New modalities in treating pneumococcal pneumonia

Despite the availability of effective antibiotics and intensive medical care, pneumococcal pneumonia is still associated with substantial mortality. Early diagnosis is becoming increasingly possible. This article reviews several adjunctive measures that might be instituted at or soon after admission in patients who are hospitalized for community-acquired pneumonia that is found to be due to Streptococcus pneumoniae. Available data favor the use of a macrolide together with a β-lactam antibiotic for treatment, based largely on immunomodulatory activity of macrolides. Two large subgroup analyses from a single major study suggest that activated protein C (eg, drotrecogin) should be considered for patients with severe sepsis, organ failure, and an Acute Physiology and Chronic Health Evaluation II score > 25 due to pneumococcal pneumonia. Statins exert an anti-inflammatory effect and several retrospective studies suggest that their use might ameliorate the adverse effects of pneumonia. Because inflammation elsewhere in the body is associated with inflammation in coronary arteries and because pneumococcal pneumonia has been shown to precipitate myocardial infarction, statins might be of further benefit by decreasing the likelihood of associated myocardial infarction. Aspirin, which inhibits platelet aggregation in inflamed coronary arteries, might also be considered for initial therapy. One reason that the association between myocardial infarction and pneumonia was not previously recognized is that aspirin was widely used in the past when people had acute febrile conditions. The literature on the benefits of corticosteroids in pneumonia is not convincing, and a particularly well-done, very recent study shows no benefit with corticosteroid use in patients with pneumococcal pneumonia, and perhaps even a worse outcome. No clinical data favor the use of platelet-activating factor antagonists.