Benefits and risks of therapeutic alternatives for macrolide resistant Mycoplasma pneumoniae pneumonia in children

Effect of bronchofiberscopic lavage with acetylcysteine instillation on refractory mycoplasma pneumoniae pneumonia in children: a retrospective clinical observation

BACKGROUND

Bronchofiberscopic lavage is a therapeutic treatment for mycoplasma infection. However, there are limited reports on the use of bronchofiberscopic lavage with acetylcysteine instillation. The aim of our study was to investigate the clinical effect of bronchofiberscopic lavage with acetylcysteine instillation on refractory mycoplasma pneumoniae pneumonia in children.

METHODS

This was a retrospective study. Clinical and laboratory data were collected from 280 children hospitalized with MPP in the Department of Pulmonary and Critical Care Medicine at Kunming Children's Hospital from January 2021 to January 2023, and these were divided into two groups: the study group and the control group. Children in the control group were treated with anti-infective, antitussive, and antipyretic routine symptomatic treatment and nebulization of acetylcysteine suspension, while children in the study group were treated with bronchofiberscopic lavage with acetylcysteine instillation along with standard treatment as in the control group. The clinical characteristics, adverse reactions, pulmonary imaging changes, and laboratory examination indicators were compared between the two groups.

RESULTS

The treatment effective rate and the absorption area of lung lesions in the study group were significantly higher than those in the control group (P < 0.05). Before treatment, there were no statistically significant differences in WBC, IgG, IgE, CRP, and IL-6 levels between the two groups (P > 0.05). After 7 days of treatment, IgG levels in both groups were higher than those before treatment, while WBC, IgE, CRP, and IL-6 levels were lower than those before treatment (P < 0.05).

CONCLUSIONS

The bronchofiberscopic lavage with acetylcysteine instillation constitutes a safe and efficacious therapeutic regimen, which might alleviate the clinical symptoms experienced and reduce the levels of inflammatory factors for children with RMPP.

Mycoplasma pneumoniae pneumonia in children

Mycoplasma pneumoniae (M. pneumoniae) is a common pathogen that causes community-acquired pneumonia in children. The clinical presentation of this pathogen can range from mild self-limiting illness to severe and refractory cases. Complications may occur, such as necrotizing pneumonia and respiratory failure. Extrapulmonary complications, including encephalitis, myocarditis, nephritis, hepatitis, or even multiple organ failure, can also arise. In this editorial, we discuss the clinical implications of the significant findings from the article "Serum inflammatory markers in children with M. pneumoniae pneumonia and their predictive value for mycoplasma severity" published by Wang et al. They reported that measuring lactic dehydrogenase, interleukin-6 levels, and D-dimer effectively predicts refractory M. pneumoniae pneumonia cases.

Effect of Early Oral Administration of Doxycycline on Macrolide Resistance in Children with Mycoplasma Pneumoniae Pneumonia: A Retrospective Study

Aims/Background Mycoplasma pneumoniae pneumonia (MPP) is typically a benign and self-limiting disease. This study aimed to investigate the effect of early oral administration of doxycycline on macrolide resistance in children with MPP. Methods This study retrospectively analyzed the clinical data of 173 MPP children treated with macrolides at the Second Affiliated Hospital of Mudanjiang Medical University from March 2020 to March 2023. Nine cases that did not meet the inclusion criteria were excluded, leaving 164 children. They were divided into Group A (early oral administration of doxycycline + macrolide treatment) (n = 85) and Group B (macrolide treatment alone) (n = 79) based on whether early oral administration of doxycycline was given. Drug sensitivity results and adverse reactions after treatment were statistically analyzed. Based on the drug sensitivity results, the MPP children were classified as having either macrolide-resistant mycoplasma pneumoniae (MRMP) or macrolide-sensitive mycoplasma pneumoniae (MSMP) infections. A stratified analysis was performed to compare the disappearance time of fever, disappearance time of shortness of breath, disappearance time of rales, and symptom improvement time on chest X-ray examination, and to further explore the clinical efficacy of early oral administration of doxycycline in different groups of children. Results No significant differences were found in baseline data such as age, sex, and weight between the two groups (p > 0.05). A total of 112 out of 164 children developed macrolide resistance (68.29%), with 47 cases in Group A and 65 cases in Group B, indicating a significant difference between the two groups (p < 0.05). The two groups showed a significant difference in macrolide sensitivity levels after treatment (p < 0.05), with no significant difference in the incidence of adverse reactions (p > 0.05). After treatment, the time to the disappearance of febrile fever, time to disappearance time of fever, disappearance time of shortness of breath, disappearance time of rales, symptom improvement time on chest X-ray examination, and time to administration of macrolides after treatment were shorter in children with MRMP in group A than in children with MRMP in group B (p < 0.05). In contrast, MSMP children in both groups exhibited no significant differences in symptom disappearance time and duration of macrolides treatment (p > 0.05). Conclusion Early oral administration of doxycycline is a safe and effective treatment for MPP. It helps relieve symptoms in MRMP children, shortens the duration of macrolide use, and reduces the incidence of macrolide resistance.

