Expert consensus on the diagnosis and treatment of macrolide-resistant Mycoplasma pneumoniae pneumonia in children
Authors: Wang Ying-Shuo , Zhou Yun-Lian , Bai Guan-Nan , Li Shu-Xian , Xu Dan , Chen Li-Na , Chen Xing , Dong Xiao-Yan , Fu Hong-Min , Fu Zhou , Hao Chuang-Li , Hong Jian-Guo , Liu En-Mei , Liu Han-Min , Lu Xiao-Xia , Luo Zheng-Xiu , Tang Lan-Fang , Tian Man , Yin Yong , Zhang Xiao-Bo , Zhang Jian-Hua , Zhang Hai-Lin , Zhao De-Yu , Zhao Shun-Ying , Zhu Guo-Hong , Zou Ying-Xue , Lu Quan , Zhang Yuan-Yuan , Chen Zhi-Min 
Published: August 2024

Abstract
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.