Background Macrolide-resistant Mycoplasma pneumoniae (MRMP), primarily driven by the 23 S rRNA A2063G mutation, is increasingly prevalent among East Asian children, diminishing azithromycin efficacy. Although some patients benefit from its anti-inflammatory properties, delayed escalation in non-responders can prolong fever and increase complications. Given the age-related risks of tetracyclines and fluoroquinolones, determining which children truly require second-line therapy remains a clinical challenge. Methods We retrospectively reviewed 112 children with MRMP carrying the 23 S rRNA A2063G mutation. Patients were categorized into an azithromycin group (n = 66) and a second-line therapy group (n = 46). Between-group comparisons were performed using the χ² test, independent-sample t test, or Mann-Whitney U test. Independent predictors of escalation were identified via multivariable logistic regression, and model performance was assessed using receiver operating characteristic (ROC) analysis. Results Compared with the second-line group, the azithromycin group had longer fever duration (median 7.00 vs. 5.00 days, P = 0.003) and slightly higher peak temperatures (39.20 °C vs. 39.00 °C, P = 0.016). In contrast, escalated patients exhibited significantly higher procalcitonin (PCT) levels (1.23 vs. 0.30 ng/mL, P < 0.001), greater chest CT total severity scores (TSS) (13.50 vs. 4.00, P < 0.001), and more frequent Streptococcus pneumoniae co-infection (65.22% vs. 39.39%, P = 0.012). Logistic regression identified elevated PCT, higher TSS, and ≥ 2 co-pathogens as independent predictors of escalation, while therapeutic bronchoscopy was protective; age was included as a covariate. The model demonstrated excellent discrimination (AUC 0.938, 95% CI 0.89–0.99; sensitivity 100%, specificity 78.8%). A five-item bedside score (cutoff ≥ 3.6) retained high accuracy (AUC 0.926; sensitivity 95.7%, specificity 86.4%). Conclusions A simple clinical scoring model incorporating PCT, TSS, co-pathogen burden, bronchoscopy status, and age demonstrated good predictive accuracy in identifying children with A2063G-positive MRMP pneumonia who may benefit from early escalation to second-line therapy. Its use in clinical practice may support timely intervention for high-risk patients while minimizing unnecessary antibiotic escalation. Further prospective validation in multicenter cohorts is needed to confirm its generalizability and clinical utility.

Clinical score for early escalation in pediatric A2063G Mycoplasma pneumoniae pneumonia: a retrospective cohort study

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2025年9月29日

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Junjie Ning,
Lina Qiao,
Zhidong Yu,
Zhang Chen

摘要

Background

Macrolide-resistant Mycoplasma pneumoniae (MRMP), primarily driven by the 23 S rRNA A2063G mutation, is increasingly prevalent among East Asian children, diminishing azithromycin efficacy. Although some patients benefit from its anti-inflammatory properties, delayed escalation in non-responders can prolong fever and increase complications. Given the age-related risks of tetracyclines and fluoroquinolones, determining which children truly require second-line therapy remains a clinical challenge.

Methods

We retrospectively reviewed 112 children with MRMP carrying the 23 S rRNA A2063G mutation. Patients were categorized into an azithromycin group (n = 66) and a second-line therapy group (n = 46). Between-group comparisons were performed using the χ² test, independent-sample t test, or Mann-Whitney U test. Independent predictors of escalation were identified via multivariable logistic regression, and model performance was assessed using receiver operating characteristic (ROC) analysis.

Results

Compared with the second-line group, the azithromycin group had longer fever duration (median 7.00 vs. 5.00 days, P = 0.003) and slightly higher peak temperatures (39.20 °C vs. 39.00 °C, P = 0.016). In contrast, escalated patients exhibited significantly higher procalcitonin (PCT) levels (1.23 vs. 0.30 ng/mL, P < 0.001), greater chest CT total severity scores (TSS) (13.50 vs. 4.00, P < 0.001), and more frequent Streptococcus pneumoniae co-infection (65.22% vs. 39.39%, P = 0.012). Logistic regression identified elevated PCT, higher TSS, and ≥ 2 co-pathogens as independent predictors of escalation, while therapeutic bronchoscopy was protective; age was included as a covariate. The model demonstrated excellent discrimination (AUC 0.938, 95% CI 0.89–0.99; sensitivity 100%, specificity 78.8%). A five-item bedside score (cutoff ≥ 3.6) retained high accuracy (AUC 0.926; sensitivity 95.7%, specificity 86.4%).

Conclusions

A simple clinical scoring model incorporating PCT, TSS, co-pathogen burden, bronchoscopy status, and age demonstrated good predictive accuracy in identifying children with A2063G-positive MRMP pneumonia who may benefit from early escalation to second-line therapy. Its use in clinical practice may support timely intervention for high-risk patients while minimizing unnecessary antibiotic escalation. Further prospective validation in multicenter cohorts is needed to confirm its generalizability and clinical utility.