Context

Current US guidelines for regular hospital unit treatment of community-acquired pneumonia recommend a 5–7 day course of therapy with either a macrolide plus a second or third generation cephalosporin, or a respiratory fluoroquinolone.1 The primary guidance offered for choosing between these alternatives is to avoid antibiotics with patient exposure in the past 3 months. In this context, azithromycin has come under increased scrutiny. Studies have reported that active users of azithromycin have a greater risk of death (particularly cardiovascular death) than comparable users of amoxicillin. However, these studies primarily included patients receiving short courses of therapy for minor infections, such as sinusitus or bronchitis. In contrast, observational studies of patients with community-acquired pneumonia report that macrolide-based therapy is associated with lower 90-day mortality than fluoroquinolone therapy, hypothetically …