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Antibiotic Commonsense “An Investment in Knowledge Always Pays the Best Interest.” Benjamin Franklin

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Antibiotic Commonsense “An Investment in Knowledge Always Pays the Best Interest.” Benjamin Franklin Volume 2, Issue 2 May 2008 Antibiotic Commonsense “An investment in knowledge always pays the best interest.” Benjamin Franklin Diagnosis and Treatment of Mycoplasma Pneumonia* Mycoplasma pneumoniae is one of the most common While microbiological studies can pathogens identified in mild ambulatory community-acquired support a diagnosis of M pneumoniae, pneumonia (CAP). The other common pathogens are routine tests are often nonspecific or Streptococcus pneumoniae, Chlamydiophile pneumoniae, falsely negative.5 and Haemophilus influenza. In recent studies, Mycoplasma 3,4,5 infection was most common among people under 50 years of Laboratory Testing age who did not have significant comorbid conditions or M. pneumoniae is a small, obligate, intracellular bacteria that abnormal vital signs. It is primarily found among school-aged has several shapes and sizes. The lack of a cell wall prevents children and young adults. Serious complications are rare. staining with traditional gram stain. Prevalence/Incidence Culture Mycoplasma pneumonia, a low level endemic disease, Advantage: Differentiation of M. pneumoniae from other reaches epidemic levels at three to seven year intervals. organisms that cause atypical CAP. These epidemics often begin in the fall and sometimes last Disadvantages: Requires cholesterol to stimulate growth. for several months. M. pneumoniae causes approximately 20 Divides by binary fission and isolation of the organism may percent of acute pneumonia infections in middle and high require 21 days or more. Does not survive well in transport school students and 50 percent among college students and media making culture insensitive for detection of this military recruits. The incidence of community-acquired M. organism. pneumonia in the adult population is approximately Complement Fixation Test 1 15/100,000. Advantage: Good sensitivity and specificity. Transmission Disadvantages: Because antibodies may persist in an infected person for a year or more, high titers may not Transmission is person-to-person by respiratory droplet. indicate current infection. Respiratory tract shedding of M. pneumoniae from both symptomatic and non-symptomatic people occurs for weeks Cold Agglutinins (even months) and likely contributes to community outbreaks. (non-specific erythrocyte agglutinating antibodies) Antibiotic therapy is more successful in relieving symptoms Advantage: If cold agglutinins present in combination with than eradicating the organism as shedding often continues clinical signs of M. pneumoniae, a presumptive diagnosis for one to two weeks after antibiotics are started.2 may be possible. Disadvantages: Cold agglutinins are not specific for M. Clinical Presentation pneumoniae and not even produced in half of the people Patients present with fever, cough, headache, and malaise. infected with these bacteria. Not recommended for definitive One half of patients have all four symptoms. Rhinorrhea, diagnosis. myalgias, chest pain, sore throat and hoarseness appear in one fourth to one half of patients. The incubation period is EIA (enzyme immunoassay) from one to four weeks.1 Advantage: Several kits available on the market for detection of M. pneumoniae IgG and IgM antibodies. Diagnosis Disadvantages: Most kits require acute and convalescent Diagnosis is based on clinical presentation (above) and is sera collected 2-4 weeks apart. Tests may be simpler and supported by chest radiography. Detection of rales or somewhat quicker to perform, but they lack sensitivity. bronchial breath sounds while important are less sensitive and specific than chest radiographs that demonstrate an PCR (polymerase chain reaction) 5 Advantage: PCR technology more available through infiltrate. In the elderly patient both clinical signs and reference laboratories physical exam findings may be altered or lacking. Disadvantages: PCR technology very expensive. A positive PCR--in the absence of