For an extremely common disease, the optimal therapy of community-acquired pneumonia (CAP) remains surprisingly controversial. A good example of the differences in opinion is the contrast between the recent guidelines of the American1–
thoracic societies with respect to their recommendations on classification of severity and choice of empiric antibiotics.
Several retrospective studies in both CAP generally,3–
and in the subset of patients with bacteremic pneumococcal disease specifically,4–5
have suggested that the combination of a macrolide and a third-generation cephalosporin provides a survival advantage over other antibiotic regimens. Gleason and colleagues6
also found a survival advantage in elderly patients treated with either the combination of a third-generation and a macrolide or with a fluoroquinolone compared to other antibiotic regimens. Although the consistent findings of these studies are very suggestive, they all suffer from one or more significant limitations predominantly arising from their retrospective nature. They have however raised significant questions regarding the need for coverage of atypical organisms (such as Legionella spp, Mycoplasma spp, and Chlamydia spp) in all patients with CAP, and especially the role of macrolides as part of a multiantibiotic empiric regimen.