What is the recommended treatment for Mycoplasma infections?

Treatment of Mycoplasma Infections

For Mycoplasma pneumoniae infections, doxycycline is the preferred first-line treatment for adults, while macrolides (particularly azithromycin) are recommended for children under 8 years of age. 1

First-Line Treatment Options

Adults and Adolescents (≥8 years)

• Doxycycline: 100 mg PO twice daily for 7-14 days 1, 2
• Alternative options:
  • Azithromycin: 500 mg PO on day 1, then 250 mg PO daily for 4 days 1
  • Levofloxacin: 750 mg PO/IV once daily for 7-14 days 1, 3
  • Moxifloxacin: 400 mg PO/IV once daily for 7-14 days 1

Children (<8 years)

• Azithromycin: 10 mg/kg on day 1 (maximum 500 mg), then 5 mg/kg on days 2-5 (maximum 250 mg) 4
• Alternative options (if macrolide resistance is suspected):
  • For children ≥8 years: Doxycycline 4 mg/kg/day in 2 divided doses (maximum 200 mg/day) 4

Treatment Considerations

Mycoplasma pneumoniae

1. Initial assessment:

   • Clinical presentation typically includes persistent cough, low-grade fever, and characteristic radiographic findings
   • Consider local resistance patterns when selecting therapy

2. Duration of treatment:

   • Doxycycline: 7-14 days 1
   • Macrolides: 5 days for azithromycin, 10-14 days for other macrolides 1, 4

3. Monitoring response:

   • Assess clinical response after 48-72 hours 1, 4
   • If no improvement after 48 hours on macrolides, consider resistance and switch to alternative therapy 1

Other Mycoplasma Species

Mycoplasma genitalium

• Azithromycin extended regimen (500 mg on day 1, then 250 mg daily for 4 days) is more effective than single 1g dose 5
• For macrolide-resistant strains: Moxifloxacin 400 mg daily for 7-14 days 6

Special Considerations

Macrolide Resistance

• Macrolide resistance in M. pneumoniae has been increasing globally, with rates of:
  • 0-15% in Europe and USA
  • Approximately 30% in Israel
  • Up to 90-100% in parts of Asia 7
• Resistance is associated with point mutations in the 23S rRNA 7, 8
• Clinical implications of resistance include longer duration of fever, cough, and hospital stay 7

Severe Infections

• For hospitalized patients with severe infections:
  • Consider IV macrolides or combination therapy 4
  • For adults, IV regimens may include levofloxacin 750 mg daily or combination therapy 1

Common Pitfalls to Avoid

1. Inappropriate antibiotic selection: Mycoplasmas lack a cell wall and are intrinsically resistant to beta-lactams (penicillins, cephalosporins) and all other cell wall-targeting antibiotics 7, 9

2. Inadequate treatment duration: Premature discontinuation can lead to treatment failure and potential relapse

3. Failure to consider resistance: In areas with high macrolide resistance rates, empiric therapy with doxycycline (for those ≥8 years) or fluoroquinolones (for adults) may be more appropriate 7

4. Not reassessing after 48-72 hours: Clinical improvement should be evident within this timeframe; if not, consider alternative diagnosis or antibiotic resistance 1, 4

By following these evidence-based recommendations and considering local resistance patterns, clinicians can effectively manage Mycoplasma infections while minimizing the risk of treatment failure and antimicrobial resistance.