Community-Acquired Pneumonia: The U.S. Perspective

Community-acquired pneumonia (CAP) is a common and serious problem in the United States, and the sixth leading cause of death in those over age 65. Not only has short-term mortality been evaluated, but 1-year mortality may be as high as 40% in Medicare patients who have been admitted to the hospital with CAP. In the United States, guidelines for CAP management have been available since 1993, with the most recent version published in 2007 as a joint effort of the Infectious Diseases Society of America and the American Thoracic Society. The current U.S. guidelines take into consideration unique bacteriologic patterns in the United States, particularly focusing on the role of drug-resistant pneumococcus, atypical pathogens, and methicillin-resistant Staphylococcus aureus, which explains why U.S. recommendations for therapy differ from those in Europe and the United Kingdom. Notable differences in the U.S. approach to CAP compared with elsewhere include not only a unique set of bacteriologic considerations and therapy recommendations that follow these concerns but also a different approach to assessing severity of illness and recommended diagnostic testing, as well as the inclusion of performance measures to optimize disease management. Compared with European and British guidelines, the U.S. therapy of CAP has a greater emphasis on the role of atypical pathogens, a more defined role for fluoroquinolones as first-line therapy, less reliance on oral therapy for hospitalized patients, and less regard for the value of certain beta-lactam agents.