eMedicine Specialties > Infectious Diseases > Bacterial Infections
Mycoplasma Infections: Treatment & Medication
Updated: Nov 17, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- Ambulatory care versus hospitalization
- The choice of outpatient management versus hospitalization for persons with community-acquired pneumonia depends on the clinical syndrome and not the organism, largely because the microbiologic diagnosis is often unavailable when the physician must make these decisions.
- Professional organizations of physicians and managed care organizations have developed management algorithms that include decision trees for diagnostic studies and management, including specifications of antimicrobial agents to be used. These guidelines vary somewhat, but, in general, the decision to hospitalize a patient depends on an assessment of the following:
- The person's ability to tolerate and comply with oral medication
- Whether the patient appears hypoxic or toxic to the extent that the physician suspects a bacteremic pneumonia
- Whether the person is immunosuppressed
- Relatively few patients with M pneumoniae pneumonia require hospitalization based on these criteria.
- Antimicrobials
- Experts formerly believed that mycoplasmal respiratory tract infections were entirely self-limited and that antimicrobial treatment was not indicated.
- Appropriate antimicrobial therapy shortens the symptomatic period and hastens radiological resolution of pneumonia and recovery, even though patients may shed organisms for several weeks.
- When treating community-acquired pneumonia, physicians usually must provide empiric coverage for several different bacterial agents that may be responsible because the microbiologic diagnosis is seldom available at the initiation of treatment. Fortunately, many of the drugs of choice for treating M pneumoniae provide broad-spectrum coverage for other organisms.
Medication
M pneumoniae remains predictably susceptible to macrolides and tetracyclines; therefore, in vitro susceptibility testing to guide therapy is not indicated.
Oral erythromycin or one of the newer macrolides such as azithromycin or clarithromycin has long been the DOC for mycoplasmal respiratory tract infections. Tetracycline and its analogues are also active. Clindamycin is effective in vitro, but limited reports suggest it may not be active in vivo and thus is not considered a first-line treatment. Several of the newer fluoroquinolones exhibit bactericidal antimycoplasmal activity but are generally less potent in vitro than macrolides against M pneumoniae. Their advantage lies in the fact that they are active against all classes of bacteria that produce clinically similar respiratory tract infections, including macrolide-resistant S pneumoniae. As would be predicted by the lack of a cell wall, none of the beta-lactams is effective in vitro or in vivo against M pneumoniae, and neither are the sulfonamides or trimethoprim.2
Mycoplasma species are slow-growing organisms that have the capacity to reside intracellularly; thus, respiratory tract infections are expected to respond better to longer treatment courses than might be offered for other types of infections. Although physicians typically prescribe most treatment regimens (ie, both oral and parenteral) for 7-10 days, a 14- to 21-day course of oral therapy with most agents is also appropriate. A 5-day course of oral azithromycin is approved for the treatment of community-acquired M pneumoniae pneumonia. Clinical data indicate that this duration of treatment is of comparable efficacy to a 10-day course of erythromycin. Other drugs, including fluoroquinolones, have been approved for the treatment of mycoplasmal respiratory infections with shorter courses because of their favorable pharmacokinetics and tolerability.
In addition to the administration of antimicrobials for the management of M pneumoniae infections, other measures (eg, cough suppressants, antipyretics, analgesics) should be administered as needed to relieve headaches and other systemic symptoms. Because extrapulmonary manifestations are often diagnosed late in the course of disease, the benefit of early treatment is unknown.
In Japan over the past decade, there has been a worrisome emergence of macrolide resistance associated with a greater morbidity in persons with mycoplasmal pneumonias. Recent surveillance in China has shown that more than 80% of M pneumoniae isolates are highly resistant to macrolides.9 Reports from Europe and the United States have also documented resistance to macrolides and that it can have clinical implications.10,11,12 This has led to development of real-time PCR-based assays to detect resistance genes directly in clinical specimens since cultures and conventional susceptibility tests require many more days.12,10,11 In view of the increasing spread of macrolide resistance, clinicians are advised to monitor patient outcomes and to consider using alternative antimicrobial agents if an initial treatment with a macrolide is unsuccessful.13
Antibiotics
Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting.
Erythromycin (E-Mycin, Ery-Tab, E.E.S.)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections.
In children, age, weight, and severity of infection determine proper dosage. When bid dosing desired, half-total daily dose may be taken q12h. For more severe infections, double the dose.
Adult
250-500 mg erythromycin stearate/base (or 400-800 mg ethylsuccinate) PO/IV q6h
Alternatively, 333 mg PO q8h; increase to 4 g/d depending on severity of infection
Pediatric
20-50 mg/kg/d PO divided in 3-4 doses; alternatively, 25-40 mg/kg/d IV divided qid
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; adverse GI effects are common (administer doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occurs
Clarithromycin (Biaxin, Biaxin XL)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
Immediate release: 250-500 mg PO q12h for 7-14 d
Extended release: 1 g PO q24h for 7 d
Pediatric
15 mg/kg PO divided bid
Toxicity increases with coadministration of fluconazole, astemizole, and pimozide; effects decrease and adverse GI effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, and HMG CoA-reductase inhibitors; serious cardiac arrhythmia may occur with coadministration of cisapride; plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmia and increase in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents
Documented hypersensitivity; coadministration of pimozide, astemizole (recalled from US market), cisapride, or terfenadine (recalled from US market)
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Coadministration with ranitidine or bismuth citrate is not recommended with CrCl <25 mL/min; administer half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies
Azithromycin (Zithromax)
Semisynthetic antibiotic belonging to the macrolide subgroup of azalides and is similar in structure to erythromycin. Inhibits protein synthesis in bacterial cells by binding to the 50S subunit of bacterial ribosomes. Action generally is bacteriostatic but can be bactericidal in high concentrations or against susceptible organisms.