Epidemiological characteristics of severe community-acquired pneumonia in children admitted to two tertiary hospitals in Shihezi, Xinjiang Region, China in 2023: a cross-sectional analysis

Background

Severe community-acquired pneumonia (SCAP) in children is associated with high morbidity and mortality, and the data of epidemiological characteristics of SCAP in Shihezi area were inadequate. The main pathogens responsible for SCAP may vary dramatically according to the geographical area. We identified two tertiary hospitals with better medical level and the largest number of hospitalized children in Shihezi as sentinel hospitals. The primary purpose of the study is to cross-sectionally summarize the epidemiological characteristics of SCAP in children admitted to hospitals in Shihezi, Xinjiang, China in 2023.

Methods

SCAP was defined as involving the respiratory and other systems, accompanied by significant systemic toxic symptoms. We prospectively included all patients <15 years old who diagnosed with SCAP according to the SCAP diagnostic criteria. We enrolled all patients <15 years who were diagnosed with SCAP during the study period (January to December 2023), a total of 309 cases were included from two sentinel hospitals in Shihezi, Xinjiang, from January to December 2023. Basic information and clinical data were collected on a standardized questionnaire, and respiratory samples were obtained for the detection of 27 respiratory pathogens using a panel, targeted next-generation sequencing (t-NGS), and metagenomic next-generation sequencing (mNGS).

Results

We enrolled 309 patients aged 1-14 years: 157 males (50.8%) and 152 females (49.2%). There were 45 infants (1 month to 1 year, 14.6%), 33 toddlers (>1-3 years, 10.7%), 121 preschool children (>3-7 years, 39.2%), and 110 school-age children (>7-14 years, 35.6%). Overall, the number of SCAP cases in spring was 39 (12.6%), in summer was 44 (14.2%), in autumn was 137 (44.3%), and in winter was 89 (28.8%). A total of 572 pathogens were detected in this study, primarily Mycoplasma pneumoniae (MP) (n=120, 21.0%), respiratory syncytial virus (RSV) (n=82 strains, 14.3%), and Streptococcus pneumoniae (SP) (n=67, 11.7%). MP was prevalent mainly during the cold season of autumn, with its detection starting from July and reaching a peak detection rate in November. By studying the interaction among 22 common respiratory pathogens, we found a strong negative correlation between MP and SP, yet the highest number of co-infected cases involved MP and SP. Seventy-six (63.3% of all MP) SCAP were identified as macrolide-resistant (all with mutations at the A2063G site). MP SCAP was associated with prolonged illness duration and fever spikes. We observed incidence of pediatric SCAP showed an inverse trend with PM2.5 level changes.

Conclusions

The most common pathogens responsible for SCAP in the Shihezi region in 2023 were MP, RSV, and SP. MP was the primary cause of SCAP in children, and increased risk of co-infections, and high prevalence of macrolides resistance-all related to mutations at the A2063G site. Early identification of SCAP pathogen epidemiological characteristics can reduce severe case occurrence.

The Clinical Significance of Pathogen Loads and Macrolide Resistance Levels for Macrolide-Resistant Mycoplasma pneumoniae Pneumonia in Children

OBJECTIVE

Mycoplasma pneumoniae (M. pneumoniae) pneumonia presses a serious threat on children's health. This study was aimed to investigate the clinical significance of pathogen loads and macrolide resistance levels for macrolide-resistant M. pneumoniae (MRMP)-induced pneumonia in children.

