Approach

Initial antibiotic treatment for any patient with pneumonia/respiratory infection is usually based on the severity of the disease, the presence of comorbidities, and the known prevalence of resistant bacteria in the community.[31] Antibiotic choice may also be guided by relevant local guidelines for pneumonia.

Scoring of the severity of illness can help determine whether the patient can be treated as an outpatient or requires hospitalisation or intensive care, regardless of the pathogen. Severity scores are based on factors, including age, respiratory rate, pulse, blood pressure, and temperature. There are a number of systems that can be used for scoring, for example, the Pneumonia Severity Index (PSI) or the Confusion, Urea nitrogen, Respiratory rate, Blood pressure, age 65 years and older (CURB-65) index.[45][46] [ CURB-65 pneumonia severity score Opens in new window ] [ Community-acquired pneumonia severity index (PSI) for adults Opens in new window ]

This topic covers management of confirmed Mycoplasma pneumoniae infection only. For more information on the general approach to community- or hospital-acquired pneumonia, including severity scoring and empirical treatment, please see Community-acquired pneumonia (non Covid-19) and Hospital-acquired pneumonia.

Antibiotic treatment

A macrolide or tetracycline is usually effective as first-line treatment of mycoplasma infections in both uncomplicated and more severe community-acquired pneumonia. Empirical treatment may be considered necessary to ensure coverage for atypical organisms. If a specific aetiology for the pneumonia is found, antimicrobial therapy can then be directed at that specific pathogen.[31] 

Macrolide-resistant M pneumoniae cases have been reported in the Western Pacific (53.4%), South East Asia (9.8%), the Americas (8.4%), and Europe (5.1%).[15] In countries where macrolide resistance in M pneumoniae is highly prevalent, it seems that tetracyclines (doxycycline or minocycline) are likely to be more effective than macrolides or fluoroquinolones.[47][48]

A fluoroquinolone antibiotic may be considered as second-line treatment if previous antibiotics fail. In severe cases, intravenous antibiotics may be considered appropriate in the hospital setting until clinical improvement, or until the patient can take oral medications.

Fluoroquinolones may also be appropriate for patients with pneumonia and comorbidities such as diabetes, alcohol-use disorder, and chronic heart, lung, liver, or renal disease. Fluoroquinolones generally provide broader spectrum coverage than required for atypical pneumonia.[31] However, their use may promote emergence of fluoroquinolone resistance and so widespread use in the community is discouraged. Additionally, fluoroquinolones are associated with serious, disabling, and potentially irreversible adverse effects, including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[49][50] The Food and Drug Administration (FDA) has also issued warnings about the increased risk of aortic dissection, significant hypoglycaemia, and mental health adverse effects in patients taking fluoroquinolones.[51][52]

Mycoplasma does not respond to beta-lactam antibiotics because of the lack of a cell wall in this organism. 

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