Mycoplasma pneumoniae
Authors: Bin Cao, M.D., Julia A. McMillan, M.D.
Microbiology
Mycoplasma pneumoniae is a Mollicute, a class of bacteria that lack a cell wall. The class includes organisms that are both commensals and pathogens for animals and plants, but the human is the only known host for M. pneumoniae. Lack of a cell wall makes it possible to grow M. pneumoniae in the laboratory on cell-free media only if it is supplemented with sterols and other nutrients provided by yeast extract and animal serum.
Epidemiology
M. pneumoniae was first recognized as a human pathogen when it was isolated from adults with atypical pneumonia syndrome (9, 12). Other causes of this syndrome include respiratory viruses, Legionella species, Chlamydia pneumoniae, and Chlamydia psittaci. M. pneumoniae causes respiratory infection in children of all ages, adolescents, and adults in the second through the fourth decades of life. Upper respiratory symptoms are its most common manifestation in children less than 5 years of age (1, 15, 16). Pneumonia due to M. pneumoniae has been shown to be responsible for approximately 20% of the lower respiratory tract disease seen in junior high and high school students and up to 50% in college students and young adults (10, 14, 16, 18, 29). Prevalence of M. pneumoniae infection may vary according to population and diagnostic methods used. M. pneumoniae infection tends to show cyclic epidemics every 3-5 years; these outbreaks are particularly likely to occur in summer or early fall (1, 13, 20, 26).
Clinical Manifestations
M. pneumoniae causes upper and lower respiratory tract infections. The onset is gradual and fever and cough are the most common presenting manifestations. The cough is usually nonproductive and can be prolonged and severe. With the exception of headache, systemic symptoms such as chills, gastrointestinal manifestations, myalgias are uncommon. Symptoms and severity of illness due to M. pneumoniae was similar in younger and older patients, and the mortality rate was low, even in the elderly (4, 28).
The Japanese Respiratory Society (JRS) guidelines on CAP included five parameters for differentiation between atypical (M. pneumoniae) and bacterial (S. pneumoniae) pneumonia. These parameters were: 1) persistent cough, 2) limited auscultatory findings on chest examination, 3) minimal sputum production, 4) a peripheral white blood cell count below 10,000/mm3. 5) nonsevere co-morbid illnesses. Based on prospective data from 4532 patients with CAP included in the German CAP Competence Network (CAPNETZ), the authors found that patients with M. pneumoniae pneumonia were significantly younger, had less co-morbidity, presented with a less severe disease, showed a lower inflammatory response in terms of leukocyte counts and CRP values, and had better outcomes (43). Cao and coauthors also demonstrated that compared with bacterial and viral pneumonia, CAP patients infected with M. pneumoniae were younger, had lower PSI score, and less likely to have adequate sputum for gram stain and culture (5).
Though effective in reducing symptoms, antibiotic therapy does not reliably eradicate shedding of M. pneumoniae. When initiated within the first 3-4 days of illness, antibiotics are beneficial in both adults and children with lower respiratory tract disease (17, 40, 41), though their impact on upper respiratory tract symptoms has not been well studied. Shedding of the organism from the respiratory tract may persist for weeks to months, even in patients with minimal or no symptoms, and even after appropriate antibiotic therapy (39, 41).
Extrapulmonary Manifestations: A wide variety of skin manifestations has been reported – the most common being erythema multiforme (Stevens-Johnson syndrome). Vascular complications include Raynaud’s phenomenon and vascular occlusion with infarction. Cardiac abnormalities have been reported in hospitalized patients with arrhythmias being the most common manifestation. Arthritis, neurological manifestations, hepatitis, pancreatitis, and ocular disease have also been reported. Most reports are anecdotal and disease is usually attributed to M. pneumoniae on the basis of antibody testing alone; however, isolation of the organism from blood, CSF, synovial fluid, and skin lesions in some patients attests to the fact that dissemination can occur. The pathogenesis of these manifestations is unknown, but immunological reactions and cold agglutinins have been postulated.
Laboratory Diagnosis
When sputum is available, Gram stain shows leukocytes, but no predominant bacteria. Conventional culture using pleuropneumonia-like organism (PPLO) broth, which requires more than 2 weeks, has not been carried out routinely. Compared with serologic tests, or molecular techniques, sensitivity of culture may be 60-70% (21, 30). Culture methods are only used for study of resistance in M. pneumoniae.
