What is the treatment for mycoplasma pneumonia?

Treatment of Mycoplasma Pneumonia

Macrolide antibiotics are the recommended first-line treatment for Mycoplasma pneumoniae infections in both children and adults, with azithromycin preferred due to superior tolerability and a 5-day course being sufficient. 1, 2

First-Line Antibiotic Selection

Macrolides (Preferred)

Azithromycin is the macrolide of choice because it offers better gastrointestinal tolerance, fewer drug interactions, and requires only 5 days of therapy compared to other macrolides 1, 2:

• Azithromycin: 500 mg on day 1, then 250 mg daily for days 2-5 (total 1.5 g over 5 days) 1, 2
• Clarithromycin: 500 mg twice daily for 7-14 days (alternative macrolide) 1, 3
• Erythromycin: Less commonly used due to significant gastrointestinal intolerance 1, 3

Age-Specific Considerations

• Children under 5 years: Start with amoxicillin as first-line empiric therapy, since Streptococcus pneumoniae is more common than M. pneumoniae 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 prevalence increases significantly in this age group 1

Second-Line Treatment Options

When to Switch from Macrolides

Consider alternative antibiotics if 1, 3:

• Patient remains febrile after 48-72 hours of macrolide therapy
• Clinical deterioration occurs
• Macrolide resistance is suspected (particularly relevant in East Asia where resistance rates exceed 90%) 4

Alternative Antibiotics

Tetracyclines (for patients ≥8 years old) 1, 2, 5:

• Doxycycline: 100 mg orally twice daily for 7-14 days 1, 2
• Minocycline: 200 mg loading dose, then 100 mg twice daily for 7-14 days 1

Fluoroquinolones (adults only) 1, 2:

• Levofloxacin: 750 mg daily for 7-14 days 1
• Moxifloxacin: 400 mg daily for 7-14 days 1

Treatment Duration

The duration differs significantly from typical bacterial pneumonia 6, 1:

• Standard M. pneumoniae treatment: 10-14 days minimum 6, 1
• Azithromycin: 5 days is sufficient due to prolonged tissue half-life 1, 2
• Other macrolides and alternatives: 7-14 days 6, 1
• Immunocompromised patients: May require 14 days or longer 6

This is notably longer than the 7-10 days typically used for pneumococcal pneumonia 6.

Monitoring and Expected Clinical Response

Timeline for Improvement

Fever resolution in M. pneumoniae characteristically takes 2-4 days, which is significantly longer than the <24 hours typical for pneumococcal pneumonia 1, 3. This is a critical distinction to avoid premature treatment changes.

When to Reassess

• 48 hours: Review patients treated as outpatients if deteriorating or not improving 1, 3
• 48-72 hours: If no improvement on macrolides, consider alternative diagnosis, complications, or macrolide resistance 1, 3
• 5 days: Consider hospitalization if no improvement after appropriate therapy or if condition worsens 1, 3

Do not assume treatment failure at 48 hours when using macrolides—the characteristically slower fever resolution in M. pneumoniae (2-4 days) should be anticipated 1.

Severe Cases Requiring Hospitalization

For patients with severe disease unable to take oral medications 1:

• Consider intravenous antibiotics initially
• Combination therapy: β-lactam plus a macrolide for severe cases 1, 3
• Switch to oral therapy once clinical stability is achieved (typically by day 3) 6

Refractory Cases

For refractory M. pneumoniae pneumonia with excessive immune response despite appropriate antibiotics 4:

• Corticosteroids: Intravenous methylprednisolone may be beneficial 4
• IVIG: Consider in combination with antimicrobials for severe refractory cases 4

Critical Pitfalls to Avoid

1. Do not change antibiotics within 72 hours unless marked clinical deterioration or bacteriologic data necessitate it 6
2. Do not expect rapid defervescence as with pneumococcal pneumonia—M. pneumoniae fever typically persists 2-4 days despite appropriate therapy 1, 3
3. Do not use single-dose azithromycin 1 g for suspected M. pneumoniae—the 5-day extended regimen is required 2
4. Do not use fluoroquinolones in children due to cartilage toxicity concerns 1
5. Do not use tetracyclines in children under 8 years due to dental staining 1, 5

Special Warnings

Azithromycin-Specific Concerns 7

• QT prolongation: Risk of torsades de pointes, particularly in elderly patients, those with electrolyte abnormalities, or on other QT-prolonging drugs 7
• Hepatotoxicity: Discontinue immediately if signs of hepatitis occur 7
• Hypersensitivity: Rare but potentially fatal reactions including Stevens-Johnson syndrome 7

Doxycycline-Specific Concerns 5

• Photosensitivity: Advise sun protection
• Pregnancy: Category D—avoid in pregnant women 5
• Dental staining: Contraindicated in children <8 years 5

Radiographic Considerations

Radiographic clearing lags significantly behind clinical improvement 6:

• M. pneumoniae may clear radiographically more rapidly than pneumococcal infection 6
• Initial radiographic worsening after starting therapy is common and has no significance if clinical response is good 6
• In severe pneumonia, radiographic deterioration is a poor prognostic feature highly predictive of mortality 6