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

Update on Quality Pneumonia Care

Tosha Wetterneck, MDPrimary Care Conference

August 18, 2004

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

disclose.

*Marrie, JAMA 2000; Dean, Am J Med 2001

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*

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

National Vital Statistics Reports, 2001 data; AHRQ Research in Action #7

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

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)

Meehan, JAMA 1997; Battleman, Arch Int Med 2002; Gleason, Arch Int Med 1999; Ramirez, Arch Int Med 1999

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

CAP - Oxygen AssessmentCommunity Acquired Pneumonia: Oxygenation Assessment

JCAHO Core Measures Performance Results

100% 100% 100%99% 98% 99% 99%97% 97%100%

98%

0%

20%

40%

60%

80%

100%

2Q03 Rates 3Q03 Rates 4Q03 Rates 1Q04 Rates

Per

cen

t C

om

plia

nce

UWHC obs. rate

UHC mean obs. rate

JCAHO mean obs. rate

Source: University HealthSystem Consortium JCAHO Core Measures, CY2003Q2, CY2003Q3, CY2003Q4, CY2004Q1


CAP – Blood Cultures (prior to Antibiotics)


Community Acquired Pneumonia: Blood Culture Prior to AntibioticsJCAHO Core Measures Performance Results

70%

84%

79%82%

80%78% 78%

82% 82%84%

81%

0%

20%

40%

60%

80%

100%


Per

cen

t C

om

plia

nce

UWHC obs. rate

UHC mean obs. rate



CAP - Antibiotic Timing, mean time

Community Acquired PneumoniaMean Times to First Antibiotic Dose

281

316

274

420

302

313

294300

245 241 237

230

250

270

290

310

330

350

370

390

410

430


Min

ute

s

UWHC mean minutes

UHC mean minutes

JCAHO mean minutes


Goal 240

CAP - Antibiotic Timing, median timeCommunity Acquired Pneumonia

Median Times to First Antibiotic Dose

223

247

210226

280293

278289

232 231 226

0

50

100

150

200

250

300

350

400


Min

ute

s

UWHC median minutes

UHC median minutes

JCAHO median minutes


Goal 240

CAP - Smoking Cessation Counseling

Community Acquired Pneumonia: Adult Smoking Cessation AdviceJCAHO Core Measures Performance Results

41%46%

49%

43%47%

52%55%

33%*

26%*

10%*

39%*

0%

20%

40%

60%

80%

100%


Per

cen

t C

om

plia

nce

UWHC obs. rate

UHC mean obs. rate


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/VaccinationJCAHO Core Measures Performance Results

14%

3% 2%

22% 20%

28% 29%

37% 38%

12%

43%

0%

20%

40%

60%

80%

100%


Per

cen

t C

om

plia

nce

UWHC obs. rate

UHC mean obs. rate



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%,

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%

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

* Patients usually young, non-smoking

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

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

* Augmentin XR is 1000mg amoxicillin and 125mg clavulanate

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

Outpatient treatment- Comorbidities*, no recent

antimicrobial therapy

Preferred treatment: Advanced macrolide Respiratory fluoroquinolone Ketolide

*COPD, diabetes, renal disease, CHF or malignancy

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



Outpatient treatment- Comorbidities, +Recent antimicrobial therapy

Preferred treatment: Advanced macrolide + beta-

lactam Respiratory fluoroquinolone Ketolide

* Augmentin XR is 1000mg amoxicillin and 125mg clavulanate

Outpatient treatment- Comorbidities, +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



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


* 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

*Pseudomonal risk: severe structural lung disease, recent Abx or stay in hospital

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

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

*Pseudomonal risk: severe structural lung disease, recent Abx or stay in hospital

Inpatient treatment- ICU, +Pseudomonal risk*

Preferred treatment: Antipseudomonal agent +

Ciprofloxacin Antipseudomonal agent +

Aminoglycoside + Respiratory fluoroquinolone OR Advanced macrolide

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



Caveats to Antibiotic Therapy

Drug resistant pneumococci Monotherapy vs. dual therapy Fluoroquinolone therapy Ketolides QT prolongation side effects Short course therapy

Doern, J Inf 2004

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%

Ewig, J Respir Crit Care Med 1999

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

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

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

Lonks, CID 2002

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

Chen, NEJM 1999

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

File, CID 2004

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

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

Martinez, CID 2004

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

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 beta-lactam therapy, outcome=in hospital mortality

1/3 also received macrolide therapy Lack of initial macrolide therapy associated with death FQ not studied

Martinez, CID 2004

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

How do you know who could be bacteremic?

Initial antibiotic choice made before blood culture results known

High risk patients for bacteremia: ≥65 years old Asplenic or immunocompromised

High risk for complications from bacteremia: 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

Ackermann, J Antimicr Chemo 2003

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

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

Ackermann, J Antimicr Chemo 2003

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

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

File, CID 2004

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

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

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

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