Serological methods are now frequently used for diagnosis of M. pneumoniae infections. But reliable diagnosis of M. pneumoniae infections still can not be made on the basis of single acute-phase sera; paired sera obtained during acute and convalescent phases in order to demonstrate rises in antibody titers; fourfold increase is thought to be significant (3, 34). Neither culture nor serologic testing can provide timely information for guiding choice of chemotherapeutic agents to use for early intervention.
Cold agglutinins are IgM antibodies that may appear in the second week of illness. They are detected at a titer of greater than 1:64 in 50-75% of patients with pneumonia due to M pneumoniae, but the test is nonspecific rendering it more of historical value than of clinical utility.
PCR diagnosis is already available in some centers, will become increasingly available, and is likely to replace serodiagnosis in the longer term. Real-time PCR has both high sensitivity and high specificity and can detect pathogen DNA even when damaged by empirical administration of antibiotics. Sensitivity (60-100%) and specificity (96.7-100%) of real-time PCR are both higher than those of serologic assays for M. pneumoniae (11, 19, 34). Almost all PCR-positive cases (>90%) also were confirmed serologically (31, 34). Where available, PCR of sputum or lower respiratory tract sample should be the method of choice for the diagnosis of M. pneumoniae. In the absence of sputum, a throat swab for M. pneumoniae PCR is recommended.
Pathogenesis
M. pneumoniae is spread through respiratory droplets and attaches to ciliated respiratory epithelial cells via an attachment protein. Toxins are produced, leading to ciliostasis and eventual desquamation of ciliated epithelial cells. Macrophages and polymorphonuclear leukocytes contribute to the inflammatory exudates in the upper, and in the case of pneumonia, the lower respiratory tract.
SUSCEPTIBILITY IN VITRO AND IN VIVO
Single Drug
Intrinsically, absence of cell walls in M. pneumoniae confers resistance to β-lactams. M. pneumoniae usually are sensitive to all macrolides, ketolides and tetracyclines (Table 1). Macrolide resistant M. pneumoniae isolates possessing a neucleolide mutation in 23S rRNA first were isolated from pediatric patients with CAP from Japan 2001 (33). In Japanese adult CAP patients, macrolide resistant strains first were isolated in 2007 (23). Emergence of macrolide resistant isolates has not been reported not only in Japan, but also in other countries, including France, the USA, Denmark, and China. A notably high isolation rate of macrolide resistant strains both from pediatric patients (90%) and adult patients (68.7%) was reported in China (6, 27) (Table 2) Tetracyclines are administrated for treatment of M. pneumoniae infections in adults and in pediatric patients > 8 years, but development of resistance to tetracyclines has not yet been reported. Telithromycin is the first of a new family of antimicrobials, the ketolides, to be approved for use in treatment of community-acquired pneumonia. MICs for minocycline and fluoroquinolones in macrolide resistant strains were equivalent to those in susceptible strains. No strains having resistance to minocycline and fluoroquinolones have been observed among clinical isolates. However, emergence of infections with fluoroquinolone-resistant M. pneumoniae might occur, considering the increasing use fluoroquinolone prescription rate among adult patients.
Combination Drugs
Susceptibility of M. pneumoniae to single drug therapy has made it unnecessary to study susceptibilities using combination drugs.
ANTIMICROBIAL THERAPY
Drug of Choice
Macrolides usually are considered the first-line choice for the treatment of M. pneumoniae infection. Treatment of M. pneumoniae pneumonia with clarithromycin or azithromycin results in clinical benefit equal to that seen with erythromycin therapy (7, 8, 37, 38) and a three-day regimen of azithromycin appears to be as effective as five days (37). Microbiologic cure has not been carefully compared in these studies, but because the clinical significance of bacteriologic persistence is not known, eradication may not be an appropriate measure for effectiveness. Treatment of M. pneumoniae pneumonia with roxithromycin resulted in good to excellent results in 12 of 13 patients and eradication of the organism in 4 of the 6 patients cultured (24).
Early studies in adults indicated that both erythromycin and tetracycline were more effective than placebo (25) or penicillin (35, 39) in reducing duration of symptoms, hospitalization, and abnormal chest x-ray in young adults (military recruits and college students) with M. pneumoniae pneumonia. Etiology was documented by culture and/or paired anti-mycoplasmal antibody response in these studies. In children less impressive benefits from antibiotic therapy have been demonstrated (17, 36). Initiation of therapy within the first five days of illness is important for the achievement of maximal benefit.
