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Editorials |

Macrolides in Community-Acquired Pneumonia : Does the Bell Toll for Thee?

Eric V. Granowitz, MD; Richard B. Brown, MD
Author and Funding Information

Affiliations: Springfield, MA
 ,  Dr. Granowitz is Assistant Professor of Medicine, and Dr. Brown is Professor of Medicine at Tufts University School of Medicine. Both are in the Infectious Disease Division at Baystate Medical Center. Dr. Brown participates in the speakers’ bureaus of Cubist, Merck, Ortho-McNeil, Pfizer, and Roche.

Correspondence to: Richard B. Brown, MD, Infectious Diseases Division, Baystate Medical Center and Tufts University School of Medicine, 759 Chestnut St, Springfield, MA 01199; e-mail: richard.brown@bhs.org



Chest. 2005;128(3):1089-1093. doi:10.1378/chest.128.3.1089
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In the preantibiotic era William Osler wrote that “(t)he most widespread and fatal of all acute diseases, pneumonia is now the ‘Captain of the Men of Death.’”1 At that time, the treatment of community-acquired pneumonia (CAP) consisted of bedrest and open drainage tubes for patients with empyema. Once penicillin became commercially available in the l940s, the most common identifiable cause of bacterial pneumonia, the pneumococcus, became amenable to pathogen-directed therapy. With the discovery and manufacture of broad-spectrum antibiotics, additional pulmonary pathogens such as Haemophilus influenzae became treatable. Atypical pneumonia, historically characterized by interstitial infiltrates and the inability to identify a pathogen on sputum Gram stain or culture was first described in the mid-1940s, but it was not until the l960s that it was recognized that some cases were due to tetracycline-susceptible mycoplasma.3Legionella pneumophila was first identified as a cause of both atypical and typical CAP during a 1976 outbreak at an American Legion Convention. Mortality was 63% lower in patients treated with erythromycin compared to β-lactams.4 Because of its activity against Streptococcus pneumoniae, Mycoplasma pneumoniae, Legionella species, and Chlamydia pneumoniae, erythromycin became a drug of choice for CAP. More recently, respiratory fluoroquinolones have been used empirically for the treatment of CAP because of their activity against the pneumococcus (including penicillin-resistant S pneumoniae), against most other bacterial causes of lobar pneumonia, and against the “atypicals.” In the United States, it has been estimated that there are now at least 500,000 cases annually of CAP requiring hospitalization with 8,000 to 18,000 due to Legionella species, 20,000 to 100,000 due to M pneumoniae, and 5,000 to 50,000 due to C pneumonia.5


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