seroconversion, positive culture or *Claudia Willis, Microbiology Supervisor, and Laura Ching, clinical disease--suggests inadequate specificity of the PCR PharmD., Franciscan Health System, were major contributors. assay, persistence of the organism after the infection has resolved, or an asymptomatic carrier state. “An investment in knowledge always pays the best interest.” Benjamin Franklin Antibiotic Commonsense Diagnosis and Treatment of Mycoplasma Pneumonia (cont.) Susceptibility Testing Resources Disadvantages: Traditional susceptibility methods not 1. Mufson MA. Mycoplasma Pneumonia in Gorbach SL, Bartlett practical due to the unusual growth requirements of M. JG, Blacklaw NR. Infectious Diseases, 3rd Edition. Lippincott, pneumoniae. No accepted standard for susceptibility Williams & Wilkins. 2004. testing of Mycoplasma. No MIC breakpoints are endorsed 2. Weiner LB, McMillan JA. Mycoplasa Pneumonia in Long SS by any regulatory agency. Lack of guidelines and (ed). Principles and Practice of Pediatric Infectious Diseases, interpretation of results can lead to inconsistent 2nd ed. Elsevier Health Sciences (UK). 2002. 1005-1010. susceptibility profiles. 3. Murray P R, Baron EJ, Jorgenson JH et al (ed). Manual of Clinical Microbiology 8th edition. ASM Press. 2003: 972-984. Treatment 4. Baseman JB, Tully J.G. Mycoplasmas: Sophisticated, Patients who present with community-acquired pneumonia Reemerging and Burdened by Their Notoriety, Emerging (CAP) are typically treated empirically with antibiotics that Infectious Disease (www.cdc.gov/ncidod/eid/vol3no1/ cover Streptococcus pneumoniae, Haemophilus baseman.htm, posted 2/15/97) influenzae, and atypical organisms, including Mycoplasma 5. Cimolai N. Mycoplasma pneumoniae Respiratory Infection. pneumoniae, Chlamydophile pneumoniae, and Legionella Pediatrics in Review 1998;19:327-332. pneumophila. 6. Mandell LA, Wunderink RG et al. Infectious Disease Society of America/American Thoracic Society Consensus Common therapies for M. pneumoniae respiratory Guidelines on the Management of Community-Acquired infections include macrolides, tetracyclines, and Pneumonia in Adults. CID. 2007 Mar 1;44 Suppl 2:S27-72. fluoroquinolones. According to the IDSA/ATS 2007 CAP 7. Mandell G, Bennett J, Dolin R. Principles and Practice of consensus guidelines, a macrolide antibiotic is the first-line Infectious Diseases, 6th Edition. Philadelphia: Elsevier, therapy when treating an otherwise healthy patient in an 2005. 6 outpatient setting. ß-lactam antibiotics, such as penicillins and cephalosporins, are not effective because M. Common Treatment of Mycoplasma Pneumonia pneumoniae lacks a cell wall: ß-lactam bactericidal activity relies on cell wall inhibition. Class Drug Adult Dose Pediatric Dose Comments Of the macrolide antibiotics, azithromycin is Macrolide Azithromycin 500 mg in one 10 mg/kg in one dose Most commonly dose, then 250 on day 1, then 5 mg/kg used; longer most commonly used due to efficacy, mg orally for 4 daily for 4 days half-life & post- convenience of dosing/duration, and tolerability. days antibiotic effect Erythromycin which is known for allows for shorter duration gastrointestinal side effects, including diarrhea, may reduce drug adherence. Clarithro- 250-500mg 15 mg/kg/day in two mycin every 12 hours divided doses for 10 In vitro studies have shown that macrolides are for 7 days days 100 times more active against M. pneumoniae than fluoroquinolones, followed by Erythromycin 500mg every 6 30-40 mg/kg/day in High rate of 7 hours for 7 four divided doses for gastrointestinal tetracyclines. The duration of treatment for an days 10 days side effects uncomplicated infection usually ranges from five to seven days, depending on antibiotic Fluoro- Levofloxacin 500mg daily for Do not use in selection and the clinical stability of the patient.6 quinolone 7 days pediatrics Moxifloxacin 400mg daily for Do not use in 7 days pediatrics Tetra- Doxycycline 100mg every 2-4 mg/kg/day in 1-2 Do not use in cycline 12 hours for 7 divided doses for 10 children less days days, (max 100-200 than 8 years of mg/day) age. Contact: Lois Lux Phone: 253 798-6416 Fax: 253 798-7666 Email: [email protected] .
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