METHODS

Serum levels of inflammatory markers including lactic dehydrogenase (LDH), D-dimer, C-reactive protein (CRP) were tested. RT‒PCR was used for the detection of M. pneumoniae infection and the macrolide resistance levels. The patients were classified into high pathogen load and low pathogen load groups based on the Ct values of the p1 gene, and high macrolide resistance level and low macrolide resistance level groups based on the relative levels of macrolide resistance associated mutations to that of the p1 gene. The rates of alternative antibiotic use and hospitalization days were recorded, and the leukocyte counts were tested.

RESULTS

The rates of elevated inflammatory markers from high to low were LDH, CRP and D-dimer. The Ct values of the p1 gene ranged from 19 to 35, and patients with higher pathogen loads had greater rates of alternative antibiotic use; higher levels of LDH, D-dimer, CRP and neutrophil counts (NEUT); and longer hospitalization durations. The range of the macrolide resistance levels was 0.31-2.11, and the rates of alternative antibiotic use, NEUT, CRP and D-dimer levels were higher in patients with higher macrolide resistance levels.

CONCLUSION

LDH was a more frequently elevated serum inflammatory marker than D-dimer and CRP, and the pathogen load and macrolide resistance levels possessed important clinical significance for MRMP-induced pneumonia in children.

Association of serum interleukin-17 level and Mycoplasma pneumoniae pneumonia in children: a systematic review and meta-analysis

Background

Mycoplasma pneumoniae (M. pneumoniae) is a common pathogen of community-acquired pneumonia. Interleukin-17 (IL-17) plays a role in host defense and contributes to disease severity in infection. This present study aims to investigate the association between Mycoplasma pneumoniae pneumonia (MPP) and changes of IL-17 level in the serum of pediatric patients.

Methods

The protocol has been registered in PROSPERO (CRD42023489451). A literature search was conducted in PubMed, EMBASE, Scopus, and Web of Science from inception to October 2023. A meta-analysis was performed to pool the mean difference (MD) with 95% confidence intervals (CIs) of IL-17 levels between patients and controls. Publication bias was assessed, and the risk of bias was evaluated using the Newcastle-Ottawa Scale (NOS).

Results

Out of 207 records, 10 studies were included in the review and 9 studies were included in the meta-analysis. Of these, 7 studies compared IL-17 in general MPP patients with controls, 6 studies compared severe MPP patients with mild MPP patients. Serum IL-17 levels were significantly elevated in general MPP patients compared with control (MD =33.94 pg/mL, 95% CI: 24.66, 43.22 pg/mL, P=0.01, I2=99.07%; P=0.01). Subgroup analyses showed a difference in serum IL-17 levels treated by macrolide between patients and control (MD =83.96 pg/mL, 95% CI: 76.62, 91.29 pg/mL, P=0.01). In severe and mild MPP, the IL-17 levels were significantly increased (MD =19.08 pg/mL, 95% CI: 11.51, 26.65 pg/mL, P=0.01) and heterogeneity was appeared (I2=99.39%; P=0.01). For the risks of bias, two studies had a "high risk" in comparability domain, and the 7 studies were classified as "low risk" and "unclear risk".

Conclusions

Our meta-analysis revealed that serum IL-17 levels are significantly elevated in pediatric with general and severe MPP. IL-17 might be a potential biomarker or therapeutic target for pneumonia caused by M. pneumoniae.

Expert consensus on the diagnosis and treatment of macrolide-resistant Mycoplasma pneumoniae pneumonia in children

BACKGROUND

Mycoplasma pneumoniae (M. pneumoniae) is a significant contributor to community-acquired pneumonia among children. Since 1968, when a strain of M. pneumoniae resistant to macrolide antibiotics was initially reported in Japan, macrolide-resistant M. pneumoniae (MRMP) has been documented in many countries worldwide, with varying incidence rates. MRMP infections lead to a poor response to macrolide antibiotics, frequently resulting in prolonged fever, extended antibiotic treatment, increased hospitalization, intensive care unit admissions, and a significantly higher proportion of patients receiving glucocorticoids or second-line antibiotics. Since 2000, the global incidence of MRMP has gradually increased, especially in East Asia, which has posed a serious challenge to the treatment of M. pneumoniae infections in children and attracted widespread attention from pediatricians. However, there is still no global consensus on the diagnosis and treatment of MRMP in children.