Alternative Therapy
At present, there is limited evidence on the clinical significance of macrolide-resistant M. pneumoniae infection among pediatric patients. Suzuki and coworkers showed that the total febrile days and the number of febrile days during macrolide administration were longer in patients infected by macrolide-resistant M. pneumoniae (33). In this study, duration of therapy and time to resolution of fever were significantly longer in those infected with resistant strains. No clinical improvement was seen 72 hours after initiation of azithromycin in patients infected with M. pneumoniae with MIC ≥ 2μg/ml of azithromycin. When macrolides are ineffective against M. pneumoniae infection, tetracycline or doxycycline are alternative agents. Respiratory tract fluoroquinolones, such as moxifloxacin, levofloxacin, sparfloxacin, and gemifloxacin may be used for adult patients with macrolide resistant M. pneumoniae infections. Fluoroquinolones are not licensed for use in children.
Empiric Therapy
Timely laboratory diagnosis of M. pneumoniae and other causes of atypical pneumonia (Chlamydia pneumoniae, Legionella pneumoniae, Chlamydia psittaci) usually is not available. Presumptive antibiotic therapy should be selected based on expected effectiveness against these pathogens as well as against the typical bacterial causes of pneumonia (Streptococcus pneumoniae, Moraxella catarrhalis, Haemophilus influenzae). Treatment guidelines for adults with community-acquired pneumonia (2) recommend a macrolide, one of the fluoroquinolones with substantial activity against S. pneumoniae, or doxycycline, for patients who do not require hospitalization. Addition of a beta-lactam antibiotic or single drug therapy using a fluoroquinolone with increased activity against S. pneumoniae is recommended for those who require hospitalization. Clinical trails of telithromycin indicate that it should be expected to be as effective as the macrolides or the quinolones in treating community-acquired pneumonia. Recommended antibiotic doses are listed in Table 3.
Extrapulmonary Disease
The role of antibiotic therapy in treatment of extrapulmonary M. pneumoniae disease has not been well studied. Though immune mechanisms are purported to have a role in hemolysis, CNS involvement, and arthritis, corticosteroid therapy has not been shown to be of benefit. Underlying Diseases Patients with sickle cell disease have been shown to have more severe and prolonged respiratory tract symptoms when infected with M. pneumoniae than do otherwise healthy individuals. Presumptive antibiotic therapy for community-acquired pneumoniae in such patients should include therapy effective against M. pneumoniae. Mycoplasmas other than M. pneumoniae have been found to cause arthritis and invasive disease in immunocompromised patients, but underlying immunodeficiency and immunosuppressive therapy have not been consistently found to be predisposing factors for complications associated with M. pneumoniae infection.
ADJUNCTIVE THERAPY
Symptomatic therapy (non-steroidal anti-inflammatory medications) may be useful early in the course of infection to relieve fever, headache, and sore throat. Antitussive agents generally provide little relief from the prolonged cough.
ENDPOINTS FOR MONITORING THERAPY
Antibiotic therapy results in only modest improvement in cough, fever, myalgia, and other systemic complaints compared to untreated infection. With or without therapy the cough persists well beyond the resolution of generalized illness. As is the case with most causes of community-acquired pneumonia, the chest x-ray may remain abnormal for 4-6 weeks following acute infection.
VACCINES
There is no available vaccine to prevent M. pneumoniae infection.
PREVENTION
Mycoplasma pneumoniae infection of household and other close contacts is frequent. Because prophylaxis using tetracycline or azithromycin may be of some benefit in preventing household spread, their use may be considered if such contacts have underlying respiratory conditions or sickle cell disease.
