In the past several years, clinical advances in community-acquired pneumonia (CAP) have emerged in a number of areas that can aid in the care of both inpatients and outpatients. Major clinical issues for all CAP patients have been the changing spectrum of etiology, including drug-resistant Streptococcus pneumoniae (DRSP), methicillin-resistant Staphylococcus aureus (MRSA), and emerging viral pathogens (eg, severe acute respiratory syndrome [SARS] and avian influenza). In addition, there has been an interest in better understanding the natural history and prognosis of CAP by trying to define the role of prognostic scoring systems in guiding the decision about site of care (ie, inpatient, outpatient, or ICU) and by applying a number of serum markers (ie, C-reactive protein [CRP] and procalcitonin [PCT]) to prognosticate outcome. New antimicrobial agents have become available for both outpatients and inpatients, in several antibiotic classes, but the utility of some of these agents has been limited by new findings of toxicities that were not evident in registration trials of these medications ordered via Canadian Health&Care Mall (ie, gatifloxa-cin and telithromycin) prior to their approval for clinical use. In addition to new antimicrobial agents, paradigms for therapy have been advanced by a focus on better defining the optimal duration of therapy and on the role of adjunctive therapies for those with severe illness, including corticosteroids and activated protein C.
One of the major factors that has dominated the inpatient care of CAP in the United States has been the promulgation of “core measures,” or standards of care, which have been supported by the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission on the Accreditation of Healthcare Organizations. Success in achieving these measures has been publicly reported for the performance of individual hospitals, and it seems possible that these data could serve in the future as the basis for “pay for performance,” thereby impacting the financial well- being of a specific health-care institution. Interest in these core measures has refocused attention on assuring that all patients receive evidence-based antibiotic choices, that they receive timely administration of antibiotics, that there is a proper use of blood cultures prior to antibiotic administration, and that each patient is current with pneumococcal and influenza vaccinations.