METHODS

We organized 29 Chinese experts majoring in pediatric pulmonology and epidemiology to write the world's first consensus on the diagnosis and treatment of pediatric MRMP pneumonia, based on evidence collection. The evidence searches and reviews were conducted using electronic databases, including PubMed, Embase, Web of Science, CNKI, Medline, and the Cochrane Library. We used variations in terms for "macrolide-resistant", "Mycoplasma pneumoniae", "MP", "M. pneumoniae", "pneumonia", "MRMP", "lower respiratory tract infection", "Mycoplasma pneumoniae infection", "children", and "pediatric".

RESULTS

Epidemiology, pathogenesis, clinical manifestations, early identification, laboratory examination, principles of antibiotic use, application of glucocorticoids and intravenous immunoglobulin, and precautions for bronchoscopy are highlighted. Early and rapid identification of gene mutations associated with MRMP is now available by polymerase chain reaction and fluorescent probe techniques in respiratory specimens. Although the resistance rate to macrolide remains high, it is fortunate that M. pneumoniae still maintains good in vitro sensitivity to second-line antibiotics such as tetracyclines and quinolones, making them an effective treatment option for patients with initial treatment failure caused by macrolide antibiotics.

CONCLUSIONS

This consensus, based on international and national scientific evidence, provides scientific guidance for the diagnosis and treatment of MRMP in children. Further studies on tetracycline and quinolone drugs in children are urgently needed to evaluate their effects on the growth and development. Additionally, developing an antibiotic rotation treatment strategy is necessary to reduce the prevalence of MRMP strains.

Cytokines and refractory mycoplasma pneumoniae pneumonia in children: a systematic review

INTRODUCTION

The relationship between cytokines and refractory mycoplasma pneumoniae pneumonia (RMPP) in children was conflicting. The aim of the current study was to perform a systematic review to determine the relationship between cytokines and RMPP in children.

EVIDENCE ACQUISITION

We searched PubMed, and the search was done on 21 November 2022. This search was limited to human studies, with language restriction of English. Studies were included if they reported the relationship between cytokines and RMPP.

EVIDENCE SYNTHESIS

A total of 22 relevant full articles were included in the review. TNF-α levels in the bronchoalveolar lavage fluid (BALF) and IL-18 levels in the blood samples were likely to be associated with RMPP. IL-2 and IL-4 lost significance regardless in the BALF or blood samples. Additionally, there was no significant difference in IFN-γ levels between RMPP patients and non-refractory mycoplasma pneumoniae pneumonia (NRMPP) patients in the BALF. Patients receiving different treatments had different levels of cytokines.

CONCLUSIONS

This analysis offers evidence linking abnormalities of cytokines with RMPP in children, which may be essential for identifying individuals with RMPP. Large prospective studies are needed for further clarification of roles of cytokines in RMPP.

Construction of a Nomogram for Identifying Refractory Mycoplasma pneumoniae Pneumonia Among Macrolide-Unresponsive Mycoplasma pneumoniae Pneumonia in Children

OBJECTIVE

The individualized prediction of treatment regimens of macrolide-unresponsive Mycoplasma pneumoniae pneumonia (MUMPP) is scarce. The aim of this study was, therefore, to evaluate the relevant data of patients and construct a nomogram for identifying refractory Mycoplasma pneumoniae pneumonia (RMPP) among children continued to be treated with macrolide after the confirmation of MUMPP, providing a reference for the choice of treatment regimen.

METHODS

We performed a retrospective study involving 162 children who continued to be treated with macrolide (azithromycin) after the confirmation of MUMPP without antibiotic changes between January 2020 and January 2022. We collected data on clinical feature, hospitalization period, treatments, laboratory data, extrapulmonary symptoms, parapneumonic effusion, and connections with other respiratory pathogens. In addition, the independent risk factors for RMPP were determined through univariate and multivariate analyses, and then a nomogram was constructed and validated.

