Adjunctive therapy in community-acquired pneumonia.

Despite potent antibiotics, community-acquired pneumonia (CAP) remains the most common cause of death from infection and the seventh overall leading cause of death in the United States. For this reason, interest has been redirected into non-antibiotic therapeutic measures. Despite theoretical benefits, the existing literature does not suggest a clear benefit for corticosteroid treatment, but large prospective randomized trials are needed. Nonsteroidal antiinflammatory drugs may benefit oxygenation but have no documented effect on mortality. Activation of the coagulation system appears to be a major pathophysiological event in severe pneumonia, possibly even more so than for sepsis in general. The CAP subgroup in phase III sepsis trials of both drotrecogin alfa (activated) and tifacogin (recombinant tissue factor pathway inhibitor) demonstrated the greatest benefit. The immunomodulatory effects of macrolide antibiotics may play a significant role in management of severe CAP. Exogenous surfactant replacement is being explored as adjunctive therapy for acute lung injury due to CAP. Statin use before CAP diagnosis is associated with improved outcome but requires further research to determine if initiation at the time of diagnosis will affect outcome. Other therapies have theoretical benefit but are not yet in the stage of clinical trials.