Current perspectives on atypical pneumonia in children

The major pathogens that cause atypical pneumonia are Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Legionella pneumophila. Community-acquired pneumonia (CAP) caused by M. pneumoniae or C. pneumoniae is common in children and presents as a relatively mild and self-limiting disease. CAP due to L. pneumophila is very rare in children and progresses rapidly, with fatal outcomes if not treated early. M. pneumoniae, C. pneumoniae, and L. pneumophila have no cell walls; therefore, they do not respond to β-lactam antibiotics. Accordingly, macrolides, tetracyclines, and fluoroquinolones are the treatments of choice for atypical pneumonia. Macrolides are the first-line antibiotics used in children because of their low minimum inhibitory concentrations and high safety. The incidence of pneumonia caused by macrolide-resistant M. pneumoniae that harbors point mutations has been increasing since 2000, particularly in Korea, Japan, and China. The marked increase in macrolide-resistant M. pneumoniae pneumonia (MRMP) is partly attributed to the excessive use of macrolides. MRMP does not always lead to clinical nonresponsiveness to macrolides. Furthermore, severe complicated MRMP responds to corticosteroids without requiring a change in antibiotic. This implies that the hyper-inflammatory status of the host can induce clinically refractory pneumonia regardless of mutation. Empirical macrolide therapy in children with mild to moderate CAP, particularly during periods without M. pneumoniae epidemics, may not provide additional benefits over β-lactam monotherapy and can increase the risk of MRMP.