Community Acquired Pneumonia: Does Optimal Management Equate to Optimal Performance Measurement

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Community Acquired PneumoniaDoes Optimal
Management Equate to Optimal Performance
Measurement?

• George C. Mejicano, MD, MS
• Associate Professor of Medicine
• University of Wisconsin Medical School

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Community Acquired Pneumonia (CAP)

• Leading cause of morbidity and mortality
• Highest risk groups include the elderly and
  persons with co-morbid conditions
• Incidence
• General population 1-12/1000/year
• Age greater than 65 25-44/1000/year
• 5-6 million cases per year in United States
• Approximately 1 million admissions per year
• CAP treatment costs gt 8 billion per year

Niederman MS, et al. Am J Respir Crit Care Med
2001 163 1730-54 and File TM, Tan JS. JAMA
2005 942712-19
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Case

• A 63 year old man presents
• with fever, shortness of breath,
• and cough productive of green
• sputum. His chest x-ray shows

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Questions to Ponder

• Is a chest x-ray necessary?
• Is a sputum sample necessary?
• What lab tests should I order?
• Where should I treat him (i.e., do I admit the
  patient to the hospital)?
• Which antibiotic decisions matter most (i.e.,
  which drug, time to first dose, duration of
  therapy)?
• How can I prevent future events?

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Is a CXR Necessary?

• In addition to a constellation of suggestive
• clinical features, a demonstrable infiltrate
• by chest radiography or other imaging
• technique, with or without supporting
• microbiological data, is required for a
• diagnosis of pneumonia.
• IDSA/ATS Guidelines for CAP in
  Adults

Mandel LA, et al. CID 2007 44 (Supplement 2)
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Is a Sputum Sample Necessary?

• Routine diagnostic tests to identify
• an etiologic diagnosis are optional
• for outpatients with CAP.
• IDSA/ATS Guidelines for CAP in Adults

Mandel LA, et al. CID 2007 44 (Supplement 2)
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Clinical Indications for Testing in CAP
Mandel LA, et al. CID 2007 44 (Supplement 2)
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Etiology of Community Acquired Pneumonia

• Typical
• Streptococcus pneumoniae
• Haemophilus influenzae
• Atypical
• Chlamydophila pneumoniae
• Mycoplasma pneumoniae 5-25
• Legionella pneumophila

Marston BJ, et al. Arch Intern Med.
19971571709-1718 Patel T, et al. Respir Med.
20009497-105 Pareja A, et al. Chest.
19921011207-1210
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Bacteriology of CAP Atypical Pathogens?

• 346 admitted adults in Israel
• 89 convalescent serology for bacteria and
  atypical agents.
• S. pneumoniae was most common pathogen L.
  pneumophila and C. pneumoniae were seen commonly
  in all age groups
• 39 mixed infection.

Lieberman D, et al. Thorax. 199651179-184
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Importance of Initial Assessment

• Almost all of the major decisions
• regarding management of CAP,
• including diagnostic and treatment
• issues, revolve around the initial
• assessment of severity.
• IDSA/ATS Guidelines for CAP in Adults

Mandel LA, et al. CID 2007 44 (Supplement 2)
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Deciding Where to Treat

• Initial site of treatment should be based on the
  following
• Calculation of a severity-of-illness score (e.g.,
  PSI or CURB-65)
• Clinical judgment by physician (e.g., subjective
  determination of the ability to take oral
  medications and quality of outpatient support)

Mandel LA, et al. CID 2007 44 (Supplement 2)
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Pneumonia Severity Index (PSI)

• A model for predicting 30 day mortality from
  community acquired pneumonia
• Stratifies patients into 5 classes by using a
  cumulative point system based on 19 variables
• Rule validated with retrospective analysis of
  38,039 patients that showed direct correlation
  between class and mortality (validated
  prospectively in later study)

Fine MJ, et al. N Engl J Med. 1997336243-250
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PSI Risk Class I

• Age lt 50
• Normal vitals
• Normal mental status
• None of the following comorbid conditions
• Neoplasm
• Liver disease
• Renal disease
• Congestive Heart Failure
• Cerebrovascular accident

Fine MJ, et al. N Engl J Med. 1997336243-250
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PSI Classification

• Risk class I II III
  IV V
• Points - lt 70 71-90
  91-130 gt 130
• Mortality 0.1 0.6 2.8 8.2
  29.2
• Recommended Out Out Out In In
• Site of Care

Fine MJ, et al. N Engl J Med. 1997336243-250
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PSI Scoring System

• Demographic factors
• Age (subtract 10 for women) age (in years)
• Nursing home resident 10
• Comorbid illness
• Neoplastic disease 30
• Liver Disease 20
• Congestive heart failure 10
• Cerebrovascular Disease 10
• Renal Disease 10
  

