Macrolides are ideal for empiric therapy of community-acquired pneumonia in the immunocompetent host.

We propose that macrolides, especially the newer macrolides (azithromycin, clarithromycin, roxithromycin), are ideal agents for community-acquired pneumonia in the immunocompetent host who is not a resident of a nursing home or long-term care facility. Macrolides have proven effective in clinical trials against typical and atypical pathogens; thus, unlike beta-lactam agents, they can be given as monotherapy. Streptococcus pneumoniae isolates exhibiting high-level resistance to penicillin and cephalosporins pose a problem not only for the macrolides, but also for quinolones, tetracyclines, and most other beta-lactam agents. The tetracycines, quinolones, and beta-lactam agents have broader spectrum activity against aerobic gram-negative bacilli, which are uncommon pathogens of community-acquired pneumonia in the immunocompetent host. This broader spectrum is not only superfluous, but the potential of emergence of resistant bacteria is enhanced unnecessarily. Serious adverse reactions to the macrolides are rare. The newer macrolides have improved bioavailability and improved pharmacokinetics such that once- or twice-daily dosing regimens can be used. Finally, a comparison of the costs of macrolides to quinolones and beta-lactam agents (especially cephalosporins) show that the oral macrolides are among the least expensive antibiotics that can be prescribed for pneumonia. Thus, macrolides seem to be the ideal empiric antibiotic for community-acquired pneumonia based on spectrum of activity, safety, and cost.