RESULTS

In this study, the multivariate logistic regression analysis showed that age, leukocyte count, neutrophil proportion, serum procalcitonin, and lactate dehydrogenase were independent risk factors for RMPP. Using the five independent associated factors, the nomogram for identification of RMPP was constructed. Moreover, the area under the ROC curve (AUC) was 0.925 (95% CI: 0.882-0.968) for the nomogram showing excellent discrimination. The calibration curve, close to the 45-degree line, exhibited good calibration of nomogram.

CONCLUSION

We constructed and validated a visual and user-friendly nomogram for individualized prediction of RMPP risk in children who continued to be treated with macrolide after the confirmation of MUMPP based on five variables. According to the nomogram model, continuation of macrolide should be considered rather than second-line antibiotics including tetracyclines (doxycycline or minocycline) and fluoroquinolones for MUMPP children with low predictive values.

Mycoplasmas as Host Pantropic and Specific Pathogens: Clinical Implications, Gene Transfer, Virulence Factors, and Future Perspectives

Mycoplasmas as economically important and pantropic pathogens can cause similar clinical diseases in different hosts by eluding host defense and establishing their niches despite their limited metabolic capacities. Besides, enormous undiscovered virulence has a fundamental role in the pathogenesis of pathogenic mycoplasmas. On the other hand, they are host-specific pathogens with some highly pathogenic members that can colonize a vast number of habitats. Reshuffling mycoplasmas genetic information and evolving rapidly is a way to avoid their host's immune system. However, currently, only a few control measures exist against some mycoplasmosis which are far from satisfaction. This review aimed to provide an updated insight into the state of mycoplasmas as pathogens by summarizing and analyzing the comprehensive progress, current challenge, and future perspectives of mycoplasmas. It covers clinical implications of mycoplasmas in humans and domestic and wild animals, virulence-related factors, the process of gene transfer and its crucial prospects, the current application and future perspectives of nanotechnology for diagnosing and curing mycoplasmosis, Mycoplasma vaccination, and protective immunity. Several questions remain unanswered and are recommended to pay close attention to. The findings would be helpful to develop new strategies for basic and applied research on mycoplasmas and facilitate the control of mycoplasmosis for humans and various species of animals.

Effects of bronchoalveolar lavage on Mycoplasma Pneumoniae pneumonia: A propensity score matched-cohort study

BACKGROUND

The purpose of this study was to evaluate the efficacy and safety of BAL in treating MPP.

METHODS

From January 2013 to January 2019, 1,689 pediatric patients with MPP were analyzed retrospectively. Patients were subdivided into BAL group and non-BAL group according to whether they received BAL treatment within seven days after admission. The propensity score matching method matched patients' baseline characteristics (1:1). The primary outcomes were hospital stays and the cure rate. Secondary outcomes included mortality, co-infection, repeat hospitalization within 30 days, and total cost of treatment.

RESULTS

After matching, 524 patients (BAL: 262; control: 262) were recorded. The BAL group had significantly shorter hospital stays (OR: 0.5, 95% CI: 0.4-0.7). Meanwhile, BAL did not significantly modify the cost, co-infection rate, and mortality. In subgroup analyses, the group with BAL intervention within three days had a significantly shorter hospital stay (OR: 0.4, 95% CI: 0.3-0.5) compared with the group with BAL intervention three days after admission.

CONCLUSIONS

Early BAL intervention is a better treatment than conventional drug therapy alone, and no significant complications were seen in this study. BAL intervention has an excellent clinical benefit. The earlier the intervention, the better the effect.

Epidemiology and clinical manifestations of children with macrolide-resistant Mycoplasma pneumoniae pneumonia in Southern Taiwan

BACKGROUND

Mycoplasma pneumoniae is a pneumonia-causing pathogen commonly found in pediatric patients in Taiwan. Recently, macrolide-resistant (MR) strains have been emerging globally. The prevalence of pneumonia due to MR-M. pneumoniae (hereafter, MPP) in northern Taiwan before 2017 has been reported to be 12.3-24%. The prevalence of MR-MPP within a specific location can vary. Hence, we investigated the prevalence of MR-MPP in southern Taiwan.

METHODS

Eighty-one children with PCR-confirmed MPP were enrolled between July 2016 and June 2019. They were assigned to macrolide-sensitive (MS) and MR groups based on their PCR results, and their clinical manifestations and laboratory data were compared.

