Clinical Considerations for Treating Patients with Pneumonia
George Sakoulas, MD, provided commentary on challenging patients with comorbidities such as COPD, structural lung disease, asthma, and other health issues.
Contagion: As we are heading into seasonal respiratory virus season, what are you seeing in your own practice and region of the country in this regard, and how should clinicians be preparing to combat a resurgence in COVID 19 and the early onset of respiratory season?
Sakoulas: I'm based in Southern California, working as an ID physician. What we're noticing here is a slight uptick in flu cases. In fact, as of this time of year, we're seeing about three times more flu cases than we had at the same point last year. This suggests we might be in for a heavier flu season than usual, at least based on early indicators. Typically, our flu season peaks in January. In Southern California, it's quite predictable—flu activity often surges right after the holiday season. People travel, visit family, return home, and then around January 5th, it's as if a fire is lit.
We also had a COVID bump in August, which mirrored trends across much of the country, though it was far less severe than what we saw during the pandemic years. We had some hospitalizations, but most were incidental.
For clinicians, the main preparation is staying informed and encouraging patient vaccination. We now have vaccines for influenza, COVID, and RSV. RSV vaccines are recommended for anyone over 60 or for anyone at high risk over 75. Encouraging vaccination is really the most effective tool we have since the therapeutic options for viral infections are limited. Although some treatments show statistically significant effects in studies, the clinical impact often seems minor.
In short, with viral infections, prevention through vaccination is key. We as healthcare providers are mandated to get vaccinated, and ideally, the best time to do so is now.
Contagion: For pneumonia patients with lung function related comorbidities—such as COPD or structural lung disease, smokers, over age 65, asthma—who are these most challenging patients and why?
Sakoulas: Older patients present unique challenges, especially those with structural lung disease. Anytime there’s an infection or problem in the lungs, entering that illness with a compromised organ system makes it significantly more challenging. This is mainly because they have limited respiratory reserve. When someone with underlying health issues gets an illness, even a minor one, it can affect them much more severely than a healthier person. Additionally, these patients often receive frequent antibiotic treatments due to repeated exacerbations and ongoing care needs. Frequent antibiotic use increases the risk of antibiotic resistance, which, in turn, makes them more susceptible to infections by unusual organisms that are less common in straightforward cases of community-acquired pneumonia.
Contagion: What are the clinical considerations you are thinking about in your treatment management?
Sakoulas: When it comes to pneumonia—and, really, most infections—it often comes down to two main factors: comorbidities and severity of illness. Stopping an infection is a bit like stopping a car. Your level of sickness can be thought of as your speed, while your comorbidities are like the type of surface you're on. If you have multiple comorbidities, it’s like driving on an icy downhill road; if you're very sick, it’s as if you're moving at a high speed. These are the two factors I explain to patients and students when discussing how we assess infection risks and make treatment decisions.
For example, if a patient has multiple comorbidities or has been on prior antibiotics, we need to make specific treatment decisions. However, if a younger patient with no major risk factors becomes severely ill—such as requiring ICU admission or ventilation within the first 24 to 48 hours of hospitalization—I start to consider staph pneumonia, particularly during the respiratory season we discussed earlier.
The conversation was edited for grammar and clarity.
