The role of macrolides in severe community-acquired pneumonia and the potential impact of macrolide-resistant Mycoplamsa pneumoniae

Purpose of review Define the utility of adjunctive macrolide therapy in patients with more severe forms of community-acquired pneumonia (CAP). Recent findings Guidelines recommend adjunctive macrolide therapy as an option for patients with CAP, admitted to the hospital. A large data set collected both retrospectively and prospectively, including several recent randomized controlled trials (RCTs) have shown that adjunctive macrolide therapy can reduce mortality and improve outcomes in patients with severe CAP, more effectively than other alternative therapies. This effect appears to be most evident in those with severe illness and appears to be independent of direct antimicrobial effects and may be a result of the immunomodulatory properties of macrolides. A recent RCT, the ACCESS study, showed a clinical benefit of macrolides in severe CAP patients, but this may have been the result of a reversal of infection-related immunoparalysis. Macrolides appear to be valuable for patients with more severe CAP, but their therapeutic value is being challenged by the recent emergence of macrolide-resistant Mycoplasma pneumoniae; however, the optimal therapy for this pathogen still needs to be defined. Summary New evidence has further advanced the role of macrolides as preferred adjunctive therapy for patients with severe CAP.