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Tables
Table 1. Comparative Activity of Antimicrobial Agents against Mycoplasma Pneumoniae
| Antibiotic | MIC90 (ug/ml) | MIC50 (ug/ml) | Range (ug/ml) |
|---|---|---|---|
| Macrolides/ketolides | |||
| Erythromycin | < 0.004 | < 0.004 | < 0.004-.063 |
| Clarithromycin | < 0.031 | < 0.004 | < 0.004-.125 |
| Azithromycin | < 0.0027 | 0.002 | < 0.002-0.0027 |
| Roxithromycin | 0.0625 | 0.0313 | 0.0156-0.0625 |
| Telithromycin | < 0.015 | < 0.015 | |
| Tetracyclines | |||
| Tetracycline | 0.2 | 0.06-0.4 | |
| Doxycycline | 0.4 | 0.1-1.2 | |
| Fluroquinolones | |||
| Ofloxacin | 1.0 | 0.5-1.0 | |
| Sparfloxacin | 0.063 | 0.031-0.063 | |
| Levofloxacin | 0.5 | 1.0 | 0.5-1.0 |
Table 2. MICs Distribution of 9 Antimicrobial Agents for 67 M. pneumoniae Isolated from 356 Adult Patients with CAP or Upper RespiratoryTract Infections in Beijing Chao Yang Hospital 2008-2009
| Antimicrobial agents | No. of strains with MIC (μg/ml) of: | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| ≤0.008 | 0.016 | 0.032 | 0.064 | 0.125 | 0.25 | 0.5 | 1 | 2 | 4 | 8 | 16 | 32 | 64 | 128 | 256 | >256 | |
| Erythromycin | 21 | 1 | 6 | 14 | 25 | ||||||||||||
| Clarithromycin | 21 | 1 | 1 | 15 | 25 | 4 | |||||||||||
| Azithromycin | 21 | 1 | 3 | 21 | 17 | 3 | 1 | ||||||||||
| Ciprofloxacin | 1 | 1 | 15 | 48 | 2 | ||||||||||||
| Levofloxacin | 4 | 3 | 51 | 6 | 2 | 1 | |||||||||||
| Gatifloxacin | 1 | 16 | 41 | 9 | |||||||||||||
| Moxifloxacin | 1 | 11 | 55 | ||||||||||||||
| Tetracycline | 1 | 9 | 20 | 24 | 9 | 4 | |||||||||||
| Minocycline | 2 | 13 | 29 | 16 | 4 | 3 | |||||||||||
Table 3: Dose and Duration of Recommended Antimicrobial Therapy for Mycoplasma pneumoniae Pneumonia
| Antibiotic | Dose | Duration |
|---|---|---|
| Erythromycin | Adults: 1-2 grams/day divided qid Children*: 40 mg/kg/day divided qid | 10 days 10 days |
| Clarithromycin | Adults: 250-500 mg/day divided bid Children*: 15 mg/kg/day divided bid | 10 days 10 days |
| Azithromycin | Adults: 500 mg on day 1 followed by 250 mg/d on days 2-5 OR 500 mg/d Children*: 10 mg/kg on day 1 followed by 5 mg/kg/day x 4 days | 5 days total 3 days total 5 days total |
| Telithromycin | Adults: 800 mg once daily | 5-10 days |
| Moxfloxacin | Adults only: 400 mg daily | 10 days |
| Levofloxacin | Adults only: 500 mg/day | 7-14 days |
| Tetracycline | Adults: 1-2 grams/day divided qid Children > 7 years*: 25-50 mg/kg/day div q 6 hrs | 10 days 10 days |
| Doxycycline | Adults: 200 mg/d divided bid Children > 7 years*: 5 mg/kg/day div bid | 10 days |
*Note: Daily dose in children should not exceed adult dose
What's New
Principi N, et al. Macrolide-resistant Mycoplasma pneumoniae: its role in respiratory infection. J Antimicrob Chemother 2013;68:506-511.
Takafumi O, et al., Rapid Effectiveness of Minocycline or Doxycycline Against Macrolide-Resistant Mycoplasma pneumonia Infection in a 2011 Outbreak Among Japanese Children. Clin Infect Dis 2012;55:1642-1652.
Thurman KA, et al. Comparison of Laboratory Diagnostic Procedures for Detection of Mycoplasma pneumoniae in Community Outbreaks. Clin Infect Dis. 2009;48:1244-9.
von Baum H, et al. Mycoplasma pneumoniae Pneumonia Revisted within the German Competence Network for Community-Acquired Pneumonia (CAPNETZ). BMC Infect Dis 2009;9:62.
GUIDED MEDLINE SEARCH FOR:
Reviews
Miyashita N, et al. Macrolide-Resistant Mycoplasma pneumoniaePneumonia in Adolescents and Adults: Clinical Findings, Drug Susceptibility, and Therapeutic Efficacy. Antimicrob Agents Chemother 2013;57:5181-5185.
Simmons WL, Dybvig K. How Some Mycoplasmas Evade Host Immune Responses. Microbe 2007;2(11): 537-543.
GUIDED MEDLINE SEARCH FOR RECENT REVIEWS
Cunha CB. The first atypical pneumonia: the history of the discovery of Mycoplasma pneumoniae. Infect Dis Clin North Am 2010:24:1-5.