Fine MJ, et al. N Engl J Med. 1997336243-250
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PSI Scoring System

• Physical exam findings
• Altered mental status 20
• Respiratory rate gt 30/minute 20
• Systolic BP lt 90 mg Hg 20
• Temperature lt 35 or gt 40 C 15
• Pulse gt 125/minute 10

Fine MJ, et al. N Engl J Med. 1997336243-250
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PSI Scoring System

• Laboratory findings
• pH lt 7.35 30
• BUN gt 10.7 mmol/L 20
• Sodium lt 130 mEq/L 20
• Glucose gt 13.9 mmol/L 10
• Hematocrit lt 30 10
• pO2 lt 60 mm Hg or O2 sat lt 90 10
• Pleural effusion 10

Fine MJ, et al. N Engl J Med. 1997336243-250
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Pneumonia Severity Index

• Download PSI calculator
• http//pda.ahrq.gov/clinic/psi/psi.htm
• Use PSI calculator on the web
• http//pda.ahrq.gov/clinic/psi/psicalc.asp

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Later Hospitalization Unlikely

• Study of 944 patients initially treated out of
  the hospital showed that only 71 (7.5) required
  hospitalization within 30 days
• 40 due to community acquired pneumonia
• 26 due to co-morbid illnesses
• 5 refused initial recommendation of
  hospitalization

Minogue MF, et al. Ann Emerg Med 199831376-380
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Is it Safe to Treat Risk Class II III Out of
the Hospital?

• Study of 224 patients diagnosed in an
  emergency department with CAP
• All patients with PSI scores lt 90
• All patients treated with levofloxacin 500 mg
  daily
• 92 of 110 (83.6) in the outpatient group had
  successful outcomes
• 92 of 114 (80.7) in the inpatient group had
  successful outcomes

Carratala J, et al. Ann Intern Med
2005142165-172
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CURB-65 Classification

• Confusion (not alert and oriented x 3)
• Uremia (BUN level gt 20 mg/dL)
• Respirations (rate gt 30 breaths / minute)
• Blood pressure (systolic pressure lt 90 or
  diastolic pressure lt 60 mm Hg)
• Age (65 years or age or greater)

Lim WS, et al. Thorax 2003 58377-82Capelaste
gui A, et al. Eur Respir J 2006 27151-7
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CURB-65 Classification

• of Factors 0 1 2 3
  4 5
• Mortality () 0.7 2.1 9.2 14.5
  40 57
• Recommended Out Out Ward ICU ICU ICU
• Site of Care

Lim WS, et al. Thorax 2003 58377-82Capelaste
gui A, et al. Eur Respir J 2006 27151-7
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ICU Admission Decision (Admit to ICU if any
major or gt 3 minor criteria present)

• Major Criteria
• Invasive mechanical ventilation
• Septic shock with the need for vasopressors
• Minor Criteria
• Respiratory rate gt 30 breaths / minute
• Pa02 / FiO2 ratio lt 250
• Presence of multilobar infiltrates
• Confusion/disorientation
• Uremia (BUN level gt 20 mg/dL)
• Leukopenia (WBC count lt 4000 cells / mm3)
• Thrombocytopenia (platelet count lt 100,000 cells
  / mm3)
• Hypothermia (core temperature lt 36 degrees C)
• Hypotension requiring aggressive fluid
  resuscitation

Mandel LA, et al. CID 2007 44 (Supplement 2)
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CAP Therapy in a Medicare Population

• 12, 945 Medicare patients with CAP
• Exclude HIV, lt age 65, transplant,
  immunosuppressive therapy, no antibiotics within
  48 hours of admission
• Major endpoint 30-day mortality
• Relate severity adjusted outcomes to initial
  therapy
• Cephalosporins utilized most frequently
• 2nd generation cephalosporin (12.3)
• 3rd generation cephalosporin (26.5)
• beta-lactam macrolide (14.4)
• Fluoroquinolone alone (2.0)
• Macrolide alone (1.8)

Gleason, et al. Arch Intern Med. 1999
1592562-2572
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CAP Decreased Mortality With Agents Active
Against Both Atypical and Typical Pathogens
Effect of Antimicrobials on 30-Day Mortality in
Hospitalized Elderly Patients
0.20