Adult
500 mg PO qd for 1 d, then 250 mg PO qd for days 2-5 or 2 go PO given as a single dose
500 mg/d IV for 2 d, then 500 mg PO qd to complete a 7- to 10-d course
For prophylaxis, 500 mg PO loading dose, then 250 mg qd on days 2-5
Pediatric
IV formulation is not recommended for use in children
<6 months: Not established
>6 months: 10 mg/kg PO once on day 1; not to exceed 500 mg/d; 5 mg/kg PO qd on days 2-5; not to exceed 250 mg/d
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients
Doxycycline (Vibramycin)
Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult
200 mg PO/IV single loading dose, then 100 mg PO/IV q12h for 7-10 d
Pediatric
<8 years: Not recommended
>8 years: 4 mg/kg PO initially, then 2 mg/kg q12h for 7-10 d
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Unsafe in pregnancy
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Minocycline (Minocin)
Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult
200 mg PO/IV single loading dose, then 100 mg PO/IV q12h for 7-10 d
Pediatric
<8 years: Not recommended
>8 years: 4 mg/kg PO initially, then 2 mg/kg q12h for 7-10 d
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Unsafe in pregnancy
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Levofloxacin (Levaquin)
Inhibits A subunits of DNA gyrase, resulting in inhibition of bacterial DNA replication and transcription.
Adult
500 mg PO/IV qd for 7-14 d; alternatively, 750 mg PO/IV qd for 5 d
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Moxifloxacin (Avelox)
Inhibits A subunits of DNA gyrase, resulting in inhibition of bacterial DNA replication and transcription.
Adult
400 mg PO/IV qd for 7-14 d
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids and electrolyte supplements reduce absorption; loop diuretics, probenecid, and cimetidine increase serum levels; NSAIDs enhance CNS stimulating effect; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity; known QT prolongation; concurrent administration of drugs that cause QT prolongation
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy; induces seizures in CNS disorder
Gemifloxacin (Factive)
Inhibits DNA gyrase and topoisomerase IV, resulting in inhibition of bacterial DNA replication and transcription.
Adult
CAP due to known or suspected S pneumoniae, H influenzae, M pneumoniae, or C pneumoniae: 320 mg PO qd for 5 d
CAP due to known or suspected Klebsiella pneumoniae, M catarrhalis, or multidrug-resistant S pneumoniae: 320 mg PO qd for 7 d
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Systemic availability reduced when aluminum- and magnesium-containing antacids, ferrous sulfate, vitamins containing zinc, and sucralfate are concomitantly administered; cimetidine and omeprazole may cause slight (clinically insignificant) increases in serum concentration; probenecid causes reduced clearance
Documented hypersensitivity; history of QT prolongation, patients with uncorrected electrolyte disorders, and patients receiving class IA or class III antiarrhythmic agents
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Self-limited maculopapular rash occurred in 2.8% of treated patients, usually after administration for 8-10 d; women <40 y and especially postmenopausal women taking hormone replacement therapy were most likely to develop rash; reduce dose in patients with CrCl <40 mg/d
Telithromycin (Ketek)
Blocks bacterial protein synthesis by binding to domains II and V of 23s rRNA of the 50S ribosomal subunit.
Adult
800 mg PO qd for 7-10 d
Pediatric
Not established
CYP 3A4 inhibitor and substrate; coadministration with other CYP 3A4 inhibitors (eg, itraconazole, ketoconazole) decreases elimination and increases Cmax and AUC; CYP 3A4 inducers (eg, rifampin) decrease telithromycin Cmax and AUC by 79% and 86%, respectively; increases Cmax and AUC of other CYP 3A4 substrates (eg, cisapride, pimozide, simvastatin, lovastatin, atorvastatin, midazolam, triazolam); HMG-CoA reductase inhibitors (eg, simvastatin, atorvastatin, lovastatin) should be temporarily discontinued because of increased myopathy risk when coadministered; increases digoxin and theophylline serum levels; decreases sotalol Cmax and AUC secondary to decreased absorption; caution with other drugs that increase QTc interval (eg, quinidine, procainamide, dofetilide)
Documented hypersensitivity; concomitant administration with cisapride or pimozide; myasthenia gravis; prolonged QT interval; uncorrected electrolyte abnormalities; clinically significant bradycardia; concomitant administration with class IA or class III antiarrhythmic agents; history of hepatitis and/or jaundice with use of macrolides
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in severe renal impairment (limited data exist); consider the diagnosis of pseudomembranous colitis if diarrhea occurs following antibiotic treatment; may prolong QTc interval (caution with heart conduction abnormalities); common adverse effects include diarrhea and nausea; visual disturbances related to slowing ability of accommodation and release of accommodation, resulting in blurred vision, difficulty focusing, and diplopia, sometimes occur; acute hepatic failure and severe liver injury (fatal in some cases) have been reported (if clinical hepatitis or liver enzyme elevations combined with other systemic symptoms occur, permanently discontinue)
More on Mycoplasma Infections |
| Overview: Mycoplasma Infections |
| Differential Diagnoses & Workup: Mycoplasma Infections |
 Treatment & Medication: Mycoplasma Infections |
| Follow-up: Mycoplasma Infections |
| References |
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References
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Further Reading
Keywords
mycoplasmata, mycoplasmal infection, walking pneumonia, atypical pneumonia, tracheobronchitis, bronchiolitis, upper respiratory tract infection, community-acquired pneumonia, CAP, bacterial pneumonia
