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In this issue of Pediatrics, Biondi et al 1 present a rigorous systematic review and meta-analysis of the literature on the use of antibiotics to treat community-acquired (CA) lower respiratory infections (LRIs) secondary to Mycoplasma pneumoniae (MP). Consistent with previous studies, but on a larger scale, the evidence is deemed insufficient to support or refute such treatments for MP.The following comments, although largely addressed in the article, are intended to highlight the caution that is required on the part of the reader when attempting to implement these conclusions to everyday practice. In particular, we must point out that lack of evidence of efficacy is not evidence of inefficacy when addressing current treatment paradigms. The problems of this and previous studies lie in the lack of uniformity of diagnostic methods, complicated by the fact that mixed infections with other microorganisms often go undiagnosed and contaminate any analysis of treatment efficacy. The small number of studies and their heterogeneity add to our inability to conclude either way, and therefore statements about results of MP-oriented antibiotic treatment are difficult to substantiate, particularly when applied to individual cases.MP is a common cause of CA LRI, particularly in school-aged children and adolescents. It is responsible for at least 40% of cases of CA pneumonia (CAP) and as many as 18% of cases requiring hospitalization in children. 2The diagnosis of MP infection is difficult and nonuniform, and serology and nucleic acid amplification (polymerase chain reaction) are mostly used. Few commercial serologic assays have been shown to have appropriate sensitivity and specificity.3 Conversely, polymerase chain reaction may overestimate the incidence of MP and cost considerations limit its use. These factors frequently limit or delay diagnosis and introduce arbitrariness to therapeutic decisions.Even when the diagnosis is made, there is evidence that MP infections are often mixed; Korppi et al 4 reported .50% of MP CAP to be mixed infections, with Streptococcus pneumoniae identified in two-thirds of cases. MP may precede and intensify subsequent infections with various respiratory viruses and bacteria.5 Such data raise the question of how statements on efficacy of therapies for MP can be made when there is not even the knowledge of which organisms are being targeted.Patients with MP infections mostly recover spontaneously, and it is difficult to assess how intervention and the timing thereof within the course of the infection can be factored in when studying the results of therapies. In human studies, antibiotics have been shown to shorten the clinical course of MP infection, 6 but at the same time carriage of organisms in the upper respiratory tract may not be eliminated.7 It is therefore difficult to assess the effect of medication when organism eradication is not achieved, and thus the response of MP, unlike bacterial infections, is inherently more subtle and variable. Biondi

Nontuberculous mycobacteria (NTM) have been increasingly recognized in recent years as contributors to clinically significant lung infection in cystic fibrosis (CF) patients. Reports of prevalence vary from 6 to 22% around the world. Prevalence estimates in childhood CF is challenging since sputum producers are rare, bronchoalveolar lavage is an invasive procedure and may not be feasible, and mounting evidence deeming throat cultures to be unsuccessful in detecting NTM. We report a case of an overall healthy 13 year old young adolescent female with CF, who presented with Mycobacterium avium complex (MAC) as her first documented lung infection, and while only presenting with minor cough proved to have severe purulent bronchial infection. Contrary to common paradigms, NTM can be the first infection in a non-previously infected airway, and, this first infection can be of a serious nature unlike the more subtle anticipated pattern. The causes of the high and probably increasing overall incidence of NTM and specifically in CF elude explanation and mandate further study. Continuing efforts should be invested into the study of all aspects of this ominous infection. Pediatr Pulmonol. 2015; 50:E5-E7. © 2014 Wiley Periodicals, Inc.

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