What antibiotics are used to treat Mycoplasma pneumonia?

Antibiotic Treatment for Mycoplasma pneumoniae Pneumonia

Macrolide antibiotics are the first-line treatment for Mycoplasma pneumoniae infections, with azithromycin 500 mg daily for 5 days or clarithromycin for 7-14 days as the preferred regimens. 1

First-Line Treatment: Macrolides

Macrolides remain the standard of care due to their excellent activity against M. pneumoniae, favorable safety profile, and lack of contraindications in children. 1, 2

Specific Regimens:

• Azithromycin: 500 mg orally once daily for 5 days 1
• Clarithromycin: 500 mg orally twice daily for 7-14 days 1
• Erythromycin: Less commonly used due to significant gastrointestinal intolerance 1

Important Clinical Consideration:

• Do not assume treatment failure at 48 hours when using macrolides—fever resolution characteristically takes 2-4 days with M. pneumoniae, unlike the <24 hours typical for pneumococcal pneumonia. 1
• Reassessment is warranted only if no improvement after 48-72 hours of therapy 1

Alternative Treatment Options (For Macrolide Resistance or Treatment Failure)

Macrolide resistance has emerged globally, with prevalence ranging from 0-15% in Europe/USA, approximately 30% in Israel, and up to 90-100% in Asia. 2, 3

Tetracyclines (Age ≥8 years):

• Doxycycline: 100 mg orally twice daily for 7-14 days 1
• Minocycline: 200 mg loading dose, then 100 mg orally/IV twice daily for 7-14 days 1
• Minocycline demonstrated superior clinical efficacy compared to macrolides for macrolide-resistant M. pneumoniae, with mean fever duration of only 1.0 day versus 4.6-5.5 days with azithromycin/clarithromycin. 4

Fluoroquinolones (Adults only):

• Levofloxacin: 750 mg orally/IV daily for 7-14 days 1, 5
• Moxifloxacin: 400 mg orally/IV daily for 7-14 days 1, 6
• Clinical success rate for moxifloxacin against M. pneumoniae is 96% (73/76 patients). 6

Critical Age-Related Contraindications:

• Tetracyclines are contraindicated in children <8 years old 2
• Fluoroquinolones are contraindicated in all children 2

When to Switch from Macrolides

Consider alternative antibiotics if:

• Patient remains febrile or shows clinical deterioration after 48-72 hours of macrolide therapy 1
• Known macrolide resistance in the community (>10-15% prevalence) 2, 3
• No improvement after 5 days of appropriate macrolide therapy 1

Special Populations

Children Under 5 Years:

• If pathogen is unknown, start with amoxicillin as S. pneumoniae is more common in this age group 1
• Switch to macrolides only if M. pneumoniae is specifically suspected based on clinical presentation 1

Children 5 Years and Older:

• Macrolides are first-line empirical treatment as M. pneumoniae is more prevalent in this age group 1

Severe Cases Requiring Hospitalization:

• Consider combination therapy with a β-lactam plus a macrolide for broader coverage 1
• Intravenous antibiotics should be used for patients unable to take oral medications 1

Treatment Duration

Complete antibiotic course is essential:

• Macrolides: Minimum 5 days (azithromycin) to 14 days (clarithromycin) 1
• Atypical pneumonia caused by M. pneumoniae requires minimum 14 days with macrolides, unlike pneumococcal pneumonia which requires only 10 days 1
• Tetracyclines or fluoroquinolones: 7-14 days 1

Common Pitfalls to Avoid

• Do not discontinue macrolides prematurely at 48 hours due to persistent fever—this is expected with M. pneumoniae 1
• Do not use fluoroquinolones in children or tetracyclines in children <8 years, even for macrolide-resistant cases—hospitalization and IV therapy may be required instead 2
• Do not assume β-lactams will provide any coverage—M. pneumoniae lacks a cell wall and is intrinsically resistant to all β-lactams 2, 7