Treatment of Mycoplasma pneumoniae in Pediatric Lower Respiratory Infection In this issue of Pediatrics, Biondi et al 1 present a rigorous systematic review and meta-analysis of the literature on the use of antibiotics to treat community-acquired (CA) lower respiratory infections (LRIs) secondary to Mycoplasma pneumoniae (MP). Consistent with previous studies, but on a larger scale, the evidence is deemed insufficient to support or refute such treatments for MP. The following comments, although largely addressed in the article, are intended to highlight the caution that is required on the part of the reader when attempting to implement these conclusions to everyday practice. In particular, we must point out that lack of evidence of efficacy is not evidence of inef ficacy when addressing current treatment paradigms. The problems of this and previous studies lie in the lack of uniformity of diagnostic methods, complicated by the fact that mixed infections with other microorganisms often go undiagnosed and contaminate any analysis of treatment efficacy. The small number of studies and their heterogeneity add to our inability to conclude either way, and therefore statements about results of MP-oriented antibiotic treatment are difficult to substantiate, particularly when applied to individual cases. MP is a common cause of CA LRI, particularly in school-aged children and adolescents. It is responsible for at least 40% of cases of CA pneumonia (CAP) and as many as 18% of cases requiring hospitalization in children. 2 The diagnosis of MP infection is difficult and nonuniform, and serology and nucleic acid amplification (polymerase chain reaction) are mostly used. Few commercial serologic assays have been shown to have ap- propriate sensitivity and specificity. 3 Conversely, polymerase chain re- action may overestimate the incidence of MP and cost considerations limit its use. These factors frequently limit or delay diagnosis and in- troduce arbitrariness to therapeutic decisions. Even when the diagnosis is made, there is evidence that MP infections are often mixed; Korppi et al 4 reported .50% of MP CAP to be mixed infections, with Streptococcus pneumoniae identified in two-thirds of cases. MP may precede and intensify subsequent infections with various respiratory viruses and bacteria. 5 Such data raise the question of how statements on efficacy of therapies for MP can be made when there is not even the knowledge of which organisms are being targeted. Patients with MP infections mostly recover spontaneously, and it is difficult to assess how intervention and the timing thereof within the course of the infection can be factored in when studying the results of therapies. In human studies, antibiotics have been shown to shorten the clinical course of MP infection, 6 but at the same time carriage of organisms in the upper respiratory tract may not be eliminated. 7 It is therefore difficult to assess the effect of medication when organism eradication is not achieved, and thus the response of MP, unlike bacterial infections, is inherently more subtle and variable. Biondi AUTHORS: Andrew A. Colin, MD, a Shatha Yousef, MD, a Erick Forno, MD, b and Matti Korppi, MD c a Division of Pediatric Pulmonology, Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, Florida; b Division of Pediatric Pulmonary Medicine, Allergy, and Immunology, Children’ s Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania; and c Center for Child Health Research, Tampere University and University Hospital, Tampere, Finland KEY WORDS mycoplasma, Mycoplasma pneumoniae, child ABBREVIATIONS CA—community-acquired CAP—community-acquired pneumonia LRI—lower respiratory infection MP—Mycoplasma pneumonia Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees. www.pediatrics.org/cgi/doi/10.1542/peds.2014-0871 doi:10.1542/peds.2014-0871 Accepted for publication Mar 25, 2014 Address correspondence to Andrew A. Colin, MD, University of Miami Batchelor Children’ s Institute, Pediatric Pulmonology, 1580 NW 10th Ave, First Floor (D-820), Miami, FL 33136. E-mail: acolin@med.miami.edu PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2014 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose. COMPANION PAPER: A companion to this article can be found on page 1081, and online at www.pediatrics.org/cgi/doi/10.1542/ peds.2013-3729. 1124 COLIN et al by guest on November 6, 2021 www.aappublications.org/news Downloaded from