• ?-Lactam/?-lactamase inhibitor macrolide ?77

0.18
0.16
0.14
Aminoglycoside other agent ?21
0.12
Nonpseudomonal 3rd-gen. cephalosporin (reference)
0.10
Adjusted mortality
Nonpseudomonal 3rd-gen. cephalosporin macrolide
0.08
2nd-gen. cephalosporin macrolide ?29
Fluoroquinolone ?36
0.06
0.04
0.02
0.00
0
5
10
15
20
25
30
Days from hospital admission
P lt0.05. Gleason et al. Arch Intern Med. 1999.
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Penicillin Resistance in S. pneumoniae United
States, 1979-2001
1979-1994 CDC Sentinel Surveillance Network
1995-2001 CDC Active Bacterial Core
Surveillance (ABCS) System
Emerging Infections Program
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Streptococcus pneumoniae Resistance Rates
for Selected Agents, 1999-2000

• Antimicrobial Resistance
• Macrolides 25.9
• Clindamycin 8.8
• Tetracycline 16.4
• Chloramphenicol 8.4
• TMP-SFX 30.3
• Fluoroquinolones 1.2

May not be clinically relevant due to high
tissue levels achieved by drugs. Doern GV, et
al. Antimicrobial Agents Chemother 2001
451721-9
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Does Antibiotic Resistance Matter?
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2007 IDSA/ATS CAP Treatment Guidelines

• Outpatient treatment when previously healthy and
  no use of antibiotics within past 3 months
• Doxycycline (weak evidence, level III evidence)
  or
• Macrolide (strong evidence, level I evidence)
• Erythromycin, Azithromycin, or Clarithromycin

Mandel LA, et al. CID 2007 44 (Supplement 2)
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2007 IDSA/ATS CAP Treatment Guidelines

• Outpatient treatment in the presence of chronic
  lung, heart, liver, or renal disease diabetes
  alcoholism no spleen malignancies
  immunosuppression or use of antibiotics within
  the previous three months
• Respiratory fluoroquinolone (strong
  recommendation, level I evidence)
• Moxifloxacin, gemifloxacin, or levofloxacin 750
  mg
• or
• Beta-lactam plus a macrolide (strong
  recommendation, level I evidence)
• Amoxicillin 1 gram po TID or amoxicillin-clavula
  nate 2 grams po BID are preferred but
  may use ceftriaxone, cefpodoxime, or cefuroxime
  500 mg po BID

Mandel LA, et al. CID 2007 44 (Supplement 2)
34
2007 IDSA/ATS CAP Treatment Guidelines

• Inpatient on a medical ward
• Respiratory fluoroquinolone (strong
  recommendation, level I evidence)
• or
• b-lactam plus a macrolide (strong recommendation,
  level I evidence)
• Preferred beta-lactam agents include cefotaxime,
  ceftriaxone, and ampicillin ertapenem for
  selected patients

Mandel LA, et al. CID 2007 44 (Supplement 2)
35
2007 IDSA/ATS CAP Treatment Guidelines

• ICU admission and no pseudomonas risk factors
• b-lactam antibiotic (strong recommendation, level
  I evidence)
• Cefotaxime, ceftriaxone, or ampicillin-sulbactam
• plus
• Azithromycin (strong recommendation, level II
  evidence) or a respiratory fluoroquinolone
  (strong recommendation, level I evidence)

Mandel LA, et al. CID 2007 44 (Supplement 2)
36
2007 IDSA/ATS CAP Treatment Guidelines

• ICU admission with pseudomonas risk factors
• Antipseudomonal b-lactam either ciprofloxacin
  or levofloxacin 750 mg dose
• Piperacillin-tazobactam, cefepime, imipenem, or
  meropenem
• or
• Antipseudomonal b-lactam an aminoglycoside
  azithromycin
• or
• Antipseudomonal b-lactam an aminoglycoside a
  respiratory fluoroquinolone

Mandel LA, et al. CID 2007 44 (Supplement 2)
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Early Antibiotic Administration
Early antibiotic intervention may lead
to Morbidity Mortality
Meehan TP, et al. JAMA. 19972782080-2084 McG
arvey RN, et al. QRB Qual Rev Bull.
199319124-130 Jagminas L, et al. Med Health
RI. 199881412-414 Fortune G, et al. Clin
Perform Qual Health Care. 1996441-43 Ross G,
et al. J Healthcare Qual. 19971922-29,36
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Early Antibiotic Administration
30-day mortality (N14,069 ?65 years of age)
Antibiotics Antibiotics gt 8 hours lt 8 hours
Odds Ratio 1.0 0.85
Plt0.001 adjusted for other factors
Meehan TP, et al. JAMA. 19972782080-2084
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Is a Delay in Antibiotic Therapy Harmful?