RESULTS

The proportions of patients with MS-MPP and MR-MPP varied with time. The average ratio of the proportion of MR-MPP was 54.3% in this study. Patients with MR-MPP had lower neutrophil counts, higher lymphocyte counts, and higher platelet counts than those with MS-MPP. In contrast with the 40% of the MR-MPP group that still had a fever after three days of azithromycin treatment, only 11.8% of the MS-MPP group still had a fever.

CONCLUSION

Our study provided valuable epidemiological survey information for children with MR-MPP in southern Taiwan. The prevalence of MR-MPP was different from that reported in previous studies in northern Taiwan. Specific MR strains should be considered in children with MPP if they still have a fever after three days of macrolide treatment.

Mycoplasma pneumoniae: Atypical Pathogen in Community Acquired Pneumonia

Mycoplasma pneumoniae is a one of most common reasons of respiratory tract infections in both adolescents and children with severity ranged from moderate to high. Many facts in the previous years regarding infections were induced via this organism having extra pathogenic mechanisms. Clinically, resistance to macrolide has produced internationally and represents a treatment trouble. Antimicrobial sensitivity checking out techniques have been applied, and novel antibiotics which are effective towards M. pneumoniae are present processing development. That evaluate concentrates on the several trends occurring in the previous quite a few years which beautify the grasp of that microorganism, which is one of the smallest pathogenic bacteria; however, is of extreme medical significance.

Rational stepwise approach for Mycoplasma pneumoniae pneumonia in children

Mycoplasma pneumoniae is a common pathogen that causes community-acquired pneumonia. In the past, M. pneumoniae was sensitive to macrolide antibiotics, and M. pneumoniae pneumonia (MPP) was usually a benign and self-limiting disease. However, despite use of the appropriate antibiotics, persistent fever and clinical deterioration may occur, leading to severe disease. Two major complicated conditions that may be clinically encountered are macrolide-resistant MPP and refractory MPP. Regarding the epidemics in Taiwan, before 2017, the mean rate of macrolide resistance was below 30%. Notably, since 2018, the prevalence of macrolide-resistant MPP in Taiwan has increased rapidly. Macrolide-resistant MPP shows persistent fever and/or no radiological regression to macrolide antibiotics and may even progress to severe and complicated pneumonia. Tetracyclines (doxycycline or minocycline) or fluoroquinolones are alternative treatments for macrolide-resistant MPP. Refractory MPP is characterized by an excessive immune response against the pathogen. In this context, corticosteroids have been suggested as an immunomodulator for downregulating the overactive host immune reaction. Overuse of macrolides may contribute to macrolide resistance, and thereafter, an increase in macrolide-resistant MPP. Delayed effective antimicrobial treatment is associated with prolonged and/or more severe disease. Thus, the appropriate prescription of antibiotics, as well as the rapid and accurate diagnosis of MPP, is important. The exact starting point, dose, and duration of the immunomodulator are yet to be established. We discuss these important issues in this review.

Tigecycline in the treatment of fulminant Mycoplasma pneumoniae pneumonia non-responsive to azithromycin and fluoroquinolone: A case report

RATIONALE

Fulminant macrolide-resistant Mycoplasma pneumoniae pneumonia (MPP) has seldom been reported, and cases of MPP usually show rapid improvement after fluoroquinolones or tetracyclines addition. The purpose of this case report is to highlight the importance of proper selection of antibiotics for treatment of severe MPP and increase awareness concerning the emergence of fluoroquinolone-resistant MPP.

PATIENT CONCERNS

A case of severe life-threatening pneumonia in a 26-year-old man with high fever and cough was non-responsive to azithromycin and fluoroquinolones.

DIAGNOSES

The patient was diagnosed with MPP based on the test results of bronchoalveolar lavage using real-time quantitative PCR method.

INTERVENTIONS

Tigecycline was given to the patient after azithromycin and fluoroquinolones failed.

OUTCOMES

The patients fever subsided within the first day of tigecycline therapy. He showed rapid symptom resolution and improvement in lung infiltration after 4 days of tigecycline therapy.

LESSONS

The case suggests that fulminant MPP should be timely treated with proper antibiotics, and the possible emergence of fluoroquinolone-resistant MPP should be of concern.