Cluster of Macrolide-Resistant Mycoplasma pneumoniae Infections in Illinois in 2012

Abstract

c Macrolide-resistant Mycoplasma pneumoniae is an increasing problem worldwide but is not well documented in the United States. We report a cluster of macrolide-resistant M. pneumoniae cases among a mother and two daughters. CASE REPORTSP atient 1. Patient 1 was an 8-year-old female with antecedent history of asthma who developed fatigue and fever of up to 104.3°F on 18 November 2012. On day 2, she consulted with her primary care physician (PCP); her chest examination was normal, and a nasopharyngeal (NP) specimen collected for influenza was negative. Her PCP recommended symptomatic treatment of the fever and a follow-up visit if there was no improvement in 3 to 4 days; no antibiotics were prescribed at this visit. By day 3 she started having additional symptoms such as cough, headache, nausea, and chest pain. She was reevaluated by her PCP on day 4; chest radiography showed an infiltrate in the right upper lobe with mild volume loss, and a 5-day course of azithromycin was subsequently prescribed. By day 6, fever persisted despite 3 days of azithromycin treatment; a repeat chest radiograph showed slight improvement in the infiltrate. Azithromycin treatment was continued, and albuterol was administered via nebulizer three times daily. Despite completion of the course of azithromycin, fever persisted, prompting the administration of cefdinir on day 8 and of corticosteroids (oral and inhaled) because of wheezing on day 9. The 10-day course of cefdinir was completed; she remained afebrile and gradually improved after 2 weeks. The total illness course was 24 days.Patient 2. Patient 2 was a healthy 38-year-old female (mother of patient 1) with no history of smoking or asthma. She developed fever of up to 103°F on 15 December 2012, approximately 1 month after onset of fever in patient 1. On day 2, she presented to her PCP with cough, dizziness, aches, and upper respiratory symptoms. An NP specimen collected at this visit for rapid influenza testing was negative. Given the marginal sensitivity of the rapid influenza test and widespread influenza A H3N2 virus activity in the country at the time, her PCP elected to treat an influenzalike illness with oseltamivir. The fever persisted, and azithromycin was added to the treatment regimen on day 3. She was reevaluated by her PCP on day 5, and a chest radiograph showed left lower lobe pneumonia. Based on the radiographic findings, azithromycin was stopped and levofloxacin was administered on day 5. Because of wheezing, inhaled albuterol was administered. Although the fever resolved by day 7, cough and wheezing persisted, which prompted the administration of a course of oral corticosteroids by her PCP on day 10. Cough and wheezing gradually improved over the following week, resulting in a total illness course of 17 days.Patient 3. Patient 3 was an otherwise healthy 10-year-old female (sister of patient 1 and daughter of patient 2) with no history of asthma. She presented with fever of up to 104.5°F, dizziness, and headache on 27 December 2012, approximately 2 weeks after the on...

Mycoplasma pneumoniae from the Respiratory Tract and Beyond

“…The CDC has described several clusters and outbreaks of M. pneumoniae infections in various states over the past several years, using serology, molecular-based detection, and strain typing techniques to characterize these events (65)(66)(67)(68)(69)(70). Between 2006 and 2013, there were 17 CDC-assisted investigations of sporadic cases, clusters, and local outbreaks (47).…”

“…Various case reports indicate that macrolide resistance also occurs in other European countries, including Finland, Belgium, and Spain, even though no surveillance studies have been reported from these countries (364)(365)(366). In the United States, MRMP has been described as individual case reports, clusters of infections, including spread within families (47,68,367,368), and one national surveillance study (62). Yamada et al tested 49 M. pneumoniae-positive specimens collected from children in Missouri between 2007 and 2010 and found that 8.2% were macrolide resistant and contained the A2063G mutation (369).…”

“…Even though there is some disagreement regarding the value of antimicrobial treatment for mycoplasmal pneumonia in children (399,400), many clinicians feel that in the absence of resistance, macrolides are useful, perhaps for both their antimicrobial effect and their anti-inflammatory properties mediated through cytokine inhibition (387,401). Overt macrolide treatment failures have been reported, highlighting a need for alternative antibiotic treatment options for infections caused by MRMP (68,361,367,(402)(403)(404)(405). Various case reports have shown that alternative agents such as quinolones (ciprofloxacin or levofloxacin), tetracyclines (doxycycline or minocycline), or the glycylcycline tigecycline (402) may result in clinical improvement after macrolide treatment failure in children (68,361,362,387,391,404,406).…”

“…Overt macrolide treatment failures have been reported, highlighting a need for alternative antibiotic treatment options for infections caused by MRMP (68,361,367,(402)(403)(404)(405). Various case reports have shown that alternative agents such as quinolones (ciprofloxacin or levofloxacin), tetracyclines (doxycycline or minocycline), or the glycylcycline tigecycline (402) may result in clinical improvement after macrolide treatment failure in children (68,361,362,387,391,404,406). Atkinson et al (404) reported a severe case of SJS in a child who was shown to have MRMP and who failed azithromycin therapy but responded to levofloxacin.…”

Clonal Spread of a Unique Strain of Macrolide-Resistant Mycoplasma Pneumoniae Within a Single Family in Italy

“…MVLA confirmed that a recent outbreak of M pneumoniae (macrolide-susceptible strains) in a French primary school was caused by a single clonal strain. 8 In addition, a familial cluster of atypical pneumonia caused by macrolide-susceptible M pneumoniae was reported in South and North Carolina, 13 and an epidemiological study reported another cluster of MR-MP infections, 14 although the relatedness of the strains in this cluster was not assessed.…”