• Medicare survey of 14,069 patients gt 65 years in
  3555 acute care hospitals in US
• In hospital mortality rate of 10.3 15.3 at 30
  days
• 30 day mortality was significantly reduced if
  antibiotics administered within 8 hours
• Mortality increased for each hour delay

TOTAL
Time of initial antibiotic
Meehan et. al., JAMA 1997 278 2080-2084
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Faster Conversion from IV to Oral

• Previously ? 7 days IV antibiotic therapy
  prior to switch to oral therapy
• Now ?3 days IV antibiotic therapy prior
  to switch to oral therapy

Ramirez JA, et al. Arch Intern Med.
19991592449-2454 Krieff D, et al. Am J Manag
Care. 19995(suppl)S539-S554 Ramirez JA, et
al. Arch Intern Med. 19951551273-1276 Weingart
en SR, et al. Am J Respir Crit Care Med.
19961531110-1115 Van den Brande P, et al.
Chest. 1997112406-415
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CAP Criteria for Clinical Stability (Switch to
Oral Therapy)

• Temperature lt 37.8
• Pulse lt 100 beats / minute
• Respiratory rate lt 24 breaths / minute
• Systolic blood pressure gt 90 mm Hg
• Blood oxygen saturation gt 90 on RA
• Ability to maintain oral intake
• Normal mental status

Ramirez JA, et al. Arch Intern Med.
19991592449-2454
Mandel LA, et al. CID
2007 44 (Supplement 2)
42
Early Switch Therapy Results

• CAP in 200 patients
• 133 qualified for early switch resulting in 88
  patients being discharged early
• Mean length of stay decreased from 7.6 days to
  3.4 days

Ramirez JA, et al. Arch Intern Med.
19991592449-2454
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When to Discharge?

• Patient is candidate for oral therapy
• No need to treat comorbid illness
• No need for further diagnostic testing
• No unmet social needs
• Inpatient observation while receiving oral
  therapy is unnecessary

Mandel LA, et al. CID 2007 44 (Supplement 2)
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Discharge Planning

• Written discharge plan
• Patient education materials
• Compliance
• Signs and symptoms of relapse
• Nutrition
• Immunizations

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CAP Duration of Treatment

• Minimum length of treatment is 5 days (level I
  evidence)
• Ideally, no fevers for 48-72 hours
• No more than one CAP associated sign of clinical
  instability

Mandel LA, et al. CID 2007 44 (Supplement 2)
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Importance of ATS/IDSA CAP Guidelines
30-day Mortality Rate
Am J Med 2004 117726-31
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Centers for Medicare and Medicaid Services.
Pneumonia. http//www.medqic.org/pneumonia.
Accessed 10/28/07
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CAP Quality/Performance Measures for Inpatients

• PN-1 Oxygenation assessment
• PN-2 Pneumococcal immunization
• PN-3a Blood cultures for patients admitted
  and transferred to ICU within 24 hours of
  hospital arrival
• PN-3b Blood cultures performed in ED prior to
  antibiotic treatment

Centers for Medicare and Medicaid Services.
Pneumonia. http//www.medqic.org/pneumonia.
Accessed 10/28/07
49

CAP Quality/Performance Measures for Inpatients

• PN-4 Smoking cessation counseling
• PN-5a/c/b Initial antibiotic received within
  4/6/8 hours of hospital arrival
• PN-6 Antibiotic selection according to
  guidelines
• PN-7 Influenza immunization

Centers for Medicare and Medicaid Services.
Pneumonia. http//www.medqic.org/pneumonia.
Accessed 10/28/07
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Wisconsin Collaborative for Healthcare Quality.
www.wchq.org Accessed 10/28/07
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Wisconsin Collaborative for Healthcare Quality.
www.wchq.org Accessed 10/28/07
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Wisconsin Collaborative for Healthcare Quality.
www.wchq.org Accessed 10/28/07
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Wisconsin Collaborative for Healthcare Quality.
www.wchq.org Accessed 10/28/07
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Potential Untoward Consequences

• Patients may receive antibiotics when they do not
  have community acquired pneumonia
• Blood cultures may be obtained when they are not
  warranted
• Patients may be shunted away from healthcare
  workers or hospitals out of concerns about public
  reporting or pay for performance

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A Question in Practice
Self assessment
Physician Performance
Didactic
Analysis
SystemObstacles
Synthesis
Reflection
Hands-on
In Practice
Knowledge
Judgment
Interactive
Regnier et al, JCEHP, Sept 2005 Mazmanian
Davis, JAMA Sept 2002
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If you pit a good performer against a bad system,
the system wins every time. Geary Rummler, 2003
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Conclusions

• New IDSA/ATS pneumonia guidelines are based on
  the best available evidence
• Excellent evidence for the following
• Deciding where patients should be treated
• Selecting appropriate antibiotics
• Giving the initial antibiotic dose quickly
• Payers and other 3rd parties are keenly
  interested in CAP performance measures
• Some measures are better than others

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• Thank you!!