Patients Presenting With Comorbidities


Bruce Jones, PharmD, FIDSA, BCPS provides commentary on treating challenging patients with comorbidities such as type 2 diabetes, higher BMI, and advanced age.

Contagion: Can you talk about your clinical concerns regarding a patient population who are presenting with comorbidities such as type 2 diabetes, higher BMI, and advanced age?

Jones: That's a lot of what we see on a day-to-day basis, right? And there are different levels within that. So, let me break it down. Take diabetes, for example. Because diabetes is so prevalent, it doesn't necessarily stand out as much as it used to. My first question is: what degree of diabetes are we dealing with? What's their hemoglobin A1c level? As we know, higher hemoglobin A1c levels raise concerns, whether it be about wound healing or adherence and compliance. This is an important aspect to consider. So, the question is: what level of diabetes are you dealing with?

BMI is another interesting factor because we're seeing more and more research in this area. For example, we have ongoing research involving vancomycin. It circles back to the degree of obesity in a patient. We categorize it by class: BMI of 30 to 35, 35 to 40, or greater than 40. Within these categories, we assess if the BMI level impacts compliance, adherence, recovery speed, length of stay, and other factors. So, the variation in BMI degrees is significant.

Age is also noteworthy. We often see a younger population with conditions like cellulitis and abscesses from other skin infections. However, it catches my attention when the patient is older, say 65, 75, or even 85 years old. This brings up inherent issues, particularly concerning their care transitions. It can be more challenging for this population. They often can't visit an infusion center, which is crucial if we’re considering IV antibiotics. We must think about their dexterity, the need for home care, and other related issues. Therefore, care transitions become a more prominent concern for older patients.

Contagion: Can you talk about your priorities and treatment goals and the criteria to ensure you are meeting those goals?

Jones: I think our first question, and even our first priority, is understanding why the patient is here. Often, this leads to more questions than answers. For example, did they fail outpatient oral therapy? If so, why? Was there a gap in their therapy or a lapse in coverage? This is usually the first area we explore.

We also consider if the patient is a frequent visitor to our facility. Some patients come and go quite often, so it's crucial to review their medical history, especially their microbiology records. One advantage of being on the inpatient side is access to their history within our healthcare system. Knowing what organisms they have grown previously is very valuable for their current treatment.

Our primary goal is to stabilize the patient as quickly as possible and move them to a transition-of-care scenario, ultimately discharging them efficiently. We've tracked our data over the years using ICD codes, which ties into this focus. For conditions like cellulitis and abscesses, coded as ICD-10 L03 or L02, we haven’t historically performed well in terms of reducing length of stay. However, we've made improvements over the years.

It's essential to start planning for outpatient therapy (OPAT) as soon as the patient is admitted, rather than waiting until discharge. We need to ask questions early on, such as: where will the patient go after discharge? Will they be on oral or IV therapy? What is their financial situation, and will they need patient assistance? These considerations are crucial for a smooth transition from inpatient to outpatient care.

Contagion: Within this patient population who presents with recurring skin infections including wounds, abscess, and cellulitis, are you more concerned with any one infection?

Jones: I think cellulitis is probably one that jumps out just because that's the most common one we see. I think the most concerning for me are the wound infections. I think first off, you start concerning yourself for deeper seeded infections. A lot of times, these require a little bit more workup. Also, too, I would say comorbidities come into effect with wound infections. You think of diabetics; you think of patients who are smokers. You think of other things that go along with that, including lymphedema, obesity tying back into BMI. So these, I think, can affect especially those wound infection type of patients where now you have an element of healing associated with it.

The conversation was edited for grammar and clarity.

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