What is the recommended treatment for mycoplasma pneumonia in a 7-year-old child weighing 62 pounds?

Treatment of Mycoplasma Pneumonia in a 7-Year-Old Child (62 lbs/28 kg)

Azithromycin is the definitive first-line treatment for mycoplasma pneumonia in this 7-year-old child, dosed at 10 mg/kg (280 mg) on day 1, followed by 5 mg/kg (140 mg) once daily on days 2-5. 1

Specific Dosing for This Patient

For a 28 kg (62 lb) child:

• Day 1: 280 mg azithromycin (10 mg/kg) as a single dose
• Days 2-5: 140 mg azithromycin (5 mg/kg) once daily 1, 2

This can be administered using the 200 mg/5 mL suspension: 7 mL on day 1, then 3.5 mL once daily on days 2-5, for a total treatment course of 21 mL (840 mg total). 2

Outpatient vs. Inpatient Decision

Outpatient management is appropriate if the child:

• Has oxygen saturation >92% on room air
• Can tolerate oral medications and maintain hydration
• Has no severe respiratory distress
• Has reliable follow-up available 3, 4

Hospitalization is indicated if:

• Oxygen saturation ≤92% on room air
• Severe respiratory distress or work of breathing
• Unable to maintain oral intake
• Toxic appearance or altered mental status 3, 4

Treatment Algorithm

For Outpatient Management (Mild-Moderate Disease)

Start oral azithromycin immediately at the doses specified above. 1

Alternative macrolides if azithromycin unavailable:

• Clarithromycin 15 mg/kg/day divided into 2 doses (210 mg twice daily) for 7-14 days, maximum 1 g/day 1
• Erythromycin 40 mg/kg/day divided into 4 doses (280 mg four times daily) for 7-14 days 1

For children ≥7 years with macrolide allergy or treatment failure:

• Doxycycline 2-4 mg/kg/day divided into 2 doses (56-112 mg twice daily) 1

For Inpatient Management (Severe Disease)

Start IV azithromycin 10 mg/kg (280 mg) on days 1 and 2, then transition to oral therapy at 5 mg/kg/day once daily on days 2-5. 1

Alternative IV therapy:

• Erythromycin lactobionate 20 mg/kg/day IV every 6 hours (140 mg every 6 hours) 1
• Levofloxacin 16-20 mg/kg/day IV every 12 hours (maximum 750 mg/day) for children who have reached growth maturity 1

Reassessment Timeline

Evaluate clinical response at 48-72 hours after starting treatment. 3, 4

Signs of treatment success:

• Defervescence (fever resolution typically within 2-4 days with atypical pathogens)
• Improved respiratory symptoms
• Decreased work of breathing 3, 5

Signs of treatment failure requiring intervention:

• Persistent or worsening fever beyond 72 hours
• Worsening respiratory distress
• Development of complications (pleural effusion, necrotizing pneumonia)
• Clinical deterioration 3, 4, 6

Management of Treatment Failure

If no improvement or deterioration at 48-72 hours:

1. Consider macrolide resistance (prevalence 0-15% in North America/Europe, up to 90% in Asia) 7, 8, 6

2. Switch to alternative antibiotic:

   • Doxycycline 2-4 mg/kg/day divided into 2 doses (56-112 mg twice daily) for 7-14 days 1, 6
   • Levofloxacin 8-10 mg/kg/day once daily (maximum 750 mg/day) for children 5-16 years for 7-14 days 1

3. Obtain chest imaging to evaluate for complications (parapneumonic effusion, necrotizing changes) 1, 4

4. Consider hospitalization if outpatient, or escalate care if already hospitalized 3, 4

Critical Pitfalls to Avoid

Do not use amoxicillin or other beta-lactams for mycoplasma pneumonia - M. pneumoniae lacks a cell wall and is intrinsically resistant to all beta-lactams. 7

Do not underdose azithromycin - the full 10 mg/kg loading dose on day 1 is essential for adequate tissue penetration. 1, 2

Do not delay alternative antibiotics beyond 72 hours if fever persists or clinical deterioration occurs, as macrolide resistance may be present. 8, 6

Exercise caution with fluoroquinolones and tetracyclines - while doxycycline is approved for children ≥7 years and fluoroquinolones for those with skeletal maturity, weigh risks versus benefits carefully, particularly regarding dental staining (tetracyclines) and tendon/cartilage effects (fluoroquinolones). 1, 7

Supportive Care Measures

Maintain oxygen saturation >92% with supplemental oxygen if needed. 3

Ensure adequate hydration through oral intake or IV fluids if necessary. 3

Use antipyretics (acetaminophen or ibuprofen) for fever control and comfort. 3

Do not perform chest physiotherapy - it provides no benefit in pneumonia. 3

Special Considerations for Macrolide Resistance

Macrolide-resistant M. pneumoniae does not increase disease severity but prolongs fever duration and extends time to clinical improvement. 8, 6

Children infected with resistant strains experience:

• Persistent fever despite macrolide therapy
• Minimal decrease in M. pneumoniae DNA load
• Extended duration of symptoms 8, 6

Clinical benefit of alternative antibiotics (tetracyclines, fluoroquinolones) includes shortened fever duration and rapid defervescence in macrolide-resistant cases. 8, 6

Duration of Therapy

Standard azithromycin course is 5 days (10 mg/kg day 1, then 5 mg/kg days 2-5), which has been well-studied and is effective for most cases. 1, 2, 5

Alternative antibiotics require 7-14 days of therapy (clarithromycin, erythromycin, doxycycline, levofloxacin). 1, 7