Mycoplasma pneumoniae pneumonia treatment: which drug is azithromycin relegated to the second line of choice?

Azithromycin is a new type of macrolide drug with convenient administration, precise curative effect and relatively mild gastrointestinal adverse reactions.

Changes in drugs for treatment of Mycoplasma pneumoniae pneumonia

With the large-scale use of macrolides, the drug resistance of Mycoplasma pneumoniae to macrolides has attracted attention at home and abroad

From the "Guidelines for the Diagnosis and Treatment of Community-Acquired Pneumonia in Chinese Adults (2016 Edition)" [2], azithromycin (and clarithromycin) have taken a back seat in the treatment of Mycoplasma pneumoniae pneumonia, replaced by doxycycline, mino Cyclic or respiratory quinolones, and macrolides in areas with low rates of mycoplasma resistance

Table 1.

Doxycycline or Minocycline?

Tetracyclines are broad-spectrum antibacterial drugs, the antibacterial spectrum includes: G+ and G- aerobic and anaerobic bacteria, rickettsia, spirochetes, mycoplasma, chlamydia and some protozoa

In terms of antibacterial activity, minocycline has the strongest antibacterial activity among tetracyclines, followed by doxycycline, metacycline, chlortetracycline, tetracycline, and oxytetracycline

In terms of safety, minocycline is highly lipophilic, has a high concentration in the central nervous system, and has high vestibular and ototoxicity, which can easily cause dizziness and dizziness in patients, especially in women

In general, minocycline has stronger antibacterial activity, but doxycycline is safer

In the treatment of Mycoplasma pneumoniae pneumonia, there is not much literature on how to choose between the two

Levofloxacin or Moxifloxacin?

At present, the commonly used clinical respiratory quinolones are levofloxacin and moxifloxacin, both of which are broad-spectrum antibacterial drugs

Quinolones have adverse reactions to damage animal cartilage and are contraindicated in people under 18 years of age

Table 2.

How to choose medication for Mycoplasma pneumoniae pneumonia?

Based on the consensus of CAP guidelines at home and abroad, it seems that respiratory quinolones are more favored

But these do not mean that respiratory quinolones are better than tetracyclines, it may just be because there is more evidence, and there is less data on tetracycline in the treatment of pneumonia

In an open-label randomized trial [5], intravenous doxycycline 100 mg twice daily was associated with faster responsiveness and fewer antibiotic switching compared with the standard antibiotic regimen

Therefore, which of the two is better or worse, how to choose depends on the actual situation

For example, patients over 8 years old and under 18 years old can choose doxycycline or azithromycin; patients over 18 years old can choose doxycycline or respiratory quinolones;

In patients with central nervous system diseases (such as epilepsy), tetracyclines may be more appropriate than quinolones; in patients with vestibular diseases (such as dizziness, vertigo), quinolones may be more appropriate than tetracyclines
.

In the case of hepatic insufficiency, quinolones are best to choose levofloxacin with more renal excretion; in patients with renal insufficiency, doxycycline or moxifloxacin metabolized by liver and kidney dual channels can be selected
.

For pregnant women, neither tetracycline nor quinolones are available, and azithromycin may be more appropriate
.

In short, clinicians need to make the most beneficial drug choice for patients after comprehensive evaluation of multiple factors such as patient age, comorbidities, organ function, drug resistance risk, adverse drug reactions, drug availability and economy
.

references:

[1] Infectious group of respiratory disease branch of Chinese Medical Association.
Expert consensus on diagnosis and treatment of adult Mycoplasma pneumoniae pneumonia[J].
Chinese Journal of Tuberculosis and Respiratory Medicine, 2010, 33(9):3.

[2] Qu Jieming, Cao Bin.
Guidelines for the diagnosis and treatment of adult community-acquired pneumonia in China (2016 edition) [J].
Chinese Journal of Tuberculosis and Respiratory Medicine, 2016,39(04):253-279.

[3] Olson G, Davis AM.
Diagnosis and Treatment of Adults With Community-Acquired Pneumonia.
JAMA.
2020 Mar 3;323(9):885-886.
doi: 10.
1001/jama.
2019.
21118.
PMID: 32027358.

[4] Mokabberi R, Haftbaradaran A, Ravakhah K.
Doxycycline vs.
levoflfloxacin in the treatment of community-acquired pneumonia.
J Clin Pharm Ther 2010;35:195–200.

[5] Ailani RK, Agastya G, Ailani RK, Mukunda BN, Shekar R.
Doxycycline is a cost-effective therapy for hospitalized patients with communityacquired pneumonia.
Arch Intern Med 1999;159:266–270.