Treatment Protocols for Patients With Comorbidities
George Sakoulas, MD, offered clinical considerations for treatment selection.
Contagion: Can you describe your overall approach to starting therapy for a patient with pneumonia and comorbidities?
Sakoulas: That's a two-tier question. The first part involves what hospitalists typically do, and the second part covers my approach as an infectious disease specialist, which is a bit different.
Hospitalists usually follow the standard approach for community-acquired pneumonia. When a patient is admitted, they generally receive ceftriaxone along with a tetracycline, often doxycycline, or sometimes a macrolide. We’ve largely moved away from quinolones due to the risk of C difficile infections, and our hospital has effectively reduced C diff risk through a multi-tiered approach.
When I get involved, it’s usually because the patient is sicker or has multiple comorbidities. In cases where a patient presents with high illness severity—such as needing ICU admission within the first day or two—I’m more concerned about Staphylococcus pneumonia. So I often start with cefepime in my treatment algorithm, alongside a macrolide or doxycycline. This is because, for severe staph infections, standard agents like ceftriaxone, quinolones, and tetracyclines are not considered first-line anti-staphylococcal therapies. Given how quickly Staph can make patients severely ill, it’s crucial not to delay effective treatment.
Most of these patients are treated empirically. We do try to obtain cultures, typically from sputum or blood, if the patient is very ill, to help tailor therapy based on specific findings. But overall, empiric treatment is the standard approach.
Contagion: Aside from cost considerations, can you offer practical guidance to treatment selection?
Sakoulas: I think this touches on why standard hospital protocols often focus on cost. Many patients who receive antibiotics in the hospital don’t actually have pneumonia. They may have breathing difficulties, heart failure, or other issues, but due to a potential infiltrate or a mild radiographic finding, they’re often started on antibiotics as a precaution. For these cases, factoring in cost makes sense.
However, when a patient reaches my level of care as an infectious disease doctor, I’m confident they have pneumonia and are seriously ill. At that point, cost should not be the priority. The main focus should be on getting the patient better as quickly as possible. This approach is not only the right thing to do for the patient’s health but also makes economic sense. A faster response can lead to a shorter hospital stay, which, in turn, saves resources.
Hospital beds are in high demand, especially recently due to discharge delays related to coverage and insurance issues. This bed crunch is only going to intensify during respiratory season. Moving patients through their admissions efficiently is both the best approach for their health and the most efficient strategy from a healthcare perspective.
The conversation was edited for grammar and clarity.
