapy Preferred treatment: Advanced macrolide + beta-lactam Respiratory fluoroquinolone Ketolide Outpatient treatmentComorbidities, +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. 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 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 Outpatient treatment- Influenza with bacterial superinfection Preferred treatment: Beta-lactam Respiratory Fluoroquinolone 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 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 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 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 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 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 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 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 Nursing Home Treatment Preferred treatment: Advanced macrolide + amox-clavulanate Respiratory fluoroquinolone Ketolide 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 Caveats to Antibiotic Therapy Drug resistant pneumococci Monotherapy vs. dual therapy Fluoroquinolone therapy Ketolides QT prolongation side effects Short course therapy S. Pneumoniae : Growing Antimicrobial resistance PCN resistance growing 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 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 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% (PCNS), p=.054 (underpowered) Song, et al. CID 2004. Asia, 233 patients. No difference in mortality but underpowered 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 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 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 Fluoroquinolone Recommendations Fluoroquinolones have established efficacy in CAP treatment Serious CAP, S. pneumo bacteremia, Macrolide & PCN resistant S. pneumo Most experts and IDSA guidelines recommend restricted use over concern of increased resistance 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 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 Can be overcome with higher doses of drug Fluoroquinolones are a last resort Monotherapy vs. Dual therapy Guidelines for antibiotics in hospitalized patients: 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 Fluoroquinolone monotherapy also with lower mortality Macrolide monotherapy studies mixed Martinez, CID 2004 Monotherapy vs. Dual therapy Quasi RCTs examining monotherapy vs. dual therapy show no difference Limited due to small ‘n’, non-blinded medication assignment Data for fluoroquinolone monotherapy more convincing Fogarty, et al. CID 2004 Randomized, non-blinded study of 269 patients with serious CAP to show Abx equivalence 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 Waterer, Arch Int Med 2001 Retrospective study of 255 patients with S. pneumo bacteremia, outcome=14 day mortality Monotherapy associated with death (even FQ) Dual therapy with ceph + macrolide or FQ best outcomes Martinez, CID 2003 Observational study of 409 patients with S. pneumo bacteremia who received initial betalactam therapy, outcome=in hospital mortality 1/3 also received macrolide therapy Lack of initial macrolide therapy associated with death FQ not studied Why might dual therapy work better? Macrolide or FQ addition thought to cover atypical bacteria co-infection Macrolides have immunomodulatory effects 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? Initial antibiotic choice made before blood culture results known High risk patients for bacteremia: High risk for complications from bacteremia: ≥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 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 Semi-synthetic derivative of erythromycin designed to overcome macrolide resistant S. pneumo 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 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 Dosing: 800 mg per day (p.o. only) 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 Telithromycin Moxifloxacin – moreso than levo, gati, cipro Recommend use with caution if: Known QT prolongation Taking drugs that prolong the QT interval Uncorrected hypokalemia Short course antibiotic therapy Proposed to decrease antimicrobial resistance, side effects & non-adherence Hospitalized patients with CAP: 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